Monthly Archives: March 2016

Where’s the breast?

 

A comical question, no doubt. Somewhat crazy: inappropriate, eccentric. Welcome to the world of psychoanalysis, or more specifically, Kleinian or Bionian analysis. This is what a Bionion therapist might ask of a group making what he/she would call a ‘basic assumption’ of a dependent group (seeking a leader), and floundering in midst of unfulfilled expectation. Yesterday I attended a four hour presentation about the work of Wilfred Bion, whose name, like his copyrighted interventions, have dotted this blog over the last year or so. This essay follows the spirit of Bion, the seminar I attended on a sluggish Saturday morning: it will be inchoate, elusive in meaning; seemingly interchangeable at times with ideas that many working in or else consuming mental health systems will take for granted. A discussion of Bion’s ideas begins plainly enough, with references to having an ‘ordinary conversation’, the ‘subjective experience’ of the patient; a search for the ‘real’ experience. Yet there is a secret attached: a sense that understanding is something that is transiently captured but then hard to retain, as if the desired knowledge (if that’s the correct term) was not meant for us.

Having taught a class once on Bion I knew the bio: born into an aspiring gentry in India at the end of the 19th century, Wilfred went to boarding school at age 8 to one of those stiff, militant academies that Harry Potter has since immortalized; he faced peer cruelty, the incomprehensibility of adults…their occasional kindness. He recounts a story of a headmaster who rebuked him for a game in which a playfriend is harmed by a game involving a rope without a knot, tied around a neck. The game might have killed the boy, the headmaster admonished. The headmaster later spoke to an assembly of boys, sparing young Wilfred humiliation, but drawing attention to the dangers of exploratory play. Young Bion felt chastened but not shamed, and oddly understood. An incident with an initial meaning took on another meaning, and its evolution was understood and modified by what Bion would later term the ‘reverie’ of an adult.

World War I was a setback in many ways. Obliterating men, obliterating meaning, Bion never felt more foreign that when he fought on European soil as a tank commander, his responsibility that of determining enemy positions, orienting his comrades. Impossible, he decided, observing the chaos. Impossible also to take in the purpose and meaning of all that slaughter, though he noted the primitive attempts, the glorifications of Winston Churchill, for example, who wrote with seeming ecstasy about the sensuous whistle of bullets in the field. After a momentous campaign in Cambrai, France, Bion was offered a Victoria Cross medal for his bravery, but declined, and when interviewed by an admiring General, later reported: ‘I couldn’t think what to say’. So Bion’s development was one of estrangement from commonplace human aspirations: for power, status, or even belonging. An outsider, Bion contemplated trauma, dissociation, the breakdown of thinking, and links to emotion, and later brought to psychoanalysis an almost mystical view of the human mind.

To consider the types of scenarios wherein Bion’s ideas are relevant, a student should invest some time and read his seminal papers of the late fifties, early sixties: “Differentiation of psychotic and non-psychotic personalities”, “Attacks on linking”, “A theory of thinking”, in which Bion asserted that many patients in psychotherapy communicate via a primitive defense known as projective identification (a defense first explicated by Melanie Klein), inserting into another’s mind a disturbed experience, which is then to be either ‘contained’ or not, metabolized or not, and re-directed back to the patient for internalization. Bion offered that the psychotic individual, or he/she existing in like borderline states, experiences their mind as composed of furniture, ‘things in themselves’, not modified by symbolic function as language, dream and metaphor (the ingredients of what Bion termed Alpha function), but lost in minutia. Thus we consider the experience of the patient who enters an office in which the therapist has made alterations to the (literal) furniture, and is rendered uncomfortable, and is not only incapable of putting words to that experience, but is also blocking of the therapist’s attempt to reflect back and give meaning. Lacking this fund of knowledge, or ‘K’ as Bion dubbed it, the patient in this proto-psychotic state exists in a world of things, drained of ideas, meaning, and feeling.

Later in his career, Bion expanded his theory to include the concept of ‘O’, or ‘being’, to denote a mystical, transformative experience. In his worldview, the outsider is a key figure: he or she is a genius, an innovator; contained by an established order, that (like me) dilutes ideas so as to make them digestible by a mass audience, the outsider is restrained only by God, ultimately. Bion’s book, Transformations, may have alienated him somewhat from the psychoanalytic community, who appear to have inherited or internalized Freud’s supposed distaste for the spiritual, but it crystallizes for the modern therapist an essential task when sitting with patients. Why? Because patients or clients don’t come into our offices with explicitly organized complaints like “Who am I?” or “I need to figure out how I think?” As therapists, our precociousness (yesterday’s speaker’s term) leads us to give premature insights, to show off our minds, deliver solutions; understand our patients before they understand themselves. We want to do that. I want to do that. And I believe the people who come see me want this also…sort of. But it is not cheaply arrived at, and between complaint and working through there is, more often than not, a nameless wasteland that elicits dread: it is a space of boredom and emptiness; it is painful in ways that are hard to describe on a somatosensory level, though we may be arrested at that point of entry. It is a dead zone of sorts, and a therapist, the person standing before an uncertain process,  is a kind of Grim Reaper.

