The importance of context: Bread and Jam for Frances and the Culture of the Cockpit

Over the past few decades the focus of psychotherapy increasingly returned to its emphasis on the internal state of the individual. While psychoanalysis focused on unconscious processes newer models emphasize a focus on thoughts, (such as Acceptance and Commitment therapy), management of emotions/self-regulation (such as DBT and Mindfulness), and even on neurobiological differences. While much has been gained from these new models they have the unintended consequence of narrowing our focus to the individual, and neglecting the context or structure that influences the individual.

I was reminded of this unfortunate narrowing by two very different sources. First, I just finished reading Michael Lewis’ excellent new book, The Undoing Project,  on the work of Amos Tversky and Daniel Kahneman, two psychologists whose work have challenged many of the basic assumptions held by psychologists, economists and others (though there work has never explicitly address issues of therapy). Second, I recently held a series of sessions with a young boy and his parents regarding the boy’s food refusal (specifically, he refused to eat any but an extremely narrow range of foods, but if served these would readily eat them).

A summary of Tversky’s thoughts on the importance of context in understanding behavior:

Lewis relates how Tversky was asked to consult with Delta airlines regarding a pattern of pilot error that worried the airlines in the 1980s. Airlines efforts reported all efforts to work with pilots on their decision making had not lessened the problem.  Tversky’s input was that the structure or organization of the flight crew was the issue. He noticed how the culture of the cockpit was such that pilots were never questioned and their decisions were always deferred to (i.e., crew members failed/were afraid to speak up) when the new the pilot was making a poor decision.  The airline reportedly implemented changes that changed the culture of the cockpit, i.e., encouraged others to speak up and question the pilot’s decisions when they had concerns. This change greatly reduced error.    

The clinical example is as follows:

The well-meaning parents detailed how they repeatedly had tried to induce their son to try other foods and be more flexible. Their efforts ranged from well-defined reward systems for trying new foods, to punishments for not trying new food, and lengthy lectures (from them and medical personnel) on the importance of nutrition. They reported considering a recommendation to go to an occupational therapist who did “food therapy” that involved having children purportedly become comfortable with different foods by playing with the foods. This psychologist was able to prevail upon the parents to let the boy eat what he wanted, to simply serve him the food he preferred and make this issue a non-issue. The parents proceeded, after some struggle, to implement this approach, and over time the child voluntarily tried new foods (in a developmentally appropriate fashion).  Rather than changing the child, the parents changed the structure or context. For the record, strategic therapists have been recommending these approaches for years (see the work of Cloe Madanes, and Paul Watzlawick and his colleagues). Moreover, wise parents and adults have used “reverse psychology” for years. Perhaps the best illustration of this in the classic children’s book, “Bread and Jam for Frances” about a picky badger who only eats bread and jam until her parents allow her to only eat bread and jam at every meal.

The point: we need to remember to look beyond the individual to understand the behavior of the individual. This adage is obvious, when we stop to reflect on it, but all too often we lose sight of this wisdom and focus on the inner workings of the individual when the context is the key.

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What makes for great psychotherapists? Practice versus Talent

What makes for great psychotherapists? Practice versus Talent

Earlier today (11/20/16) I had the good fortunate to listen to the Freakonomics Radio Hour on NPR, which featured a discussion between the show’s host, Stephen Dubner, and the psychologist, K. Anders Ericsson, a professor of psychology at Florida State University in Tallahassee, Florida. Ericcson’s work has focused on how one achieves excellence. It is his thesis that “deliberate practice” is the key to developing excellence, in almost any field. Ericcson’s argument that focused practice, in which one works to strengthen and develops specific skills, is the key to achieving excellence. Ericcson stresses that experience, hours of doing something is not equivalent to deliberate or focused practice. In fact, he cites research which supports this thesis simply doing more of something does not make one better. He provided the example that more experienced physicians were no better at detecting problematic heart beats, on routine exam, than less experienced physicians, and that in fact the more experienced physicians might be less adept at this. A more germane example for therapists would be research cited by Scott Miller showing that more experienced clinicians simply become more proficient at doing what they normally do, not more effective in terms of patient outcome (helping clients feel better and accomplish their treatment goals).

What made this show particularly engaging was that Dubner also interviewed Malcom Gladwell, the author of “Outliers”, which examined the question why certain people excel in their given field. Gladwell argued that while the role of practice is critical, and that Ericcson has made a seminal contribution, that Ericsson has overstated his case, and that focused practiced will not lead to excellence, without talent. Gladwell discussed the “10,000 hour rule” which he highlights in his book, reiterating his main point, that while extensive practice is critical to developing excellence, that talent is essential to the development of excellence in a given field.

