Evidence Based Practice

What Is The Clinical Supervisor Doing? Part I, Substance Abuse

Frank Heitmann

When I look at the competencies for the substance abuse supervisor (CSI and CCS) posted on the North Carolina Substance Abuse Professional Practice Board (NCSAPPB) website, I read a high standard of knowledge and practice which is daunting even after 20+ years in the field.   [Go to the url below, see pp. 50-53.]

Since most clinical supervisors are conducting “other business” as their main focus at any one time – they are either in their own private practice, they are conducting clients’ individual and group treatment in an agency setting, or they are administrators – their own development as clinical supervisors is uneven.   The administrative components – “Program Development” & “Administration – could take several years of concentrated effort before one achieved competence in that area alone.

Keep in mind: the NCSAPPB only requires 15 hours of clinical supervision specific training to obtain the Certified Supervisor Intern (CSI) credential and an additional 15 hours of clinical supervision specific training (plus the two years experience and passing the examination) to obtain the Certified Clinical Supervisor credential.   And those two years of experience could be limited to the CSI supervising one CSAS – Intern or one LCAS-Associate.

Supervisees may not detect the range of supervisor competence (or lack of) until they’ve met their second (or third of fourth…) supervisor.

Unless the supervisor takes the time to explain their limits and lacks as well as their competencies and proficiencies.  Which behavior on part of the supervisor itself would indicate some supervisory competence (!), and should be a relief to the supervisee, even if there are gaps in the supervisor’s “resume.”

I have found myself studying hard to stay a few steps ahead of some supervisees. Either their beginning personal interest in some therapy or practice or their employing agency’s embracing a new service definition or evidence-based practice has me researching on-line or driving to Chapel Hill to the graduate or health sciences libraries.   And there is, at least on my part, not just for the clients I see, but for the supervisee’s benefit, ‘going back to the well,’ revisiting topics.  The other week I picked up an anthology of Motivational Interviewing, applied to various problems I hadn’t tackled, but that might come up in supervision, and what to do you know, one week later I had a patient who may have benefited. Who knows: maybe a supervisee next?

http://www.ncsappb.org/wp-content/uploads/2016/05/NCSAPPB_Cred_Manual_5_18_2016PDF.pdf

Thoughts on Competence, Healing and the Passage of Time (Acceptance and Commitment Therapy)

Frank Heitmann

http://www.psychotherapy.net/article/Acceptance-and-Commitment-Therapy-ACT

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.

Modern Depression

Frank Heitmann

Note:  This blog post includes a case study for illustrative purposes.  Various efforts have been pursued to adhere to ethical guidelines in using case material.

An article in the Wall Street Journal (May 28/29, 2016) woke me up to the latest book by Peter Kramer, M.D., perhaps best known for his 1994 book, Listening to Prozac.   The new book, Ordinarily Well: The Case for Antidepressants (2016), both revisits some of the themes addressed in Listening to Prozac, and adds yet again to the defense of biological psychiatry by noting what is the author’s view: that after twenty years, the number of cases of advanced depression appears to have been greatly reduced by the use of anti-depressants.  By the way, Dr. Kramer is not against psychotherapy, is for good evidence, and takes note of the fact that some recent studies and meta-studies have questioned the efficacy of anti-depressants.

Here’s a quote from the article:

“[When I was in training in the early 1970s] I saw men and women who suffered depression at the deepest level.  On general hospital wards, such patients were not rare.  Thin, stooped, immobile suffering souls, they had the classic depressive habitus, the attitude or physique of the disease.  They spoke slowly and repetitively.  They were hard to interview.”

In the article Dr. Kramer goes on to note that at the time, his clinical supervisors, his training, all directed him to apply psychotherapy as the first line of treatment.  Only after a great deal of time and lack of response to psychotherapy were the medications of the day used.  Concerning today’s psychiatric ‘landscape,’ he goes on to note that not only he, but a number of experts in depression who he interviewed in preparing his latest book, have noted the diminishing numbers of such immobilized melancholics in our current time.  His thesis is that the broad prescribing of anti-depressants – on the whole, the Selective Serotonin Re-uptake Inhibitors (SSRI) – has greatly changed the epidemiology of the worst sort of depression.

After reading the article, I reflected on my encounters with such debilitated individuals and, accounting for only outpatient settings (I am not including day hospitalization treatment), I could only recall two.

Since I began working in an integrated care setting I’ve seen one of those two suffering individuals. That person reminded me that the isolating effect of such an advanced stage of the illness can baffle the sufferer and the helpers.  As I reviewed the chart prior to meeting the patient, I saw that over five years each of five different primary care providers – all of them seeing the patient only one time – had noted the patient’s depression.  Each had made an attempt to address the depressive illness in the provider’s own way: a prescription for a low dose of an SSRI or a referral to psychiatric care  – or both.  None had diagnosed Major Depression, Moderate (or Severe): the diagnosis was “Depression,” which coded as 311 under the DSM-IV – Depressive D/O Not Otherwise Specified.  Not a diagnosis that usually shouts out the worst of depressive suffering.

Only the most recent encounter gave me some insight into the level of depression. The provider had used an evidence based practice – she had used the Personal Health Questionnaire  (PHQ-9) – and the overall score was very elevated and there was also a positive for the suicidal ideation item (#9). 

Nonetheless, I was not prepared for the extent of the patient’s retrograde depression: the monosyllabic replies, the latency of response, the effort needed on my part to draw out the simplest details, the blankness of expression, the downturned eyes, the entire lack of the gestural postures that add to our verbal expressions – no shrugs, no shaking the head “no,” just quietly sitting there.  No spontaneous narrative.  And, no, the patient could not recall feeling much better than this the past couple of years. No fidgeting or tearing up.  Nothing.

It took a great deal of time, but I managed to draw out that this person took various responsibilities seriously. Those extended into the future and seemed sufficiently strong commitments that I could relieve myself of concern that the patient would attempt suicide (and there was no intent or plan).  Other risk factors were nil or minimal.  The patient agreed the medical provider and I could help the patient with a more comprehensive treatment plan (including a higher dosing of the SSRI and telephone coaching by this clinical social worker) and, no, having made it through so far without hospitalization, that option was declined. With this we began our attempt to revive the human being in our care. 

Not fancy, but what we do is extend the effort, in each individual’s treatment, to achieve efficacy.  The big picture is that our training should include a good grasp of the simple (and the cheap) to change the course of the worst illnesses.

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

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.“