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

Mountains and Molehills, or What the JFK Assasination and the Therapeutic Relationship have in Common?

April 14, 2019 By scottdm 5 Comments

Over the last 10 days or so, I’ve been digesting a recently published article on the therapeutic alliance — reading, highlighting, tracking down references, rereading, and then discussing the reported findings with colleagues and a peer group of fellow researchers. It’s what I do.

The particular study has been on my “to be read” pile for the better part of a year, maybe more. Provocatively titled, “Is the Alliance Really Therapeutic?” it promises to answer the question in light of “recent methodological advances.”

I know this will sound strange — at least at first — but throughout, I kept finding myself thinking of the assasination of the 35th President of the United States, John F. Kennedy. Bear with me as I explain.

I personally remember the shock and grief of this event. Although I was only six years old at the time, I have vivid memories, watching televised segments of the funeral procession down Pennsylvania Avenue under a grey, overcast and rainy sky. “Why?” my family and the Nation asked, and “How?”

You likely know the rest of the story. Within hours, a suspect was arrested. Two days later, he was murdered on live TV by a Dallas nightclub owner. Ever since, events surrounding the assasination have been the subject of heated debate. More than 2,000 books have been published, each offering a different theory of the event — a veritable “Who’s who” of suspects, including but not limited to the Soviet Union, CIA, Mafia, Cuban government, and Vice President of the United States.

Whatever you might believe, it’s hard to fault the majority of Americans — 61% in the most recent polls — who seriously doubt that the slight, unemployed, thrice court-martialed former marine, acted alone. To many, in fact, it’s simply inconceivable. And, that’s the point. As investigative reporter, Gerald Posner, observed in his book Case Closed, “The notion that a misguided sociopath … wreaked such havoc [makes] the crime seem senseless” (p. xviii). By contrast, concluding there was an elaborate plot involving important and powerful people, embues Kennedy’s death with meaning equal to his stature and significance in the mind of the public.

Said another way, maybe, just maybe, in our attempts to reconcile the facts with our feelings, we made a molehill into a mountain … which brings me back to the article about the therapeutic relationship. The empirical evidence is clear: the quality of the alliance between client and clinician is one of the most potent and reliable predictors of successful psychotherapy.

According to the most recent and thorough review of the empirical literature:

Better alliances result in better outcomes when working with individuals, groups, couples and families, children and adolescents, and mandated/involuntary clients;
With regard to specific qualities, better outcomes result the more therapists:
- Like, value, and care for the client (known as the “real” relationship, it contributes more to outcome than relational elements associated with the doing of therapy. Effect Size [E.S.] ~ .80 );
- Communicate their understanding of and compassion for the client (E.S. ~ .58);
- Collaborate with the client regarding the focus (e.g., problem) and goals for treatment (E.S. ~ .49);
- Present as accessible, approachable, and sincere (i.e., congruent and genuine, E.S. ~ .46)
- Demonstrate respect, warmth, and positive regard (E.S. ~ .36);
- Seek and utilize formal feedback regarding the client’s experience of progress and the therapeutic alliance (E.S. ~ .33 – .49);
- Express emotions and generate hope and expectancy of positive results (E.S. = .56 & .36, respectively).

Sounds pretty straightforward and simple to me. In a relatively efficient fashion (worldwide the average number of visits is around 5 visits), we establish relationships with people that result in significant improvements in their well being. With regard to the latter, as reviewed many times on my blog, the average recipient of psychotherapy is better off than 80% of those with similar problems that do not.

That said, is the relationship we offer people so astounding that it forever changes them? Judging by the article’s dense language and near inpenetrable statistical procedures, you’d assume so. Yet ultimately, it fails to show as much, focusing instead on defining characteristics and qualities of clients amenable to a particular theoretical orientation rather than the relationship.

Now, before you object, please note, I did not say relationships — in life or in therapy — were easy. But therein lies the risk. Challenging or difficult (e.g., a lone gunman taking out a beloved and powerful figure) is equated with complicated (i.e., must have been a conspiracy). Add to that the tendency of professionals to embue their interactions with clients with life-changing significance and voila! we are poised, as a field, to make mountains out of molehills. Nowhere is this more easy to see than in the language we use to describe our work. We “treat,” have “countertransference reactions,” “repair ruptures,” and form “therapeutic alliances” rather than connect, experience frustration (or other feelings), and develop relationships.

It’s time to embrace what 50 years of evidence plainly shows: yes, we offer an important service, an opportunity for someone to feel understood, get support while going through a difficult period, solve problems, learn new and different ways for approaching life’s challenges, and every once in a while –maybe one in a hundred — something more. To do that, what’s needed is humility and a relentless focus on the fundamentals. Given the history of our field, that alone will prove hard enough.

