The Baader-Meinhof Effect in Trauma and Psychotherapy

August 28, 2019 By scottdm 20 Comments

Have you heard of the “Baader-Meinhof” effect? If not, I’m positive you’ll soon be seeing evidence of it everywhere.

That’s what “it” is, by the way — that curious experience of seeing something you’ve just noticed, been told of, or thought about, cropping up all around you. So …

You buy a car and suddenly it’s everywhere. That outfit you thought was so unique? Boom! Everyone is sporting it. How about the conversation you just had with your friend? You know, the one that was so stimulating and interesting? Now the subject is on everyone’s lips.

Depending on your level of self-esteem or degree of narcissism, Baader-Meinhof either leaves you feeling on the “cutting edge” of cultural trends or constantly lagging behind others. For me, it’s generally the latter. And recently, its a feeling that has been dogging me a fair bit.

The subject? Trauma.

Whether simple or complex, ongoing or one-off, experienced as a child or adult, trauma is the topic de jour — a cause célèbre linked to an ever-growing list of problems, including depression, anxiety, dissociation, insomnia, headaches, stomachaches, asthma, stroke, diabetes, and most recently, ADHD.

Then, of course, there are the offers for training. Is it just me or is trauma the subject of every other email solicitation, podcast announcement, and printed flyer?

The truth is our field has been here many times before. Over the last 25 years, depression, multiple personality disorder, rapid cycling bipolar disorder II, attention deficit disorder, and borderline personality disorder have all burst on the scene, enjoyed a period of intense professional interest, and then receded into the background.

Available evidence makes clear this pattern — aha, whoa, and hmm what’s next? — is far from benign. While identifying who is suffering and why is an important and noble endeavor, outcomes of mental healthcare have not improved over the last 40 years. What’s more, no evidence exists that training in treatment modalities specific to any particular diagnosis — the popularly-termed, “evidence-based” practices — improves effectiveness. Problematically, studies do show undergoing such training increases practitioner perception of enhanced competence (Neimeyer, Taylor, & Cox, 2012) .

On more than one occasion, I’ve witnessed advocates of particular treatment methods claim it’s unethical for a therapist to work with people who’ve experienced a trauma if they haven’t been trained in a specific “trauma-focused” approach. It’s a curious statement — one which, given the evidence, can only be meant to bully and shame practitioners into going along with the crowd. Data on the subject are clear and date back over a decade (1, 2, 3). In case of any doubt, a brand new review of the research, published in the journal Psychotherapy, concludes, “There are no clinically meaningful differences between … treatment methods for trauma … [including those] designed intentionally to omit components [believed essential to] effective treatments (viz., exposure, cognitive restructuring, and focus on trauma)” (p. 393).

If you find the results reported in the preceding paragraph confusing or unbelievable, recalling the “Baader-Meinhof” effect can be help. It reminds us that despite its current popularity in professional discourse, trauma and its treatment is nothing new. Truth is, therapists have always been helping those who’ve suffered its effects. More, while the field’s outcomes have not improved over time, studies of real world practitioners show they generally achieve results on par with those obtained in studies of so-called evidence-based treatments 1, 2, 3).

Of course, none of the foregoing means nothing can be done to improve our effectiveness. As my Swedish grandmother Stena used to say, “The room for improvement is the biggest one in our house!”

To get started, or fine tune your professional development efforts, listen in to an interview I did recently with Elizabeth Irias from Clearly Clinical (an approved provider of CEU’s for APA, NBCC, NAADAC, CCAPP, and CAMFT). Available here: What Every Therapist Needs To Know: Lessons From The Research, Ep. 61.

In it, I lay out several, concrete, evidence-based steps, practitioners can take to improve their therapeutic effectiveness. It’s FREE, plus you can earn a FREE hour of CE credit. Additionally, if follow them on Instagram and leave a comment on this post, you’ll be automatically entered into a contest for one year of free, unlimited continuing education — the winner to be announced on September 30th, 2019.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

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Responsiveness is “Job One” in Becoming a More Effective Therapist

June 28, 2019 By scottdm 4 Comments

Look at the picture to the left. What do you see?