How does all of this apply to psychotherapy? My first reaction was that the application may be less relevant, given that psychotherapy is an interactive task, unlike composing music or playing a musical instrument. However, this argument is likely faulty in that many other skills or areas expertise cited by Ericcson are obviously interactive, from chess master to star athlete. My second reaction was that focused practice might be more challenging for therapists, in that psychotherapy has always emphasized the “sanctity” i.e., the privacy, of the therapeutic hour, and Ericcson and Dubner both noted that focused practice requires feedback from experts, to help craft and focus one’s skill development. While clearly not an insurmountable obstacle (therapists have audio and videotaped sessions when in training for decades) professional development and training programs typically often do not emphasize this type experience (do not utilized review of sessions as a central component of training). Finally, psychotherapy appears to have developed a culture that may be inimical to the ethos of focused or deliberate practice, which requires a critical and challenging examination of one’s performance. While this type of challenging approach is common in athletics and the arts, training in psychotherapy seems to have moved in the opposite direction, in which a critical and focused assessment of performance is not normative. Thus, a challenge to the field may be to reconsider our models of training, to include more of the critical ethos that is more typically associated with medical residencies.

The sixty four thousand dollar question remains unanswered: are great therapists born or made? Is there a certain amount of talent (empathy, adeptness in reading social cues, and so forth) that one is born with that is essential to becoming an excellent clinician or can one be trained/practice his/her way to greatness. While most people would argue that in the performing arts and athletics that talent is critical, that this suggestion in professional fields is not accepted so readily. Scott Miller and his colleagues have repeatedly argued that practice and feedback are keys to becoming an exceptional therapist, but their work begs the question: is a certain level of talent plus practice necessary, or is practice alone sufficient? While attempting to answer the chicken versus the egg question of talent versus focused practice, it is clear that we can all better develop our skills by seeking to incorporate focused practice into our professional development.

 

For more on these issues please consider:

1)      The Freakonomics podcast “How to become great at almost anything” at http://freakonomics.com/podcast/peak/  (from April 2016)

2)    Outliers: The Story of Success by Malcolm Gladwell

3)      Psychological Review 1993, Vol. 100. No. 3, 363-406. The Role of Deliberate Practice in the Acquisition of Expert Performance K. Anders Ericsson, Ralf Th. Krampe, and Clemens Tesch-Romer. Available at: http://projects.ict.usc.edu/itw/gel/EricssonDeliberatePracticePR93.PDF

4)      Scott Miller’s article, “Achieving Excellence” in the Psychotherapy Networker,  as well as more on this issue by Miller, at his blog: http://blog.myoutcomes.com/scott-miller-achieving-clinical-excellence/, and at http://scottdmiller.com/wp-content/uploads/2012/11/Achieving-Clinical-Excellence-Handouts-2013.pdf

 

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Therapist Concerns and the Interface with Clinical Issues

Therapist Concerns and the Interface with Clinical Issues

October 2016

In the fall of 2015 I had the privilege of participating in a panel discussion with other members of the Illinois Psychological Association’s Ethics Committee, at the Illinois Psychological Association’s annual conference. The panel consisted of a number of experienced psychologists and an attorney specializing in mental health law. The focus of our discussion was on how personal issues that the therapist may have in his or her life impact/interface with concerns that clients are seeking assistance for. The panelists discussed a number of examples of these issues ranging from: therapists struggling with parenting issues with their own children to therapists facing issues of aging and health concerns to therapists struggling with relationship problems, who encountered clients struggling with similar issues.

The challenge identified by several of the panelists was how to keep their personal values from impacting their responses to their clients.  This is often an issue in parenting decision making. Panelist and audience members discussed how our family values influence our reactions to parenting struggles our clients may face. Examples of this ranged from what (if any) video games to let younger children play to appropriate rules on dating and sexual behavior, with adolescents. Similarly, work with couples can be quite challenging for therapists who are struggling with their own relationship issues, or if therapists encounter families whose values/lifestyle are quite different than the therapist’s.

One other challenge that was identified by the panel was how much, if at all, should therapists share about their own life challenges. There was some difference of opinion on this, but panelist agreed that the decision to share personal information needs to be evaluated carefully.  Risks of sharing one’s personal issues with a client included: the risk of clients perceiving the therapist’s story as an implying how the client should react/manage the challenges he or she is facing; and the risk that the client may view the therapist’s sharing as the therapist using the therapy hour to meet his or her own needs, rather than focusing on those of the client.

