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
In sympathy as a recent and frequent loser/mis-placer of keys because of a radical change in workday schedule, I’ve discovered what causes it in my life: Putting the keys in a place that I don’t usually do, even if only for a few seconds, as on the top of the car, so to free a hand for a few seconds. One time I drove a few miles and discovered my keys when I got out. They were stuck in the rain runoff chute on the top of the car!
More serious response to follow.
You are a great communicator. Thanks for the update. We are swamped with Trauma Based Treatment ideas and everybody is tweeting, faceboooking, and suggesting we read Vander Kolk! I have and it essentially tells me to get another Doctorate because I am a stupid old guy that still tries to relate to people and listen carefully.
The warnings about doing more harm if we fail to get people’s eyes to flutter or don’t do YOGA with them.
Thanks for reinforcing my ideas and disabusing me of the abuse and trauma I received from the experts.
Will you EVER come to the Northwest????? Specifically, Boise, Idaho. Yes, really.
Scott and Colleagues
When I read some of the research on trauma I am reminded of the 5 Financial Newsletters I receive. These are most of top rated financial newsletters in the field and the writers are very experienced, very competent and very knowledgeable in their field. The massive data, graphs and tables etc, they have access to online is the same. Still they are very selective in what they report as they see things through very different lenses. So their interpretations of the financial data differs greatly and their recommendations are frequently quite different from each other. In there own way they are not just informing and educating but also trying to persuade the reader (me and others)) This is OK with me as I sort through these reports and integrate them in my own way. Then I decide what to do.
In the psychotherapy field it appears to be very similar. Same data available but different lenses and interpretations and attempts at persuasion. As long as it doesn’t get ‘political’ and involve attacks on other points of view I am OK with it. For example.
It is always good to go back to the original references.
Norcross and Wampold reference a number of meta-analysis of trauma based treatments.
The most recent is the 2016 meta analysis called:
The relative efficacy of bona fide psychotherapies for post-traumatic stress disorder: a meta-analytical evaluation of randomized controlled trials (2016)
by Ulrich S. Tran and Bettina Gregor
(BTW the so-called bona fide psychotherapies don’t include the more recent somatic therapies such as Sensorimotor Therapy,
Somatic Experiencing; Emotional Freedom Techniques and
Accelerated Resolution Therapy among others)
Reading the article online this morning I discovered that in fact prolonged exposure and exposure therapies did slightly outperform other approaches and specific trauma based therapies did outperform non specific trauma based therapies though again slightly compared for example to supportive, present-centered, problem-solving, and psycho-educative element oriented therapies.
This is not to say that “The therapeutic relationship and responsiveness/treatment adaptations don’t rightfully occupy a prominent, evidence-based place in any guidelines for the psychological treatment of trauma.” However it is not the whole picture.
Note that trauma focused therapies and exposure focused therapies did in fact come out ahead in the meta-analysis.
See below
BMC Psychiatry. 2016; 16: 266.
Published online 2016 Jul 26. doi: 10.1186/s12888-016-0979-2PMCID: PMC4962479PMID: 27460057
The relative efficacy of bona fide psychotherapies for post-traumatic stress disorder: a meta-analytical evaluation of randomized controlled trials (2016)
by Ulrich S. Tran and Bettina Gregor
Here are parts of their results, conclusions and description of types of treatments.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4962479/#
Results
Head-to-head comparison between trauma focused and non-trauma focused treatments revealed a small relative advantage for trauma focused treatments at post-treatment (Hedges’ g = 0.14) and at two follow-ups (g = 0.17, g = 0.23) regarding PTSD symptom severity. Controlling and adjusting for influential studies and publication bias, prolonged exposure and exposure therapies (g = 0.19) were slightly more efficacious than other therapies regarding PTSD symptom severity at post-treatment; prolonged exposure had also higher recovery rates (RR = 1.26). Present-centered therapies were slightly less efficacious regarding symptom severity at post-treatment (g = −0.20) and at follow-up (g = −0.17), but equally efficacious as available comparison treatments with regards to secondary outcomes. The improved omnibus test confirmed overall effect size heterogeneity.
