Monthly Archives: June 2013

Dodos In Rehab: What’s Effective Therapy (part one)

Not that long ago I was speaking to a group of practitioners in a community mental health setting, posing a series of challenges designed to tease out what biases exist regarding the above question: what makes for a positive therapeutic outcome, and how do we know who’s doing what kind of therapy?

“How many of you consider that you are practicing evidence-based methods?” A dominant percentage in the room raised their hands, uncertainly in some cases. “How many consider yourselves CBT or solution-focused therapists?”, implying a chestnut belief in mental health circles: Cognitive Behavioral Therapy, or models similar to it, are the scientifically-based, empirically supported models of psychotherapeutic care. Roughly the same proportion of practitioners raised their hands after the second question. I then asked the audience to consider factors in outcome studies: time frames for follow up (were outcome measures made within 48 hours of treatment completion? 2 years? five?) What was the method of data collection (clinician assessment? participant self-report?) How did researchers determine what methods were actually being used in psychotherapy sessions? Among the practitioners, there was a smattering of speculations, but none knew definitively how the pronouncement “evidence-base” was being arrived at. I further asked if any in the room made audio tape recordings of their sessions, or made verbatim transcripts of sessions and then submitted them for scrutiny of methods. No one raised their hand. Someone shrugged and called out, “who does that?” I admitted that few did, but then asked one more volley of questions: given that mental health treatment is a confidential undertaking, and the likelihood that few psychotherapists subject their methods to rigorous scrutiny, how is it that researchers know who is doing what kind of therapy? I pointed my finger at my audience: how would they know you are CBT therapists?

The commonplace belief that psychodynamic models of therapy are not effective, or that pronouncements as to its efficacy are not grounded in science, is getting debunked. Meta-analyses of studies are accumulating, presenting effect sizes of close to or above 1.0 (this refers to a standard deviation above a normal distribution, and .8 is considered a large effect). This is the reporting of Jonathan Shedler, whose famous article in the March 2010 edition of American Psychologist is changing minds in professional circles. He is one of many sources quoted in my own non-fiction book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment. I worked in this business for fifteen years, originally under the supervision of professionals who frequently spoke in psychodynamic terms, affording me a rich, comprehensive lens through which I could work with and understand my clients in long-term residential care. Over time this influence was eroded, as shorter term models, with their myopic treatment goals, and sometimes insipid criteria for change (example objective: “reduce instances of tearfulness from 8 out of 10 occasions to 5”), increasingly impinged upon the treatment culture. Imagination, thoughtfulness, even common sense was being squeezed out, in favor of a supposedly utilitarian approach that presented common denominators for care. A reductionist assessment of symptoms, based largely upon Aaron Beck’s depression inventories, prevailed as the means by which treatment progress, and thereafter effective outcomes, were measured. Meanwhile, within the dusty crevices of program operations manuals, there existed old articulations of purpose that aimed for an implicitly internal process, the “core” experiences of the suffering individual in treatment.

In my book I make considerable reference to the work of Fonagy and Bateman (2008) whose mentalization-based treatment model (a psychoanalytically-derived technique) has yielded enormously positive results. At 5 year follow ups, 87% of patients who originally presenting with psychiatric symptoms and measures of social functioning consistent with Borderline Personality Disorder dx. continue to present criteria for the diagnosis, compared to 13% of those patients who received Fonagy and Bateman’s psychodynamic treatment. The centerpiece of Fonagy’s model is this concept of mentalization: the ability to experience another’s mind; to mentalize. Attachment research and decades of clinical observation has revealed the significant problems of those who present for care in community mental health care settings: poor impulse control, low self esteem, lack of empathy, or sensitivity for others’ needs and feelings; the inability to soothe uncomfortable feeling states–the aggregate of deficits that culminate in self destructive, anti-social attitudes and behaviors; drug abuse. Utilizing an index designated as SWAP (Shedler-Westin Assessment Procedure, available at, Jonathan Shedler coalesces some of the factors that yield positive treatment outcomes from a broader, in-depth perspective: increased capacity for sensitivity; attention to others’ needs and feelings; recognizing others viewpoints, even when feelings run high; healthy use of humor, knowledge of consequences of behavior; linking of feeling states to past experiences; the ability to soothe negative affect (w/out substances). All this constitutes an attempt to operationalize mental health, via clinician report; a means of assessing mental health not just from the absence of symptoms as delineated by past or present versions of the DSM, but by the presence of capacities, strengths and resources that are internal.