The panelist did not offer specific rules or guidelines, but instead focused on  highlighting that clinicians need to be sensitive to how our concerns and values can influence how we view and react to our clients. Therapists were encouraged to be particularly aware of this dynamic, and to not minimize its’ impact, even on seasoned clinicians.

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Couples at an Impasse: Changing Therapists versus Changing Treatment Modality

Recently I have had two clients referred to me for individual therapy, by therapists who had worked with the client and his/her spouse in couples’ therapy. In both instances the referring therapists explained that the clients had “individual issues” which “needed” to addressed in order for the client to be able to work on their relational issues. Both therapists stressed that the couples’ therapies were not proceeding well: in one instance the spouses were extremely hostile towards each other, while in the other instance the therapist identified how one of the partners had issues stemming from his childhood that needed to worked through in order for the client to effectively participate in marital therapy (the therapist planned to work with this individual and referred the spouse to me for individual therapy).

However, when I met with each of the individual clients both described the primary source of their problems as their relationships. One client, detailed how he was very upset by how his partner treated him: called him names, did not help at home, and was generally inconsiderate. He reported thinking, at times, that he might be “a little depressed” but he clearly stated that the main source of his upset was his relationship and how he was treated. Similarly, the second client detailed how she was very upset by the state of her marriage. She reported that her husband berates her over little things (no physical violence), accuses her of having anger problems, and will not be sexually intimate with her. She acknowledged that she does have “issues” of her own. Specifically, she noted that she does get angry (verbally) with her partner and will yell at him when she is being yelled at. While she detailed childhood issues with her father she stressed that her primary concern was the deplorable state of her marriage.

In both instances the clients who had been referred for individual therapy expressed confusion about the referral and made comments that raised questions about the appropriateness of individual therapy.  The male client stated that his partner only would go for individual therapy if he went as well, and that he was coming for therapy in hopes that his partner would go to therapy and work on her issues. In the case of the female client, she expressed confusion about the referral for individual therapy. She talked about how she and her partner had argued quite angrily in the couple’s sessions, particularly just prior to the referral, but noted that she wanted to work on the couples’ issues.  The therapist who referred the later client did state, when making the referral, that the therapist did not think that the couple could talk productively in co-joint sessions.

Clearly, how therapists proceed, the modality we each choose, is influenced/dictated by our treatment model/approach, personal beliefs, and assumptions about human nature.  My systems approach leads me to involve spouses, partners and family members in treatment, and focus on patterns of interaction/current relational issues. More individually oriented therapists focus on the individual: patterns of thinking for CBT therapists, values and self-regulation for ACT therapists, past trauma and lost for Trauma Informed therapists, and history and past experiences (particularly relational) for more psychodynamic therapists, and so on.

However, when considering which treatment approach to utilize/recommend it also behooves us to take into account clients’ needs and preferences. The issue of preference should also be paramount when considering or recommending a change in modalities, particularly if this recommendation is coming from the therapist rather than being requested by the client. Therapists need to ask themselves: why am I recommending the change in modalities, is the modality or my ability to effectively work with this client/clients the problem, how will the clients experience a recommendation for a change in approach?  Clients may feel rejected or abandoned if therapists recommend a change in modality. In the case of the male client, he noted that his wife had said “you’re abandoning us” when the therapist referred each of them to individual therapy. Moreover, clients may interpret such referrals as meaning that their marriage is not workable or viable.

When couples therapy is not progressing/when couples are at an impasse we need to be open to the idea that changing modalities may not always be the best option. Obviously, there are cases where this would be true, such as one spouse having an untreated and active addiction, or one spouse continuing an affair. However, in most instances it would seem more appropriate to discuss the lack of progress with the couple and to evaluate our own ability to effectively assist a given couple.  It is quite possible that changing clinicians may be a better option than changing modalities. It also is critical to discuss the lack of progress with clients, as such a discussion may help clients address their lack of progress more effectively, i.e., identify what else they need from therapy and the sources of their difficulties making progress.

The research on psychotherapy outcome strongly supports the idea of finding the approach and therapist that best fits for a client rather than trying to fit the client to a school of therapy. The issue of best fit is particularly salient for couples therapy as this type of therapy is often extremely challenging. While it is difficult for most of us to acknowledge when we are not helping a given client (individual, family or couple) we need to be aware of the fact that no one helps everyone. Being open to discussing impasses in treatment, and even considering a different therapist as an option, will likely benefit the couples we work with more than trying to push them to work on issues that are not salient to them, at the time.