Conclusions
Trauma focused treatments, prolonged exposure and exposure therapies were slightly more efficacious than other therapies in the treatment of PTSD. However, treatment differences were at most small and far below proposed thresholds of clinically meaningful differences. Previous null findings may have stemmed from not clearly differentiating primary and secondary outcomes, but also from a specific use of the omnibus test of overall effect size heterogeneity that appears to be prone to error. However, more high-quality studies using ITT analyses are still needed to draw firm conclusions. Moreover, the PTSD treatment field may need to move beyond a focus primarily on efficacy so as to address other important issues such as public health issues and the requirements of highly vulnerable populations.
*******
Types of Treatment
Types of treatment included in the analyses were: Exposure therapies (EX), prolonged exposure (PE [42]), and both combined (EXPE), EMDR [41], cognitive behavioural therapies (CBT), and present-centered therapies (PCT). PCT included bona fide psychotherapies that were mostly linked to elements of Roger’s client-centered psychotherapy [43] and encompassed supportive, present-centered, problemsolving, and psychoeducative elements. Treatments coded as CBT included some therapies that utilized, but did not primarily rely on, elements of other therapies (e.g., exposure [44, 45]), and treatments such as Seeking Safety [46] or Image Rehearsal [47].
All treatments were coded whether they were trauma focused (TF) or not (NTF). TF treatments were defined as focusing on the memory for the traumatic event and/or on trauma-related appraisals [12]. Najavits and Hien [48] recommended to name non-trauma focused therapies for what they are providing and not just to qualify them for what they are not providing. Nevertheless, we adhered to TF/NTF distinction as it is frequently used in this field of research. The TF/NTF distinction served to strictly compare two categories on the same level of abstraction and to address the question of whether trauma focused treatments were more efficacious than non-trauma focused ones. Again, treatment descriptions in studies were utilized as closely as possible to code whether treatments were trauma focused or not. Within the CBT category we also examined the efficacy specifically of trauma focused treatments that included elements of exposure (TFCBT + EX).
Many Blessings for Peace and Happiness
Phil
I appreciate your metaphor but disagree with implied conclusion (e.g., claims of no difference are mere examples of seeing what we wish to see). Truth is, regardless of what the studies show, we are all forced to make decisions under uncertainty. The question is, then, what’s best?
And the advocates of specific treatments for specific problems have long argued that certain methods work better than others. But, what does the long view suggest? Ultimately, to use your example, the recommendations of your newsletters prove either true or false. You could look at the track record of those making the predictions. Even then, however, as every prospectus says, “past performance is no guarantee of future performance.” In psychotherapy, the search for methods which work best for specific problems has been going on now for 40 years. The overall thrust of the findings is no difference, including the article you cite. Many would say, instead of chasing winning stocks (or, treatment models), you should follow principles (investing for the long term, or example), because at the individual level (whether client or stock), outcomes are largely random and unpredictable. Voila! Welcome to the world of psychotherapy. Outcomes are at the individual client level random. Using RCT’s that depend on the aggregate mean comparisons is a fools errand as it applies to the person then. So, what can a regular person do who has to make a decision under uncertainty? Follow established principles (e.g., relatively speaking, alliance is more important than specific treatment model. Therefore, spend time learning to improve your ability to connect and engage). As regards the specifics of the 2016 study cited, the issues are complex when it comes to making sense of such studies. The temptation is to focus on the conclusion section. One very important issue is ensuring that comparisons are fair. So, as in past studies, meta-analyses that compare a treatment focused on one particular issue (e.g., trauma) to a treatment that could include, as the present study did, “supportive, present-centered, problem solving, and psychoeducative elements,” are simply comparing apples to oranges. This is a matter that has been brought up again and again to those advocating specific approaches to no avail. Support is not treatment. Psychoeducation is not treatment. Present-centered therapy was a sham treatment that emerged from Foa’s RCT’s which our team in part worked to have included on the list of evidence-based practice to show the hollowness of the claims being made by those advancing particular treatment approaches. But let’s not miss the main point of the study cited, “treatment differences were at most small and far below proposed thresholds of clinically meaningful differences.” In other words, having a TF makes no clinically meaningful difference. When you compare the results to the claims of advocates, the latter fall serious short and border on unethical. Also, I love the authors final statement, which is what WOULD happen, IMHO, if the field stopped wasting precious time and resources in pursuit of the “Holy Grail” of specificity. To wit, advocates need to “move beyond a focus primarily on efficacy so as to address other important issues such as public health issues and the requirements of highly vulnerable populations.” In other words, how to we attend to the individual. Second, what is the best public policy as regards care for people who are suffering.