In no time at all, most report a large face with deep set eyes and slight frown.

Actually, once seen, it’s difficult, if not impossible to unsee. Try it. Look away momentarily then back again.

Once set in motion, the process tends to take on a life of its own, with many other items coming into focus.

Do you see the ghostly hand? Skeletonized spine and rib cage? Other eyes and faces? A clown hat?

From an evolutionary perspective, the tendency to find patterns — be it in clouds, polished marble surfaces, burn marks on toast, or tea leaves in a cup — is easy to understand. For our earliest ancestors, seeing eyes in the underbrush, whether real or illusory, had obvious survival value. Whether or not the perceptions or predictions were accurate mattered less than the consequences of being wrong.

In short, we are hardwired to look for and find patterns. And, as researchers Foster and Kokko (2008) point out, “natural selection … favour[s] strategies that make many incorrect causal associations in order to establish those that are essential for survival …” (p. 36).

As proof of the tendency to draw incorrect causal associations, one need only look at the field’s most popular beliefs and practices, many of which, the evidence shows, have little or no relationship to outcome. These include:

Alas, all of the above, and more, are mere “faces in the clouds” — compelling to be sure, but more accurately seen as indicators of our desire to improve than reliable pathways to better results. They are not.

So, what, if anything, can we do to improve our effectiveness?

According to researchers Stiles and Horvath (2017), “Certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (p. 71).

Sounds good, right? The recommendation that one should “fit the therapy to the person” is as old as the profession. The challenge, of course, is knowing when to respond as well as whether any of the myriad “in-the-moment” adjustments we make in a given therapy hour actually help.

That is until now.

Consider a new study involving 100’s real world therapists and more than 10,000 of their clients (Brown and Cazauvielh, 2019). Intriguingly, the researchers found, therapists who were more “engaged” in formally seeking and utilizing feedback from their clients regarding progress and quality of care — as measured by the frequency with which they logged in to a computerized outcome management system to check their results — were significantly more effective.

How much, you ask?

Look at the graph above. With an effect size difference of .4 σ, the feedback-informed practitioners (green curve) were on average more effective than 70% of their less engaged, less responsive peers (the red).

Such findings confirm and extend results from another study I blogged about back in May documenting that feedback-informed treatment, or FIT, led to significant improvements in the quality and strength of the therapeutic alliance.

Why some choose to actively utilize feedback to inform and improve the quality and outcome of care, while others dutifully administer measurement scales but ignore the results is currently unknown — that is, scientifically. Could it really be that mysterious, however? Many of us have exercise equipment stuffed into closets bought in the moment but never used. In time, I suspect research will eventually point to the same factors responsible for implementation failures in other areas of life, both personal and professional (e.g., habit, lack of support, contextual barriers, etc.).

Until then, one thing we know helps is community. Having like-minded to interact with and share experiences makes a difference when it comes to staying on track. The International Center for Clinical Excellence is a free, social network with thousands of members around the world. Every day, practitioners, managers, and supervisors meet to address questions and provide support to one another in their efforts to implement feedback-informed treatment. Click on the link to connect today.

Still wanting more? Listen to my interview with Gay Barfield, Ph.D., a colleague of Carl Rogers, with whom she co-directed the Carl Rogers Institute for Peace –an organization that applied person-centered principles to real and potential international crisis situations, and for which Dr. Rogers was nominated for the Nobel Peace Prize in 1987. I know her words and being will inspire you to seek and use client feedback on a more regular basis…

OK, done for now,

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

P.S.: Registration for the Spring 2020 Advanced and Supervision Intensives is open! Both events sold out months in advance this year. Click on the icons below for more information or to register.
ICCE Fit Supervision Intensive 2020 Scott D Miller

What does losing your keys have in common with the treatment of trauma?

April 24, 2019 By scottdm 9 Comments

Last week, I was preparing to leave the house and could not locate my keys. Trust me when I say, it’s embarrassing to admit this is not an infrequent occurrence.