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Challenges to Coordinating Care in the age of “Integrated Care”

For those who regularly follow the news on health care the push for “integration” is one of the most frequently highlighted issues.  The Affordable Care Act calls for and mandates greater integration of services.  Moreover, professional organizations and insurance companies have been advocating for greater integration of care for some time. Part of this push for integration is an emphasis on greater communication and sharing of information between treatment providers.  Most clinicians have received communications from insurance companies requesting that we coordinate care with our clients’ physicians.  More recently, professional organizations have been advocating for greater integration of services. The American Psychological Association (and locally, the Illinois Psychological Association) have been very strong proponents of integrating care.  What stands out about the calls for greater integration is the seeming lack of concern about unanticipated negative consequences of such efforts and the emphasis on the value of such efforts. At a recent panel discussion at the November, 2015 Illinois Psychological Association, one presenter identified the only risk of integrated care as being that it is not occurring rapidly enough.

We at the Centers for Family Change have recognized and stressed the value of coordinating our treatment efforts with others (school personnel, physicians, EAP staff, and other professionals) since our inception.  Several of our founders were trained in Community Mental Health, which stressed the importance of coordinated treatment efforts. However, we have and continue to strive to be sensitive to the benefits and risks of coordinating and integrating care.  Specifically, while increased communication between clinicians, school personnel, physicians, and EAP staff frequently allows for improved quality of care, there are risks to such communication. These include: increased risk that confidential information will be released or that more information than necessary will be released/shared with others, compromising clients’ privacy; a possible devaluing of rights to privacy (e.g., some therapy clients do not want their information shared with others); and a danger that the integrity of psychotherapy will be compromised if clients have to be concerned about who may access their records (we need to remember that one of the foundations of therapy is that it is a safe and protected place to share one’s most personal thoughts, feelings and experiences).

We have to keep in mind that there are instances where it likely more appropriate to not share information. For example, a couple seeking marital therapy may not want their issues shared with their primary care physician, particularly when they are not experiencing physical symptoms and have had limited interactions with their physicians. Other examples, include families that decline to share information about their child with school personnel, when the child is not having problems within the school setting. Moreover, there may be an insidious impact on requiring the sharing of information. Individuals may become more guarded in therapy and thus limit the efficacy of therapy.

We are the Centers for Family Change are continuing to do our best to balance the competing pressures for integration and sharing of information, with a respect for our clients’ privacy and the importance of maintaining therapy as a private and safe place for our clients. Specifically, we have found that the most effective strategy is to openly address and discuss these issues and challenges with our clients and to decide collaboratively with our clients when and what information they want shared. Not only is this process more respectful to clients, but it offers an opportunity to help our clients examine and consider their understanding of the concerns and problems involved in sharing and not sharing information.  Obviously, we are aware that there are a few instances when the refusal to share information may be problematic. If we believe that this may be the case we raise and address these issues with our clients. It is our experience that some concerns stem from unrealistic fears (e.g., that school personnel want to “railroad our child”). In these instances we try and address our clients’ concerns (and the fears that may underlie their hesitation to share information) while also being clear regarding the potential negative impact of not sharing information when this clearly is called for, e.g., to physicians prescribing psychiatric medications, to school personnel working with children who are struggling in school and at home, and with EAP professionals working with clients whose work place has mandated their treatment. Unfortunately, there are a few instances in which clients resist sharing information, e.g., a client who is abusing his/her prescription medications. In these instances we will more directly confront these issues and evaluate the appropriateness of continuing treatment.

Clearly, the issues of integration and coordinated care are going to remain a challenge for all of us. An additional component of integrated care involves electronic records. Electronic record keeping systems pose a particularly daunting and complex issue that is beyond the scope of this short article, but given their increased prominence in the integration of care the risks associated with electronic record keeping need to be carefully evaluated. In closing, it behooves all of us to be cognizant of the challenges that sharing of information pose. While sharing of information and coordination of care are often valuable we need to carefully consider the potential risks and negative consequences that may occur when we share our clients private and personal information.

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Improving Effectiveness with an Integrative Approach to doing Therapy

A few weeks ago I attended an all day workshop on the Integrative Problem Centered Metaframeworks  (IPCM) approach to therapy (1).  This workshop  activated my thinking about how to improve effectiveness in therapy, an issue I have been delving into more fully in the past year. Specifically, the IPCM model offers an approach to therapy which should improve effectiveness because it is problem focused, parsimonious, and utilizes client feedback.

