Results tagged “CBT” from Ψ Dare To Dream...

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Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.

"Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.

Any general rules of the game for (self) empowering belief?"

Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.

"All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes. "

Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.

My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.

"Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how."

Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.

I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.

There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.

Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:

"There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself. "

More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:

"...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient.... In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way."

Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!

There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.

Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)

Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.

"When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.

Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect to attachment, then he or she has a larger capacity for assisting clients to achieve integration and awareness. This understanding derives from the primary attachment relationship within the developmental psychobiological perspective in which parents who have secure or "earned" secure states of mind with respect to attachment function in certain ways (including attunement and sensitivity) with their infants that result in attachment security in their children. Therefore, from an attachment point of view, the more secure the therapist is, the greater the likelihood is that he or she can assist clients with achieving greater security (Beebe, 1998, cited in Grillion et al. (2008). Therapist self-awareness broadens "clinical intuition", which is referred to as the art of psychotherapy (Bugental, 1987; Schore, 2006; cited in Grillion et al. (2008). "

Thus the relationship of between therapist and client is perhaps the second most important aspect therapy, right behind client characteristics and motivation. So it is critically important that the client has a good relationship with the therapist. Clients must be willing to shop around to make sure there is a good match. Cooper (2008, quoted in Croft, 2008) makes research based recommendations for finding the right therapist.

"Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

References

Croft, Alison. (2008, October 17). Clients, Not Practitioners, Make Therapy Work. Press release by the British Association For Counselling & Psychotherapy on a new book Cooper, Mick (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. In Medical News Today. Retrieved May 1, 2009, from http://www.medicalnewstoday.com/articles/125815.php.

Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009). Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder Biological Psychiatry DOI: 10.1016/j.biopsych.2008.12.028

Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008). Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8 (6), 753-765 DOI: 10.1037/a0014123

Patterson, C. H. (1984). Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 21, 431-438

Patterson, C. H. (1986). Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 29, 427-435

Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008). Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8 (6), 792-802 DOI: 10.1037/a0013976

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I have been really enjoying my access to a large number of professional journals over the past couple years. Working at a teaching hospital definitely has it's academic perks. I've been particularly gratified to see a growing sophistication in research methods, creative approaches and a maturing view of results.

Until recently, practice based research articles have often taken the form of providing some support for a therapist preferred approach to therapy. I can understand that, for I am too, highly invested in how I do and why I do it. But many if not most therapy based research describes a new fangled therapy with a new name. This sort of research seems to me to be more self-serving and contributing to a ever fracturing of psychological science. There are so many theories and therapy methods with rather limited clear definitions or research support, there is little opportunity for advancing knowledge of what works.

A new book was announced at the Annual Conference of the British Association For Counselling & Psychotherapy. Titled Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly, it is written by Professor Mick Cooper of the University of Strathclyde. The book is a research review focused on common factors successful therapy. "The book, which is the first reader-friendly summary of research findings in the field, also offers advice to people who are considering seeing a therapist, on their choice of practitioner and the best type of therapy available to them." The author concludes that the most important factor is a client who is motivated and actively involved in using therapy to build on his or her strengths. In addition, one of the best indicators of a positive therapeutic outcome is a strong relationship between therapist and client. These two factors are far more important than a therapist's ideology or particular techniques.

This is not news to those inside the field who have been paying attention. When I was in training in the late 70's, warmth, empathy, genuineness and humor were thought of as important therapist attibutes because they contributed to a good working relationship with the client. Then it was widely understood that psychologically minded persons, capable of abstraction, insight, self-reflection, and most importantly, with motivation to follow through on treatment outside of the session were found to be ideal candidates for therapy. Unfortunately, they were those least likely to need therapy!

Research took an ideological turn when Cognitive Behavior Therapy became the most thoroughly researched treatment method. And early claims were that results were consistently better than what they called "placebo". Now it seems, advocates, academia, even insurance companies are on the CBT bandwagon, tauting this one method as the only way to go. Even the British government has invested committed £170 million over three years to expanding the availability of CBT.

The trouble is that 20 years of research had complied an impressively large pile of research papers that document a very little differences in improvement when comparing CBT, every kind of manual defined treatment modality known to man. The author of the book argues:

"Many clients will benefit from CBT but there is a danger in putting too much emphasis on the type of therapy that a therapist provides, rather than the therapist's ability to relate to his or her client in caring and understanding ways, and the needs and preferences of individual clients. Rather than moving towards a therapeutic 'monoculture', we need to be able to provide people with a range of therapies and therapists, so that they can choose the one that best suits them and build on their particular strengths.

[..]Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

What a breath of fresh air!

Reading this book review reminded me of a number of articles I read a couple years ago linked to The Institute for the Study of Therapeutic Change (ISTC) founded by Scott Miller, Barry Duncan, and Mark Hubble. Their collaboration "resulted in several books and dozens of articles, and culminated in the APA best selling, The Heart and Soul of Change. As detailed in that book, the things that make therapy work are largely about the client--the true hero of therapeutic change--and the quality of the relationship formed with the therapist, far more important than model or technique."

Michael J. Lambert of Brigham Young University in 2005 published an article in the Journal of Clinical Psychology on common factors in effective psychotherapy. Lambert takes his argument down a creative path. He suggests that the attention placebo includes therapeutic effective common factors.