* Bateman and Fonagy (2008) An 8-year follow up of patients treated for Borderline Personality Disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165, 631-638.

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Sprawling, muddled and hard to follow

Consider the following beta elements: Hitchcock, Bolinas, fire, towering infernos, The Wizard of Oz, terrorism, telecommunications, and Birnum Wood. A meaningless collection of terms? Maybe…that’s what you’d think upon a quick read through of my novel, Crystal From The Hills. My “sprawling”, “muddled” brainchild was written intermittently over the last three years, and is currently receiving a smattering of appreciation, interspersed with triage-like criticisms, some valid and useful, some merely indicative of a drive-by reading. It’s early days yet. Mostly there is silence and the resounding feel of indifference. As with Weed, my villain, there is an overriding absence.

It’s to be expected. I’m not sure what kind of readership I’m aiming for, except for one of fantasy: an ardent following that reads things over and over again, ever searching for nuance. One review suggested a Joycean or Proust-admiring following–wrong. A book of minutia? The word implies triviality, or meaninglessness. I guess Wilfred Bion’s concept of beta elements doesn’t register for average readers; it doesn’t resonate. What do I mean? you may wonder…may wonder. Well, here goes, again: in drama, as in life, there is repetition; repetition that reveals. That’s basic Freud. The paraphenalia of society serve as microcosms of existence, illustrating the unconscious while it fills out the canvas of life. Chris Leavitt’s life is a canvas of elements, speaking in code and then blended into an inchoate mass. Alfred Hitchcock was a fan of psychoanalysis, which informs the themes of CFTH; the same is true of the many motion picture references contained in the novel. Other examples: Macbeth was a man who denied reality, and who failed to understand clues. Fires are part of the back-story of the protagonist, while towering infernos and terrorism now fuel the paranoia of American culture. Texting, e-mail, and the ubiquity of cell phones may dominate as mediums of communication, but it is ancient oral traditions that will whisper truths and pass them along, perhaps especially in small towns in West Marin County, where cell phone towers don’t exist still. Bolinas: the Luddite enclave. May the best grass roots movements of the future be born amongst your wooded seclusion. Within the mass of elements there is order and meaning, and for the attentive observer (as in reader), there is a pattern; an internal logic that ultimately should not baffle. Thus, events unfold in a manner that should feel familiar, perhaps like deja vu. There is a sense of things congealing with centripetal urgency (oops! careful Graeme–that’s a lot of syllables you’re stacking there.)

I guess not everyone will see things as I see them. That, after all, is the point of Crystal From The Hills. Take, for example, a climax of sex in CFTH (not the only climax). A critic has complained that a sexual episode between Chris and his girlfriend Jill–a clumsy grapple and possible rape–retroactively colors their relationship. My response: this passage is foreshadowed about once every ten pages of the novel without actually revealing the event (of course, I’m doing that here). Colors the relationship? The protagonist is guilt-ridden yet avoidant; Jill? she is conflicted: contemptuous and shamefaced, yet uncertain in her revenge. The explicit revealing towards the end is matched by the undercurrent that develops over the course of the narrative. The unconscious in which I place faith enables the reader to find logic and continuity in the unfolding. Meanwhile, the psychologically-minded know that the traumatized take their time, forget and distort, and even when finding clarity, they gauge the safety of those poised to hear their secrets. Is it safe to let you know what’s really been happening? How far have you made it into the novel? Are you ready to hear what its characters really have to say?

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Crystal takes it on the chin

Pardon the deflection. Actually, it’s me that’s taking the hits, the most important ones from sources yet to be revealed. But I’ll tell you what they’re saying, and why it stings.

I’ve asked people to put their thoughts down in writing so that I can track feedback. With Crystal From The Hills I’ve given them 140,000 words, or thereabouts. I’m getting about 250 back, on average–not that they should write more–but it isn’t fair is it? Where’s the balance? The triage of my not-so-picaresque (according to my harshest critics) yarn has yielded some of the following: words like “muddled”, “unwieldy” (referring to prose), and “not making sense”. With respect to certain elements, such as those calling for psychological terms, a passing knowledge of psychoanalysis, I’d agree that a perceptive, though not necessarily learned reading is required if one is to fully appreciate my tale of trauma, disordered identity, and social conscience.