The IPCM model is an integration itself: of Bill Pinsoff’s Integrative Problem Centered Therapy (2) and Doug Breunlin’s, Dick Schwartz’s and Betty Karrer’s Metaframeworks approach (3).  Both Pinsoff and Bruenlin et al have argued that an integrative model, a model which guides therapists on when and how to intervene is the most efficacious approach to therapy.  Rather than arguing for a specific approach to therapy, e.g., my model is the best approach, the IPCM model advocates for a parsimonious and problem focused approach to therapy. Specifically, in the IPCM approach to therapy, the therapist initially utilizes the most straightforward methods and strategies for helping clients solve their problems, and only takes more in-depth and intensive approaches when more straightforward problem focused efforts have not succeed.  For example, if parents present for therapy with a child who is have a variety of behavior problems the IPCM model would recommend the use of behavioral or family therapy approaches which take a here and now problem focused approached, i.e.,  offer parents specific strategies and assistance on how to more effectively manage and resolve the child’s behavior problems.   Only if these strategies/interventions were not helpful would therapists take more in-depth and expanded approaches, e.g., ranging from addressing family of origin issues to examining the values and beliefs of individual family members.

The IPCM model is also feedback driven and focused on the therapeutic alliance. Therapists routinely solicit and review feedback (rating scales) completed by clients to assess client progress and concerns, and to monitor the therapeutic alliance. Thus, the IPCM model is congruent with the extensive  research of  Scott Miller and his colleagues, Michael Lambert, and John Norcross which stresses the importance of client feedback and the therapeutic alliance as key ingredients for successful therapy.

Finally, the IPCM model is a systems model. The model not only argues that we start by taking a straightforward here and now approach to problems, but that we also try and include the client’s significant others (parents, children, spouses, partners) in the therapy process. The advocates of the IPCM model persuasively argues that by including client’s parents, spouses and family in therapy that we can improve effectiveness. The argument is both theoretical, i.e., that family members will react to changes the client makes and that their support of these changes will help strengthen the client’s effort to change (and ignoring their negative reactions will undermine therapeutic efficacy, including the therapeutic alliance), and research based (citing data that support that treatment of individual problems such as anxiety, have better outcomes when family members are involved in the treatment).

Any brief discussion of a complex model, like the IPCM model, cannot do justice to the complexities and richness of the IPCM model.  Rather my goal here is to encourage readers of this blog to consider this model, as its integrative approach appears to offer therapist an organized approach to improving effectiveness.

However, before closing there are some caveats to my recommendation of the IPCM model: (1) its complexity can be daunting; (2) its efforts to be all inclusive are its strength and its weakness; trying to take into account all variables that possibly impact clients from a biological, psychological, familial, societal, to spiritual could be overwhelming and confusing; (3) to successfully use the model a therapist would need to either be adept in using multiple approaches, and/or being willing to refer to other colleagues who use such approaches; (4) the choice points for when to switch models/approach versus persist with one’s approach, appear to be left more to therapist discretion, which runs the risk of clinicians prematurely abandoning their interventions (or conversely sticking with unsuccessful strategies); and (5) there does not appear to be solid empirical data supporting the efficacy of the IPCM model over other approaches. The last point is particularly critical because of the increasingly consistent data stressing the importance of the therapeutic alliance and client feedback above all other variables in determining therapy outcome. Thus, before a compelling case for using the IPCM or other integrative models can be made there should be more evidence to support their efficacy relative to feedback informed treatment (as it may be that the feedback component is the critical factor and not the other aspects of the IPCM approach).

In closing, I would recommend and encourage therapists to learn about the IPCM model.  Many of its components have been shown to be related to improved efficacy, and it provides a valuable heuristic for thinking about how to be a more effective therapist.

1. Breunlin, D., Pinsof, W., Russell, W., Lebow, J., & Burgoyne, N. Integrative Problem Centered Metaframeworks (IPCM), Illinois Association of Marriage and Family Therapy, March 6, 2015.

(2) Breunlin, D.C., Schwartz, R.C., & MacKune-Karrer, B.M., Metaframeworks: Transcending the models of Family Therapy. Jossey-Bass, San Francisco, 1992.

(3) Pinsof, W.M., Integrative problem centered therapy: A synthesis of biological, individual and family therapies. Basic Books, New York, 1995.

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Some thoughts on Andrew Solomon’s “Far From the Tree: Parents, Children and the Search for Identity”

Far From the Tree: Parents, Children and the Search for Identity 

 by Andrew Solomon

                 How do parents understand, accept, nurture, value, support and cope  with children who are different from them? Are conditions we may normally think of as handicaps really unique and different types of identities that need to be respected and appreciated? Would we lose something as a society if these conditions vanished? These questions are at the heart of Andrew Solomon’s new book. Solomon delineates the challenges that children who are fundamentally different from their parents pose to families. Solomon interposes personal stories of families who have struggled with their child’s differentness/handicaps and, wrestled with the question of whether to try and normalize their child or at least help their child overcome their differentness as much as possible,  with more abstract discussion of the conditions that make children significant different from their parents (Autism, Deafness, Transgender, Down’s Syndrome and others) and the challenges and variations associated with these conditions or different ways of being.  For example, when discussing Dwarfs Solomon contrasts those who have attempted to cure their child’s short stature with those who have accepted and supported their child’s identity as and participation in Dwarf culture.  Similarly, he examines the tensions parents of the Deaf face: whether to allow and/or facilitate their child’s involvement in the Deaf Community, become part of Deaf culture, versus trying to cure their child’s deafness with cochlear implants.

