Missing the boat

August 7, 2024 By scottdm 9 Comments

All of us have them. Key developmental experiences. Ones that stick in our memory, make a permanent “dent” in our thinking or behavior.

I was sitting behind a one-way mirror watching a therapy session. The young man being interviewed was dying, his immune system failing due to the AIDS virus. It was the early days of the outbreak. Lots of fear, death, helplessness, and indifference.

“He’s in denial about dying,” the resident physician told us before my fellow psychology intern entered the hospital room, “If things need doing, they have to be done soon as he doesn’t have long.”

The conversation that ensued was painful to watch. The young man talked about what he was going to do when he was released from the hospital. My colleague gently but firmly focused on the man’s impending death.

Pointing to a magazine on a bedside table, “I’m planning a trip, going to sail around the world.”

Following a brief pause, “I know this must be hard to accept, but you are dying.”

“I have been looking at sail boats,” he continued, “I learned how to sail when I was coming up.”

Silence. Then, “Perhaps we should talk about what’s happening right now.”

Once again pointing to the magazine, “Can you hand me that? I’ll show you sailboat I’m thinking about getting.”

And on and on it went.

As a grad student, I’d learned about resistance and denial – according to Freud, “the violent and tenacious” rejection of the therapist’s efforts “to restore the patient to health, to relieve him of the symptoms of his illness.” It was the challenge of therapeutic work, the precursor to being able to help.

To me, however, it seemed like torture. “I don’t get this,” I said to the group, “He’s dying.”

“The point,” our supervisor responded, “is to help him address this, and take care of what needs to get done before he dies.”

“And what if he doesn’t?” I thought to silently to myself, “What’s the worst that can happen? Either way, he’s dead.”

The interview dragged on for another 15 minutes or so. I just watched, feeling helpless. After all, at the time, I didn’t have any alternate suggestions for what to do – something that wouldn’t be seen as participating in or perpetuating the man’s … “denial.”

Next morning, I learned the young man had died during the night. It took my breath away. Then, as now, I felt we really missed … the boat.

The Growing Inaccessibility of Science

July 23, 2024 By scottdm 7 Comments

It’s a complaint I’ve heard from the earliest days of my career. Therapists do not read the research. I often mentioned it when teaching workshops around the globe.

“How do we know?” I would jokingly ask, and then quickly answer, “Research, of course!”

Like people living before the development of the printing press who were dependent on priests and “The Church” to read and interpret the Bible, I’ve long expressed concern about practitioners being dependent on researchers to tell them how to work.

I advised reading the research, encouraging therapists who were skittish to skip the methodology and statistics and cut straight to the discussion section.
I taught courses/workshops specifically aimed at helping therapists understand and digest research findings.
I’ve published research on my own work despite not being employed by a university or receiving grant funding.
I’ve been careful to read available studies and cite the appropriate research in my presentations and writing

I was naïve.

To begin, the “research-industrial complex” – to paraphrase American president Dwight D. Eisenhower – had tremendous power and influence despite often being unreflective of and disconnected from the realities of actual clinical practice. The dominance of CBT (and its many offshoots) in practice and policy, and reimbursement is a good example. In some parts of the world, government and other payers restrict training and reimbursement in any other modality – this despite no evidence CBT has led to improved results and, as documented previously on my blog, data documenting such restrictions lead to poorer outcomes.

More to the point, since I first entered the field, research has become much harder to read and understand.

How do we know? Research!

Sociologist David Hayes wrote about this trend in Nature more than 30 years ago, arguing it constituted “a threat to an essential characteristic of the endeavor – its openness to outside examination and appraisal” (p. 746).

I’ve been on the receiving end of what Haye’s warned about long ago. Good scientists can disagree. Indeed, I welcome and have benefited from critical feedback provided when my work is peer-reviewed. At the same time, to be helpful, the person reviewing the work must know the relevant literature and methods employed. And yet, the ever-growing complexity of research severely limits the pool of “peers” able to understand and comment usefully, or – as I’ve also experienced – to those whose work directly competes with one’s own.