Action? This brings me to the biggest complaint: what’s happening? some ask. Or worse, where’s the happy ending? Where’s the hope? What am I doing? I wonder: d’ya think I’m gettin’ the wrong people to read my stuff. D’ya think? I know. Try not to be defensive, right? These people are telling me what’s out there; what the average reader is looking for. Do I want you, average reader? do I need you?

Apparently, but maybe I can help…just a bit. Just a nudge, a hint here and there to clue you in as to what I’m doing, and why? Please.

So, first of all, with respect to my much maligned “flurries” of exposition, with respect to workplaces, memories related to fire, make-overs, terrorism, ruminations on women’s opinions, telecommunications: it’s all necessary. It’s all a story, the aggregate of these fragments. Believe me, I worked hard to make all these pieces add up and lodge in the reader’s mind. They are referenced circularly, but not repetitively, and the story of CFTH–it’s plot–runs alongside this collage of reality. Sorry, fans of the unfettered narrative flow, if I’m making life difficult.

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Working In Rehab: a numbers game

Check this out: Do you like numbers? Ok, here’s a few statistics: according to the Treatment Episode Data Set (TEDS) report, as published online by the Substance Abuse and Mental Health Services Administration (SAMHSA), almost 2 million people were admitted for substance abuse treatment in 2010 across the United States, and just over 2 million people were admitted for the same problem in 2009. These are the most recent years for which such statistics exist. The average number treated over the five years prior to this was between 1.8 and 1.9 million people per year, admitted to just over 13,000 facilities licensed or certified to treat individuals for substance abuse. According to the same data tables, between 7 and 8 percent of these admissions—again, on average—are kids. By kids, I mean ages 12-17, and most of these kids are between 15 and 17. That’s about 150,000 teens per year entering programs, in outpatient or inpatient settings—rehab, as the shorthand goes—for the treatment of substance abuse. And by the way, substance abuse is only one of many problems these kids have. This is the kind of information you’ll find in my forthcoming book about drug rehab and teens, due out soon–though, don’t be misled: my book won’t be dominated by numbers. In fact, you’ll see (I hope) that it takes a skeptical view in general of the application of numbers to my profession.

You see, my profession, that of a therapist, is about making a personal connection with people. I know that sounds like sanguine bullshit, but unlike the average entrepreneur, I’m not selling a product alongside a transient interaction that purports to represent commitment. I’m talking about a solid idea that’s quietly being marginalized in the business of mental health services: it’s the relationship(s) that heal. Not so, according to the larger systems in charge: hospitals, insurance companies; managed care. For them, it’s about “quantifiable” aims, that which can be tracked in terms of symptoms, so-called “scales”, tests of one sort or another. Go to a program, especially a hospital based program and you’ll hear the mantra: tests, tests, we must do tests. Later there will be estimates, both of prognosis, and of the money involved. It’s a reductionist process. Why? Because those paying say so, that’s why. They’ve even enlisted scientists to this cause. By scientists I mean researchers of mental health, people scrambling to publish studies whose findings will rubber stamp the proposed treatment approaches. The process here is tautological: find that which confirms efficacy of the pre-ordained standards. Make it understood that the most cost-effective approaches are the best. Proselytize use of those models that are the easiest to train to the growing numbers of fledgling professionals who are eager for jobs and at best secondarily concerned as to what they’re teaching.

How do I know people like me are looking for jobs? If you don’t believe me, believe a ph.d. Hey, that rhymes. In a report for the California department of Mental Health in 2009, John Shea indicated that positions for social workers, marriage and family therapists, and other counselors would grow by 22%, 21%, and 33% respectively (projected until 2016). His report indicated that over 22,000 people held MFT licenses at that time. That number now stands at over 33,000 according to department statistics. Whoa, that’s growth for you. I wonder if the jobs will run out. At what point does the Board of Behavioral Sciences start making its licensing exams harder to pass, thus titrating the numbers coming into the field. There. That’s a token for those who may wonder who I am to say what’s happening in the business of drug treatment. My question back: who do I need to be?

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