Logic and reason are always my first problem solving choices. That’s why I paused after looking in the kitchen drawer where I am supposed to keep them, along with my wallet and glasses, and found it empty. When did I last have them? Not finding them there, the “search” began.

Upstairs to the bedroom to check my pants pockets. No. Downstairs to the front closet to look in my coat. No. Back upstairs to the hamper in the laundry room. No. Once more, down the stairs to the kitchen hutch. I sometimes leave them there. This time, however, no. I then headed back up the stairs to the master bathroom — my pace now a bit frantic — and rummaged through my clothing. No. They’ve gotta be on my office desk. Down two flights of stairs to the basement. Not there either.

In a fit of pique, I stormed over to the landing, and yelled at the top of my voice, “DID SOMEONE TAKE MY KEYS?” the accusation barely concealed. Although my head knew this was nuts, my heart was certain it was true. They’ve hidden them!

“No,” my family members kindly reply, then ask, “Have you lost them again?”

“Arrgh,” I mutter under my breath. And that’s when I do something that, in hindsight, make no sense. I wonder if you do the same? Namely, I start the entire search over from the beginning — pants, coat, hamper, closet, hutch, office — often completing the exact same cycle several times. Pants, coat, hamper, closet, hutch, office. Pants, coat, hamper, closet, hutch, office. Pants, coat, hamper, closet, hutch, office.

I can’t explain the compulsion, other than, by this point, I’ve generally lost my mind. More, I can’t think of anything else do. My problem: I have somewhere to go! The solution: Keep looking (and it goes without saying, of course, in the same places).

(I did eventually locate my keys. More on that in a moment)

Yesterday, I was reminded of my experience while reading a newly released study on the treatment of trauma. Bear with me as I explain. Over a decade ago, I blogged about the U.S. Veteran’s Administration spending $25,000,000 aimed at “discover[ing] the best treatments for PTSD” despite a virtual mountain of evidence showing no difference in outcome between various therapy approaches.

Since that original post, the evidence documenting equivalence between competing methods has only increased (1, 2). The data are absolutely clear. Meta-analyses of studies in which two or more approaches intended to be therapeutic are directly compared, consistently find no difference in outcome between methods – importantly, whether the treatments are designated “trauma-focused” or not. More, other highly specialized studies – known as dismantling research – fail to provide any evidence for the belief that specialized treatments contain ingredients specifically remedial to the diagnosis! And yes, that includes the ingredient most believe essential to therapeutic success in the treatment of PTSD; namely, exposure (1, 2).

The new study confirms and extends such findings. Briefly, using data drawn from 39 V.A. treatment centers, researchers examined the relationship between outcome and the degree of adoption of two so-called “evidence-based,” trauma-informed psychotherapy approaches — prolonged exposure and cognitive processing therapy. If method mattered, of course, then a greater degree of adoption would be associated with better results. It was not. As the authors of the study conclude, “programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.”

So what happens now? If history, and my own behavior whenever I lose my keys, is any indication, we’ll start the process of looking all over again. Instead of accepting the key is not where we’ve been looking, the field will continue it’s search. After all, we have somewhere to go — and right back to the search for the next method, model, or treatment approach, we go.

It’s worse than that, actually, as looking over and again in the same place, keeps us from looking elsewhere. That’s how I generally find my keys. As simple and perhaps dumb as it sounds, I find them someplace I had not looked.

And where is the field not looking? As Norcross and Wampold point out in an article published this week, “relationships and responsiveness” are the key ingredients in successful psychological care for people who are suffering as a result of traumatic experiences, going on to say that the emphasis on model or method is actually harmful, as it “squanders a vital opportunity to identify what actually heals.”

Improving our ability to connect with and respond effectively to the diverse people we meet in therapy is the focus on Deliberate Practice Intensive, held this August in Chicago, Illinois. Unlike training in protocol-driven treatments, studies to date show learning the skills taught at the workshop result in steady improvements in clinicians’ facilitative interpersonal skills and outcomes commensurate with the rate of improvement seen in elite athletes. For more information or to register, click here.

Until next time,

Scott

Scott D. Miller, Ph.D.
International Center for Clinical Excellence