Solomon examines conditions we would normally think of as handicaps, and questions whether these conditions are really handicaps or alternative identities.  This argument in most challenging when raised in regard to questions that we typically think of as handicaps, such as deafness, Autism and Down’s Syndrome.  In his examination of  deafness and Down’s Syndrome he notes the technological innovations that may lead to a decrease if not the potential elimination of Down’s Syndrome and Deafness, questions whether this will be a benefit or a loss for our society. By contrast he notes the dramatic increase in Autism and questions how this will change how we view people with Autism.

Solomon notes that historically certain conditions, homosexuality, were previously considered handicaps or forms of deviance, but now have been accepted (by many) as a normal variation of human experience. He muses about whether technological advances that might allow for parents to “cure” or prevent differentness (by early identification and abortion or even more advanced technologies) will truly be a boon for humanity or a loss.

This is a valuable book because it makes us rethink questions we may think we have answered. While it may be unsettling to think of conditions we normally think of as handicaps as “identities” (a different but equally valid way of being in the world) and as part of human diversity (the loss of which would lessen our diversity and potentially some aspects of our humanity) these questions are worth pondering.  Moreover, for those with children who are significantly different than their parents this book offers hope, inspiration and a reassessment of how we think about certain conditions.

I would also note that at times this book can be repetitive both in drawing out distinctions between vertical (inherited) and hierarchical (constructed) identities and in offering one too many personal stories of families who have grown from accepting and valuing their child’s differentness. However, in Solomon’s defense his discussion of and interviews with families with Autistic children is certainly not upbeat or overly positive.  In addition, there are times where  Solomon seems to be stacking the deck  when considering how a child’s differentness as facilitated their parents’ emotional growth and allowed the child to form a unique identity.  In  Solomon’s defense this may have been unavoidable as the parents he interviews and draws inspiration from are ones who have found much to value in their child’s differentness. Obviously, it would be much harder to find parents with the opposite perspective.  Finally,  the question of differentness is clearly not an either or situation: being Deaf or a Dwarf can be a different identity and a handicap; trying to nurture and support children who are different in forming their own identity while also helping them learn to navigate mainstream society is clearly superior to insisting that only one of those alternatives is correct.   Despite these weakness this is a valuable book that can make us all appreciate the humanity and grace, as well as the challenges and limitations, of conditions we all too often quickly dismiss as handicaps.

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Acceptance and Commitment Therapy (ACT): Not Just CBT Light!

            To begin with a little self-disclosure: I have been highly skeptical of ACT.  First, the clinicians who first explained ACT to me probably were not the best ambassadors for the model. Their descriptions and explanations made ACT sound as if the focus was simply on telling people it is okay to think and feel what you think and feel (not exactly a novel intervention for psychotherapists)  and some vague talk about remembering one’s values. Second, being an “experienced” clinician I have witnessed the arrival of many new models during the course of my career.  Many of the models have lacked coherent theoretical basis, not to mention reasonable empirical evidence to support them. Third, (and most importantly) there is a very solid body of literature that strongly suggests that the benefits of psychotherapy primarily result from the common or non-specific factors that are part of each therapy (e.g., the therapeutic alliance).  Research by a variety of well respected professional has demonstrated that  the client’s relationship with the therapist, therapist empathy, and sensitivity to the client’s goals  are the active ingredient in therapy (the factors which help clients change/feel better/relieve symptoms). (see below for source). Fourth, the overlap between ACT and CBT appears significant. Many CBT therapists, particularly more sophisticated clinicians, clearly focus on helping clients develop more realistic expectations of themselves, and work on helping clients be more accepting of themselves. Thus, in some respects ACT appeared to be a softer version of CBT.

In all fairness, the first two factors clearly reflect a combination of personal bias and chance. However, the third and fourth factors merit more serious consideration. Clearly, CBT is derived from CBT; it is often referred to as part of the “third wave” of cognitive behavioral approaches.  The question remains: is it that distinct from CBT or is it really reflecting a more sophisticated and nuanced use of CBT.  In addition, while there is empirical evidence support the benefits of ACT there is no reason to expect that the common or non-specific or core elements of therapy are what account for much of the benefit clients’ derive from ACT.

