Research Notes

I was struck – again, as I often am – by the claim of effectiveness. Persons with psychosis exposed to four hours of ACT, if not healed, functioning better, at least by one measure. The patients in the ACT “arm” of the study: their re-admission rate was halved. The citation was in the Psychotherapy,net article, and here, you can read it for yourself:

http://www.actmindfully.com.au/upimages/bach&hayes-_act_schizophrenia.pdf

As I read it I wondered: Why haven’t these wonderful results ended up in my local inpatient psychiatric facility? What happened between 2002, when the article was published, and now, 2016? This should be a big deal if it can be replicated!

You, reader, please look at the article. Maybe I missed something.

I did notice that they asked for volunteers, which is always a bias – the bane of the age of the Institutional Review Board (IRB), which requires your informed consent before participating in any trial. We could leave that aside, as across studies, that is a constant. Nonetheless, the researchers were refused by four of every five patients they asked. That seems a selection bias of some importance. And they sought to exclude those who had psychosis and substance abuse, those who had developmental disabilities. Could that be the reason why this hasn’t been disseminated? Too narrow a group, uncommon in the general milieu of your average state inpatient psychiatric hospital?

Another question is how has ACT avoided the near universal cycle – the phases the “big” psychotherapies go through in their journey – from idea to hypothesis to experiment to revision to experiments on a larger scale (proliferation) to model to growth (dissemination) to popularity (even enthusiastic popularity!). With results like that cited above, where is the growth and popularity?

Mind you, ACT’s root dates from 1986. And it has a “pedigree.” Descending from B.F. Skinner’s work in behavioral psychology. DBT started around the late 1980s – and in the same location, the University of Washington (Seattle, WA).

Or could it be this, noted in one line in the article? That the treatment was delivered by “a psychology intern who had been trained to the point of competence by the developer of the treatment approach.”

How much difference does it make if your clinical supervisor is the developer of the therapy model and you are “trained to the point of competence?”

The popularization of psychotherapy in the 1960s and the 1970s, with headlines in Time for Gestalt Therapy and Transactional Analysis – the unlimited, pervasive and ongoing jokes and cartoons about Psychoanalysis – none of that has happened or is happening with EMDR or ACT or DBT or MI or CBT.

Even though Steven Hayes (the developer of ACT) and ACT were written up in a six page article in Time magazine in 2006.

Serious therapies for serious people, our acronym laden therapies we get training in today, with limited claims – except for their curative powers. Those psychotherapies of the ‘60s and ‘70s did make vast claims as well: they claimed that “Therapy was too good to be limited to the sick.”

Today let’s aim to get reasonably good training, attend workshops, aim for adherence and combine our competence in our selected therapies along with our healing, aim for the alleviation of misery and perhaps better than “just normal” as a result of our efforts.

Postscript: http://www.stevenchayes.com/

See what Steven Hayes has to say for himself about his major influence – B.F. Skinner – experiences that were linked to Gestalt Therapy at Esalen at Big Sur, California – and what motivates him.

“Turning Evidence into Evidence-Based”…(Part 2)

May 16, 2016May 29, 2016 Frank Heitmann

I recently visited the Motivational Interviewing website and caught Theresa Moyers, Ph.D. and other M.I. luminaries giving us a few of their thoughts in the seven minute long Vimeo on their website. Well worth watching and taking not quite seven minutes of your Time. http://motivationalinterviewing.org/

In the middle of it Ms. Moyers speaks to ‘where’ Motivational Interviewing is in its development – in its research and in its practice. Its refreshing to hear someone, anyone, say that their therapy model has not “arrived” yet, that it is still a work in progress. Which is what Theresa Moyers says explicitly, and I admire that its up on their website.

Not all the current models pushing their way forward as Evidence-Based or Evidence-Supported Treatments leave you with that impression. I don’t mean that elsewhere they don’t critique their models – they do – but maybe not on the front page of their website!

You’ll find that Marhsa Linehan, Ph.D., and her cohort continue to persist in seeking out what the active ingredient(s) are in her model. They publish their research in peer reviewed journals. There’s a book too -Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings – that has twelve articles on adapting DBT to various sites and populations, adaptations that are not fully adherent.

Yet you are not going to see as much on the Behavioral Tech website (the official DBT website).

Elsewhere, when did you last see Solution-Focused Brief Therapy in the news? What’s the latest on that model?

Don’t think I am knocking the advancement of our field. I am pointing out that there is a faddish-ness about our therapies: good numbers that one condition or one population or some other unique identifier responds to the therapy model morphs into multiple conditions. From CBT for depression to CBT for virtually everything. From Solution-Focused Brief Therapy for family problems to many other concerns.

Thus has it been in the U.S.A. Our models begin humble then acquire the status of panacea and sometimes gain cachet, and go on to totem or talismanic status. That happened with psychoanalysis, it happened with Carl Rogers’ therapy, it happened with Transactional Analysis and Gestalt Therapy. And then their moment passes. Some more quickly than others.

I can’t say that I know with certainty that same cycle does or doesn’t occur on the European or South American or Asian or African continents, but I can tell you that many varieties of psychoanalytic practice persist in Europe and South America as common treatments; that in Germany inpatient hospitalization is considered the norm for conditions that in the U.S.A. would only be treated on an outpatient basis; in the United Kingdom a hodge-podge of therapies including REBT, Transactional Analysis, Neuro-Linguistic Programming and others are used. Many of these therapies import a nice sized dose of Object Relations-informed psychodynamics, which is the original attachment theory. See Margaret Mahler’s book (1975) The Psychological Birth of the Human Infant : Symbiosis and Individuation.

About the latter: Attachment, which is another Big Wave happening now in the USA. Could it be the traditions in the U.K. allow them to keep the old ways of doing things – not cleaning house without regard for the “grain of truth” in those models which are now disenfranchised in the USA?

Here’s hoping that your clinical supervision incorporates some humility about our current state of knowledge and practice, and perhaps some consideration to the history of psychotherapy, not just the current “best practice.“

“Turning Evidence into Evidence Based”… (Part 1)

May 2, 2016July 17, 2016 Frank Heitmann

There are days when it seems everyone is seeking some specialty training. You, reader, could be one of those people. After all, whether you are filling out credentialing and privileging forms for insurance companies, or, in North Carolina, the LME/MCOs that disburse the State’s monies, many of them ask you to specify what specialized training (in treatments and populations) you’ve gotten post-masters or post-doctoral degree. I recently filled out an insurance company’s form myself and realized I could only click on a few check boxes out of seven pages of listings. It was humbling.

You could be looking at Cognitive-Behavioral Therapy (CBT); Dialectical Behavior Therapy (DBT); Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT); Eye Movement Desensitization and Reprogramming Therapy (EMDR); Motivational Interviewing (MI) and, continuing the acronym salad, CPT, REBT, RBT and so on. And I am not listing the specific therapies for children and couples/families! Do you too wonder how you’ll keep up?

Have you looked at how these therapies compare with each other? What does the research literature show about the processes and outcomes? Do you scratch your head about the clear differences between CPT and EMDR for the treatment of Post Traumatic Stress Disorder? Or how about Alan Marlatt’s cognitive-behavioral therapy for substance abuse, Relapse Prevention, compared to Motivational Interviewing? Do you wonder what they have in common – what active ingredient(s)?

A recent article by Laska & Wompold at http://www.apa.org/pubs/journals/features/pst-a0038245.pdf is thought provoking. Check it out, it’s a short read.