Embracing the evidence and focusing on fundamentals is precisely what we’ll be doing, by the way, at the Deliberate Practice Intensive this summer coming August in Chicago. Join colleagues from around the world to learn how to use this simple (not easy) way for improving your effectiveness! For more info, click here or on the banner below.

Until next time,

Scott

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

It’s Time to Abandon the “Mean” in Psychotherapy Practice and Research

April 8, 2019 By scottdm 7 Comments

Recognize this? Yours will likely look at bit different. If you drive an expensive car, it may be motorized, with buttons automatically set to your preferences. All, however, serve the same purpose.

Got it?

It’s the lever for adjusting your car seat.

I’m betting you’re not impressed. Believe it or not though, this little device was once considered an amazing innovation — a piece of equipment so disruptive manufacturers balked at producing it, citing “engineering challenges” and fear of cost overruns.

For decades, seats in cars came in a fixed position. You could not move them forward or back. For that matter, the same was the case with seats in the cockpits of airplanes. The result? Many dead drivers and pilots.

The military actually spent loads of time and money during the 1940’s and 50’s looking for the source of the problem. Why, they wondered, were so many planes crashing? Investigators were baffled.

Every detail was checked and rechecked. Electronic and mechanical systems tested out. Pilot training was reviewed and deemed exceptional. Systematic review of accidents ruled out human error. Finally, the equipment was examined. Nothing, it was determined, could not have been more carefully designed — the size and shape of the seat, distance to the controls, even the shape of the helmet, were based on measurements of 140 dimensions of 4,000 pilots (e.g., thumb length, hand size, waist circumference, crotch height, distance from eye to ear, etc.).

It was not until a young lieutenant, Gilbert S. Daniels, intervened that the problem was solved. Turns out, despite of the careful measurements, no pilot fit the average of the various dimensions used to design the cockpit and flight equipment. Indeed, his study found, even when “the average” was defined as the middle 30 percent of the range of values on any given indice, no actual pilot fell within the range!

The conclusion was as obvious as it was radical. Instead of fitting pilot into planes, planes needed to be designed to fit pilots. Voila! The adjustable seat was born.

Now, before you scoff — wisecracking, perhaps, about “military intelligence” being the worst kind of oxymoron — beware. The very same “averagarianism” that gripped leaders and engineers in the armed services is still in full swing today in the field of mental health.

Perhaps the best example is the randomized controlled trial (RCT) — deemed the “gold standard” for identifying “best practices” by professional bodies, research scientists, and governmental regulatory bodies.

However sophisticated the statistical procedures may appear to the non-mathematically inclined, they are nothing more than mean comparisons.

Briefly, participants are recruited and then randomly assigned to one of two groups (e.g., Treatment A or a Control group; Treatment A or Treatment as Usual; and more rarely, Treatment A versus Treatment B). A measure of some kind is administered to everyone in both groups at the beginning and the end of the study. Should the mean response of one group prove statistically greater than the other, that particular treatment is deemed “empirically supported” and recommended for all.

The flaw in this logic is hopefully obvious: no individual fits the average. More, as any researcher will tell you, the variability between individuals within groups is most often greater than variability between groups being compared.

Bottom line: instead of fitting people into treatments, mental health care should be to made to fit the person. Doing so is referred to, in the psychotherapy outcome literature, as responsiveness — that is, “doing the right thing at the right time with the right person.” And while the subject receives far less attention in professional discourse and practice than diagnostic-specific treatment packages, evidence indicates it accounts for why, “certain therapists are more effective than others…” (p. 71, Stiles & Horvath, 2017).

I’m guessing you’ll agree it’s time for the field to make an “adjustment lever” a core standard of therapeutic practice — I’ll bet it’s what you try to do with the people you care for anyway.

Turns out, a method exists that can aid in our efforts to adjust services to the individual client. It involves routinely and formally soliciting feedback from the people we treat. That said, not all feedback is created equal. With a few notable exceptions, all routine outcome monitoring systems (ROM) in use today suffer from the same problem that dogs the rest of the field. In particular, all generate feedback by comparing the individual client to an index of change based on an average of a large sample (e.g., reliable change index, median response of an entire sample).

By contrast, three computerized outcome monitoring systems use cutting edge technology to provide feedback about progress and the quality of the therapeutic alliance unique to the individual client. Together, they represent a small step in providing an evidence-based alternative to the “mean” approaches traditionally used in psychotherapy practice and research.

Interested in your thoughts,

Scott

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

PS: Want to learn more? Join me and colleagues from around the world for any or all three, intensive workshops being offered this August in Chicago, IL (USA).

The FIT Implementation Intensive: the only workshop in the US to provide an in depth training in the evidence-based steps for successful integration of Feedback Informed Treatment (FIT) into your agency or clinical practice.
The Training of Trainers: a 3-day workshop aimed at enhancing your presentation and training skills.
The Deliberate Practice Intensive: a 2-day training on using deliberate practice to improve your clinical effectiveness.

Click on the title of the workshop for more information or to register.