Thus, the question remains: Is ACT really a unique model that can offer therapists a new approach to helping clients (or at least a subset of clients)?

I would argue that ACT does have something to offer clinicians above and beyond (or distinct from) CBT.  It is important to note that this line of argument is based on the belief that the specific model of therapy also has a contribution to therapeutic outcome, above and beyond the benefit of the common or core factors.  More specifically, I would hypothesize that  for certain problems/clients certain models of therapy may be more effective. There is some evidence to support this line of thinking (see research from psychotherapy networker) and clearly there are many advocates of this concept.

 

What are ACT’s potentially unique contributions and benefits?

First, ACT’s focus on helping clients accept their thoughts and feelings (their inner experiences) and developing the understanding  that they do not have to be consumed/organized/overwhelmed by these thoughts/feelings stands in contrast to many therapeutic models focus on helping people change their thoughts and feelings.  However, it is important to note that these concepts are derived from a variety of sources (ranging from Buddhism to Salvatore Minuchin’s notion of “partial selves”,  to name only two). However, the way in which ACT integrates and understands these concepts brings a different focus to the therapeutic process.

Second, the concept of being present, in contact with the present moment, offers clients and therapists an increasingly important pathway to being more aware of our inner experiences.  While most ACT practitioners would argue that ACT and Mindfulness are not the same, ACT’s emphasis on being present in the moment overlaps significantly with Mindfulness. While it is a cliché to talk about how hectic and distracted modern life can be, there is much truth to this assertion. Thus, the emphasis on being more present , more in touch with one’s self, is increasingly important.

Third, ACT’s emphasis on values is also worth highlighting. As many social critics have noted we live in an increasingly materialistic world in which worth is often derived from wealth, fame, and appearance. A therapeutic model which helps our clients become more aware of their values (see below for definition) and use their values to strengthen their self-image, sense of worth, and guide their actions, is clearly important. While some advocates of ACT appear to struggle to explain values, the simplest explanation that values are akin to character traits: honesty, kindness, and the like, rather than aspects of specific belief systems.  By focusing clients on their values (and how to better live their values) ACT can help people live less frenetic and more congruent lives.

Proponents of ACT might take umbrage with this summary of ACT.  Clearly a blog piece cannot capture the richness of any therapeutic model. Moreover, different proponents of any model are likely to stress one or more aspects of the model over others.  However, for this write, these are the features of ACT that make this model stand out in a crowded field.

In other respects ACT is more the same old wine in new bottles. The focus on committed action really seems to be very similar to the effective use of homework, or the concept of “baby steps” so well explicated by Richard Dreyfuss’ character, in the movie “What about Bob?”.

Overall, I would argue that ACT is a model worth considering. I suspect that it may be more applicable for certain types of disorders and/or clients.  For example, clients with anxiety disorders ACT  may be an exceptionally good fit.  Similarly, those clients who struggle with negative thinking and who are prone to ruminating on their difficulties might also be excellent candidates for ACT.  However, ACT may be less applicable to more impulsive individuals, and to those persons we might consider less psychologically minded.

An additional concern regarding ACT is that it is one more model which focuses on the individual’s inner experience (thoughts and feelings) and appear to neglect the power and impact of the client’s social context and current relationships. While many have argued that the behavioral therapies represented a major break from psychodynamic and analytic models, it is also true that all of these models (later iterations of behavioral therapy from CBT to DBT to ACT) continue the focus on the individual and his or her inner experience (even when applied to work with couples or families these models frequently focus on the individuals thoughts and experiences, rather than taking a more systemic focus). The real revolution in therapy is much more likely to be the inclusion of others (spouses, partners, parents and children) into therapy and a shift off focus from the individual to systemic. Thus, ACT practitioner may be at neglecting the importance of day to interactions/relationships and overemphasizing inner experience of the client (which ironically is often a by-product of the client’s day to day life/ongoing relationships).

In sum, I am now far more accepting of ACT, than I previously was, and consider a therapy learning more about and integrating into my work with clients, particularly for those struggling with anxiety and depressive disorders.

 

 

Note: as this is a blog I tend to be less formal than a paper. However, I still believe that it is important to cite source material for my thinking:

First, for my new and improved and vastly expanded understanding of ACT:

Roger Thomson, PhD  and Kaimy Oehlberg, PhD, “Acceptance and Commitment Therapy,”  June 27, 2014, Illinois Psychological Association.

