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 http://www.SWAPassessment.org), 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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