Hi Scott,
Firstly, congratulations on breaking the cycle that allowed you to find the keys.
Secondly, congratulations on writing such beautiful lines. Loved reading the whole story, and thirdly, where did you find the keys? What led you to look elsewhere.
Most importantly, how can others learn to slightly be more creative when looking for treatment solutions – instead of boringly (and harmfully as you alluded to in your writing..) repeating the cycle.
Interestingly, I was writing an essay (for psych major)…and surprise surprise, I actually found exactly what you were alluding to, to also be found in so many cognitive psych articles. But what do I know.
Thanks again. I hope you have a moment to read this. I really like what you write.
2 coAngel’s. The first:
Only One Shoe
by John Forster & Tom Chapin
© 2005 Limousine Music Co. & The Last Music Co. (ASCAP)
Mommy, oh Mommy, what can I do?
I want to go out and I can’t find my shoe!
Did you look in the closet? I didn’t. Well, do!
You’re not going out with only one shoe!
I’m here in the closet, it doesn’t look good,
One cross-country ski and your coat with a hood,
There’s jackets and racquets, a bottle of glue.
But Mommy, oh Mommy, I can’t find my shoe!
Did you look in the basement? I didn’t. Well, do!
You’re not going out with only one shoe!
I’m here in the basement. It’s dark and it’s damp.
A barbell, some lumber, an old skateboard ramp,
There’s hammers and chisels and screwdrivers too.
Lots of great stuff, Mom, but so far no shoe.
Did you look in the attic? No. Well, hurry, tout de suite!
You’re not going out without shoes on your feet!
I’m up in the attic. There’s some kind of nest,
Cobwebs and droppings, a dusty old chest,
And photos of Grandma and Grandpa and you.
Piles of clothes, but no trace of my shoe.
Oh me, what can I do? I haven’t got a clue.
It’s really discouraging, maddening too.
Where, oh where is my/your shoe?
Did you look in the living room? Look in the hall?
Look in the bathroom? I looked in them all!
Did you look everywhere? That’s what I said!
How ’bout your room? Under your bed?
I’m here in my room, under my bed.
There’s a beach ball, a snowsuit, an old bobble-head.
A few Reese’s Pieces, a stuffed kangaroo,
And Mommy, oh Mommy, I just found my shoe!
Isn’t it funny,
Whenever we lose a toy or a shoe or a book.
Though we turn every room in the house inside out,
It’s always the last place we look!
This song appears on Tom Chapin’s Some Assembly Required CD.
Return to Home Page
Send comments to info@tomchapin.com
© 1997 – 2015 Sundance Music Inc.
100 Cedar Street, Suite # B-19, Dobbs Ferry, NY 10522 (914) 674-0247
Second comment:
Regarding work on PTSD, if you work with veterans, it is worth your time to look up Betty Merritt at the Merritt Center in Payson Arizona. She pairs senior returned veterans with newly returned veterans in a for weekend program, free to the veterans paid for by donations. This is not a commercial for her program, but an invitation to research.
Best regards to all who do this work, the work of angels.
Historians may refer to this period of endless speculation about what makes psychotherapy effective, or most effective, as the Era of the Self-Inflicted Blind Spot.
The most common client experience is talking. I claim that the second most common experience is emotional experiencing, ranging from mild agitation, which doesn’t interfere with the client’s thinking, to deep sobbing. The Blind Spot is that our beloved profession has yet to understand clients’ emotional experiencing, and the more intense instances of it in particular.