David Carbonell, Ph.D, “Acceptance Based Treatment of GAD,” June 3, 2014, Northern Illinois Employee Assistance Professionals Association 36th Annual Conference.

These excellent presentation on ACT helped further my understanding significantly.

 

Second, for more info on the research and arguments that the “common factors” model best explains the effects or benefits of psychotherapy I would recommend the work of John Norcross, Michael Lambert,  Bruce Wampold, Scott Miller and Barry Duncan, to name just a few.

-for some brief articles and resources on the topic: http://www.psychotherapy.net/

-the article by Robert Jay Green, on the aforementioned site offers a nice summary of this research, and references to materials that support  this thesis: http://www.psychotherapy.net/article/therapeutic-alliance

-for more resources on this topic see Barry Duncan’s website: https://heartandsoulofchange.com/

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Brothers: On his Brothers and Brothers in History: by George Howe Colt

                Brothers, by George Howe Colt, is a combination memoir and psychological examination of the relationship between brothers.  Colt alternates between an examination of his relationship with his three brothers (from their early childhood into adult life) and a psychological and historical consideration of the relationship between brothers throughout history.  He devotes  5 chapters to the complex relationship of 5 sets of brothers: Theo and Vincent Van Gogh, John  Wilkes and Edwin Booth, Will and  John  Kellogg, the Marx Brothers, and John and Henry David Thoreau, while also touching more briefly on other sets of brothers.

                Colt’s thesis appears to be that the relationship between brothers is one great emotional intensity, characterized by intense competition and complex conflicts between loyalty and rivalry.   In considering his own relationship with his brothers, and those of famous brothers, he offers vivid examples of how brothers’ struggle to manage a sense of loyalty versus the desire to best, or even rid oneself, of one’s brother.  Colt discusses David Kaczynski’s loyalty to and eventual decision to turn in his brother, Ted, the Unabomber, and contrast this with how Whitey Bulger’s brother Bill (a successful Massachusetts politician) appeared to turn a blind eye to his criminal brother’s actions, and even possibly help his brother allude capture for many years.  Colt also discusses research suggesting that the relationship between brothers is fraught with conflict, often physical at younger ages, while noting that this conflict can continue through adult life.  While it may be of comfort to know that conflict is common, it is also disconcerting to acknowledge just how difficult and strained the relationships between brothers can be.

                I would highly recommend this book to anyone interested in the relationship between brothers, particularly those of you with brothers.  The personal memoir provides a window in to the complexities of one’s relationship with one’s brothers, while the historical discussions are both interesting history as well as thought provoking. If there are any shortcomings to this book, and frankly I can think of hardly any, they would be the fact that Colt can only write from his own perspective, a younger brother, and that the role of parents in influencing sibling relationships is not given great attention.  However, in the case of parental influence, it may be that parents have less ability to positively influence sibling relationships than we (psychologists and parents) would like to acknowledge.

Brothers, Colt, G.H.  Scribner, New York, 2012 .

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Ethical Challenges Posed by Technology & Social media

Today’s therapists have the opportunity and challenge of using a variety of tools that did not exist (or were not readily accessible) 10 years ago. Many private practitioners have websites and participate in on-line forums and list-serves. Email, social media and text messaging all offer new ways for potentially communicating with clients. In addition, how and when to move to electronic record keeping and other innovative practice management tools are questions most therapists need to consider. Not only do these new technologies pose technical challenges for clinicians (we must learn how to use them effectively) but new technology also raises a number of ethical challenges for clinicians. Questions ranging from: should I communicate with my clients via email? by text messaging? to whether to have a website (and more vexing, what and what not to have on the site), or even whether to have a personal Facebook page? need to be considered.
Fortunately, there are a number of solid resources for clinicians looking for guidance on these issues. Keeley Kolmes, Psy.D., has an excellent websiteand offers clinicians guidance and resources on how to navigate the challenges posed by new technology and social media. Dr. Kolmes describes her social media policy and generously offers clinicians the opportunity to copy and modify her social media policy.
For those interested in more resources on the topic the journal, “Professional Psychology: Research and Practice,” published a number of articles examining the impact of technology on clinical practice (see Dec. 2012, Vol. 43 #6, and Dec. 2011, Vol. 42, # 6). A number of these articles focus on ethical challenges these innovations pose. In addition, the American Psychological Association’s has recently released a draft set of guidelines on Telepsychology.

In upcoming posts I will consider some of the specific challenges new technologies pose and offer some discussion and suggestions on how to respond to these challenges. Finally, I would like to thank my colleagues on the Illinois Psychology Association’s Ethics Committee for their thoughts and ideas on these issues, which have been invaluable in helping me continue to refine my thinking on these issues.

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