Placebo is a research concept that is most commonly used in pharmacological research. Basically, if you find a drug that most people find better than a sugar pill, you have a new product! There is a problem when you apply this concept to researching outcomes in psychotherapy. Just what is the therapy version of a sugar pill? A placebo for therapy outcome has been said to include life events, social support, hopeful expectations, and biochemical changes that accompany treatment and enhance immune function and biochemical balances that facilitate recovery. The problem is therapy is all about providing social support and hopeful expectations from the effectiveness of the therapeutic relationship, the so called "attention placebo."

The "social support, hopeful expectations" part of therapy are essentially the "attention" part of the placebo effect. Certainly this part of a placebo effect is an essential part of psychotherapy, not something to be merely separated or controlled from measurement of therapeutic effectiveness. Lambert effectively makes that point:

"Placebo controls make less sense when extended to psychotherapy research because the benefits of treatments and placebos depend on psychological mechanisms. Many authors in the 1980s rejected the placebo concept in psychotherapy research because it is not conceptually consistent with testing the efficacy of psychological procedures (e.g., Dush, 1986; Horvath, 1988; Wilkins, 1984). Nevertheless, the search for causes of improved patient functioning within the traditional scientific method has persisted, albeit under a variety of different terms. Rosenthal and Frank (1956) defined a placebo as being theoretically inert. It is inert, however, only from the standpoint of the theory behind the therapy studied. As Critelli and Neumann (1984) have observed, "virtually every currently established psychotherapy would be considered inert, and therefore a placebo, from the viewpoint of other established theories of cure" (p. 33). Consequently, placebos have sometimes been labeled as nonspecific factors (e.g., Oei & Shuttlewood, 1996). This conceptualization raises serious questions about the definition of nonspecific. Once a nonspecific factor is labeled, does it then become a specific factor and fall outside the domain of a placebo effect? For example, if a variable like therapist warmth is operationally defined and measured does it then become a specific factor, but if not measured a nonspecific (i.e., placebo)? (Bowers & Clum, 1988). Others have suggested the term common factors as a replacement for terms like placebo and nonspecific, in recognition that many therapies have ingredients that are not unique but are nonetheless efficacious. Thus, research on placebo effects might be better conceptualized as research on common factors versus the specific effects of a particular and unique technique.

Common factors are those dimensions of the treatment setting (therapist, therapy, client) that are not specific to any particular technique. Research on the broader concept of common factors investigates causal mechanisms such as expectation for improvement, therapist confidence, and a therapeutic relationship that is characterized by trust, warmth, understanding, acceptance, kindness, and human wisdom. But also can be expanded to include some mechanisms that are often regarded as unique to a particular form of treatment such as exposure to anxiety-provoking stimuli, encouragement to participate in other risk-taking behavior (facing rather than avoiding situations that make the patient uncomfortable), and encouraging client efforts at mastery such as practicing and rehearsing behaviors. Such a view of common factors recognizes that while specific theories of psychotherapy may emphasize systematic in vivo or in vitro exposure to frightening situations, or social skills training, nearly all therapies encourage people to review and discuss the things they fear and face rather than avoid such situations. Common factors, no matter how unimportant they may be from the point of view of a particular theory (theoretically inert or trivial) are central to nearly all psychological interventions in practice, if not, theory."

Lambert's review reports one factor that is consistently found to be important to therapeutic effectiveness, the relationship between the therapist and the client. Most notably, outcome may be largely related to early response to treatment, before the core techniques have been implemented by the therapist.

"At present, the active mechanism linking early response to long-term outcomes is unknown. Whatever the active ingredients are, they appear to work quickly in many cases. The timing of improvements during psychotherapy has theoretical implications beyond placebo explanations for change. If response to therapy precedes introduction of theoretically important techniques, then it is difficult to attribute central importance to these techniques in the healing process. Early responders to psychotherapy may be more resilient, better prepared, more motivated, and thus more receptive to therapeutic influences of any kind. Early response may also indicate a better fit between client and therapist and reflect the positive effects of the working alliance which often can be detected by the third session of treatment. For example, Krupnick et al. (2000) found that the relationship between the client and his or her therapist was most predictive of outcome. This finding is notable because the authors encountered this result across treatment modalities, including two distinct psychotherapies, as well as antidepressant medication, and placebo conditions."

This and a number of other research reviews make a persuasive argument that therapeutic technique is relatively unimportant in maximizing a positive outcome. CBT has been found to be minimally more effective than other therapy approaches. I could imagine how manualized treatment that is most common in these research studies may well minimize the early response factors Lambert mentions above. CBT, designed for a manualized approach, may be less susceptible to suppressing early responses and thus has a more consistent record of comparatively more positive outcomes. Since the magnitude of response when comparing outcomes across therapeutic techniques are minimal in most cases, it seems particularly unwise to attribute CBT with the best outcomes, especially since some of the most important factors related to therapeutic outcomes have been systematically controlled out or inadvertently suppressed by the manualized approach.

References:

Michael J. Lambert (2005). Early response in psychotherapy: Further evidence for the importance of common factors rather than "placebo effects" Journal of Clinical Psychology, 61 (7), 855-869 DOI: 10.1002/jclp.20130
Miller, S., & Duncan, B. (n.d.). "What Works" in Therapy? TalkingCure.com. Retrieved December 28, 2008, from http://www.talkingcure.com/reference.asp?id=100.