Still, as Hayes notes, the far greater threat is the lack of openness and transparency resulting from scientists’ inability to communicate their findings in a way that others can understand and independently appraise. Popular internet memes like, “I believe in science,” “stay in your lane,” and “if you disagree with a scientist, you are wrong,” are examples of the problem, not the solution. Beliefs are the province of religion, politics and policy. The challenge is to understand the strengths and limitations of the methodology and results of the process called science — especially given the growing inaccessibility of science, even to scientists.

Continuing with “business as usual” — approaching science as a “faith” versus evidence-based activity — is a vanity we can ill afford.

Until next time,

Scott
Director, International Center for Clinical Excellence

How to (and not to) become a more effective therapist

July 2, 2024 By scottdm 8 Comments

I’m not sure what was going on in our field last week. From the emails I received, it seemed something big — no, monumental. Here are just a handful of the highlights:

“The single modality that’s transforming how clinicians do therapy … and making them so successful.”

A new approach for “Getting to the heart of complex and deep-rooted clinical issues, fast.”

A “unique and integrative approach for … building thriving relationships that last!”

You will learn to offer “transformative trauma healing results … [and] become the go-to trauma healer.”

Plus, certifications in “complex trauma, PTSD, and dissociation,” “polyvagal therapy,” and — no irony intended — “Narcissistic Abuse Treatment Clinician.”

Now, truth is, I get a lot of email. On any given day, a certain percentage of what lands in my inbox is made up of solicitations. A couple of advertisements for training in this or that therapy would, therefore, have gone unnoticed.

This was different. One day alone I received 41 separate come-ons — all with the same bold promises and time-limited discounts for “special customers” like me.

I still don’t know what led to the deluge. What is certain is that it had nothing to do with advances in the “science of psychotherapy.” Over the last 50 years, treatment methods have proliferated despite a lack of evidence of differential effectiveness between approaches. And even when a randomized controlled trial indicates a particular approach works, none show practitioners become more effective when they are trained in that modality.

Consider a study out of the United Kingdom (1). There, massive amounts of money have been spent training clinicians to use cognitive behavioral therapy (CBT). Clinicians participated in a high intensity course that included more than 300 hours of training, supervision, and practice. Competency in delivering CBT was assessed at regular intervals and shown to improve significantly over the course of the training program. And yet, despite the tremendous investment of time, money, and resources, outcomes did not improve. In short, clinicians were as effective as they’d been before being trained.

Contrast the field’s relentless pursuit of “treatment technology” with the work of psychologist Timothy Anderson. A decade-and-a-half ago, he developed a tool for measuring therapists’ interpersonal skills. Known as The Facilitative Interpersonal Skills Performance Task (FIS), it assesses a range of abilities (e.g., warmth, empathy, verbal fluency, hope, emotional expression and persuasiveness) by rating therapist responses to video simulations of challenging client-therapist interactions. It turns out that therapists who perform well on the FIS establish stronger relationships and are more effective (2). More to the point, the evidence shows FIS-related skills are trainable and that such training leads to better results (3, 4, 5).

Next month, I’ll be posting a summary of a study my colleagues and I just published documenting the impact of using deliberate practice to improve interpersonal skills — namely, empathy (You won’t be surprised to learn that clinicians’ assessment of their abilities did not correlate with their actual performance).

In the meantime, take a listen to the interview below with Dutch researchers, Sabine van Thiel and Kim de Jong. Their recently published study identified multiple, different types of therapist FIS response styles — including the elusive, “supershrink.”

Until next time,

Scott

Director, International Center for Clinical Excellence

P.S.: The final fireside chat with me and Daryl Chow is scheduled for the last Tuesday of this month. It’s free, of course, but you must register to secure a spot. Click here.