Basic assumption (which took me years to formulate): There exists a natural healing process for psychological “injuries,” just as there is one for physical injuries/illnesses. Working definition of a psychological “injury:” It has a psychogenic cause; major problematic aspects cannot be significantly altered by a conscious act; unprocessed aspects are stored in a “frozen” state as an imprint.
Most effective treatment is my concept of therapeutic catharsis. It offers, I believe, the only criterion for differentiating a therapeutic emotional release from a non-therapeutic one. The criterion is the unforced activation of the client’s emotional experiencing; i.e., it arises coincident with clients receiving sufficient support for their experiencing. (The forced activation of emotional experiencing, which usually occurs outside of session – though it can occur in a session with a too insistent therapist – is seen when the client arrives in an existing upset state, is not therapeutic. Reason: too much unresolved stuff has been forced up, overloads the pain processing mechanisms, and results in a fight or flight response. All the therapist can do is listen supportively and allow the intense response to dissipate on its own.
The unforced activation of emotional experiencing is a delayed fight or flight response, or a sympathetic ANS response. It is the first sign that the healing process is getting into gear. It is controlled by the healing mechanisms in the nervous system. This phase has been mistakenly, though understandably, regarded as re-traumatizing. Despite appearances, that is simply not the case. If the therapist continues to offer sufficient support for the client’s experiencing, it will reach an intensity, determined by that person’s nervous system, and spontaneously and immediately transition to the healing, or parasympathetic, phase.
All sympathetic reactions immediately disappear. Freed of them, clients eagerly discuss their unprocessed experiencing from past hurtful events. Features of the healing phase are crying, indignation (preferred over anger) for objectively unfair/ unjust treatment, and clients arriving at their own understanding of the adverse effect of the past event(s), and which is typically more profound than any insight I could offer. Depending on the client’s psychological history, a healing response, or a sympathetic- parasympathetic autonomic nervous system sequence, can be as short as a minute or two, or take many minutes.
Notes on the history of catharsis. Freud and Breuer advocated abreaction, without operationalizing it. Rosenzweig (1936) mentioned catharsis as one of the four factors, without operationalizing it. In Rogers’ 1942 book, he wrote frequently and enthusiastically in favor of catharsis, (and without you know what) and didn’t do so after that. In Jerome Frank’s 1971 article in the American Journal of Psychotherapy (not available in PsycINFO) one of the therapeutic conditions, the first one I believe, is stated it as “an intense cathartic or emotional relationship with the therapist.” The point here is that in later writings he de-emphasized somewhat the catharsis aspect.
In the EMDR literature, there are many examples of client’s crying/sobbing. See in particular Shapiro’s 1989 article on a new treatment for trauma. Foa states that many clients in imaginal exposure – which is more easily therapist supported than in vivo exposure – cry deeply. An example from Energy Psychology: When the therapist finished tapping on the back of the girl’s hand (she was about 15) her deep sobbing had come to an end.
If one assumes a natural healing process for psychological “injuries,” the therapist is just a mid-wife. Someone who creates the conditions for a natural process to operate, which Rogers suggested in one his later writings. I would add a critical clarification to that idea. That is, in supporting the client’s experiencing – which includes the tacit or implicit dimension as that is where unresolved stuff first emerges into the client’s awareness – the therapist does so without – at least ideally – distracting the client from her/his sense of his/her experiencing.
This is absolutely critical! It takes the most concentration and all kinds of nonverbal support; i.e., facial expression, slight forward lean, tone of voice, all in support of the words that speak to what the client’s last words implied but was left unsaid.
We all know from ordinary conversation what it’s like for a listener to misinterpret what we are saying. We can easily disregard the sudden intrusion. Client’s cannot do that! They may act as it they weren’t upset by the unexpected intrusion (see research by David Rennie), but that’s not the case. It does not take much to force a client to be guarded in what they reveal.
My view of the role of the therapist, and in particular with a client who has a psychological injury. It’s just you and me, with nothing in between, including any theory that says what you must be experiencing and what I’m supposed to do, beyond supporting the client’s experiencing.
Fascinating thoughts! Thanks so much for writing/sharing…..