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The war of evidence-based psychotherapy: part three

 

So the efficacy debate doesn’t matter, but only in so far as it’s moot to the powers that be. For providers (therapists) of all traditions it can also be moot to one degree or another. Perhaps suspecting that evidence-based research is a ‘sham’ (as Jonathan Shedler puts it), therapists can diversify their approaches, be flexible, incorporate interventions that don’t fit prescribed models because control of the process from the top is… illusory? As stated earlier, depth therapy providers can at times aim their interventions at cognitions and not affect; CBT providers can aim their words at cognitions but hold knowledge of an intrapsychic defense structure. If a client or patient (I know. I use the terms interchangeably. Sorry) asks in a session, “Do you find me boring,” it’s not from the CBT workbook or ‘cookbook’ to demur upon gratifying curiosity while exploring the meaning of the question itself. The pedigree of that approach is clearly psychodynamic, counter to the social norm of saying “of course not!” (to spare rather than understand feelings), and is understood as an accepted technique by all but the most pedestrian members of my profession.

And there are countless other moments that call for an effort to understand rather than soothe. However, I think most providers, working variously upon a taut schedule and budget, become selective. Highly selective. In my book, Working Through Rehab, I opine that psychodynamic depth-therapy models are not so much prohibited as institutionally proscribed. In most mental health agencies, hospitals, especially, there’s no one listening in on a consistent basis, determining that interventions fit the principles of CBT versus alternative approaches. It’s more that the conditions imposed on providers and consumers lend themselves to CBT methods, and at least make more difficult a committed psychodynamic approach. On one level, these conditions include limited numbers of sessions authorized, reflecting expectations of linear treatment progress; frozen reimbursement rates for providers, which incline them to respond to rising costs with more patients, which in turn makes more difficult a depth approach with any given individual; in many but not all contexts, the requirement of copious documentation, intended to support interventions (rarely achieving this, actually), which also impinges upon providers’ tasks.

But let me give (finally?) a subtler illustration of how mental health systems (agencies, insurance providers) intrude upon a therapeutic process. In order to understand the following case anecdote, the reader must first understand something about the concept of transference, which pertains to unconscious thoughts and feelings, drawn from past relationships, which manifest in relationships between therapists and patients. Across theoretical orientations, transference is understood as an essential ingredient of a therapeutic episode (despite not being an evidence-based phenomenon); one that must be attended to by a therapist, otherwise therapy is undermined. This transpires via what James Masterson once termed transference acting out: a variation on transference wherein the patient acts out (unconsciously) old and pathological relationship patterns. Examples include missing appointments, arriving late, or not paying fees (or co-pays)—behaviors that constitute passive resistance to treatment, difficulties with authority, or responsibility-taking, that mirror broader problems in life. From the moment a trainee therapist first sits with a patient, he or she is told by a clinical supervisor that such behaviors ARE important; that they must be addressed directly, or else real therapy won’t occur.

So consider a patient who is acting out a resistance to therapy via missed sessions, late cancellations or lateness, versus talking about ambivalence to treatment openly, even consciously. In the extant system of managed care, a therapist can treat those behaviors as examples of transference acting out, but will have to do so on his or her own dime, so to speak. Meaning, they cannot charge the patient for missed appointments, or bill the insurance company for missed sessions (unless acting fraudulently), because technically no service is provided if there are no sessions. In the minds of administrators, nothing is happening when this occurs. So the patient is not held responsible for missed sessions, which in turn undermines efforts to explore the behavior’s meaning if and when the person does return to therapy. After all, why should they take seriously a behavior for which there is no consequence?

Why won’t third party payers observe the bedrock principles of psychotherapy? Because they only reimburse that which is observable; because transference is not an evidence-based phenomenon; because the administrators of our populist, utilitarian mental health system (third party payers, funding sources and insurance), utilize the rubric of “medical necessity”, authorizing services which are intended to reduce an observable syndrome of pathology, not “contain” the projections of a disordered intrapsychic structure, in part because they wouldn’t know what that last clause means. Insurance companies might mimic CBT practitioners by, as one supervisor of mine once put it, acting as if the unconscious doesn’t exist, but more importantly, they won’t pay for its unfolding process, whether they understand it or not. Assuming a provider relations official would engage me on this subject, he or she would likely suggest that a beneficiary who repeatedly misses sessions be fired; meaning, that their therapy be terminated. Beyond that, there would be little room for confronting acting out behavior, holding the patient responsible for resistant behavior while “holding” therapeutic space available—again, unless the provider is willing to foot the bill for missed sessions.

The following is not an overstatement: those within the psychoanalytic community argue that the implications of this kind of system-wide policy are profound. Recently, a patient I see via a public health contract missed back-to-back sessions. Days later he called to apologize, knowing I couldn’t bill for the missed sessions, and also knowing that I was contractually bound to not charge him. He offered to withdraw from therapy, expressing regret and feeling disentitled, and proclaiming that there were others more needy or deserving that could use my services. On the one hand, it seemed a craven gesture, this passive retreat. But it also seemed to reflect a rather sad and commonplace expectation: that failure will be ruthlessly punished, with no conversation necessary; that individuals are replaceable, or that conflicts are best dealt with swiftly; that is, until the next one arises, thus cycles perpetuate. I think there are few in our culture who would have called for a suspended sentence in the above instance, much less a protracted discussion, yet this is what I did, reeling this man back in with my interpretations of inner conflict while absorbing the cost of his absences. I’m not looking for applause, for there’s certainly a limit to how often I can do this if I want to make a living. But I am echoing the psychoanalysts’ utilitarian-balking complaint. Borrowing language from behaviorism (turnaround is fair play), they’d assert that extant policies of mental health systems reinforce a societal tendency towards splitting: of dualism, black and white, either/or, all-or-nothing (pick your synonym) thinking and being, wherein the lines are drawn between stay or go, profit and loss; the good and the bad, the evidenced-based and the not. The space for a longer, slower, more involved, subtler exchange between what Bion called the container and the contained is squeezed in our national apparatus of care—some say destroyed, leaving in its place a system beset with pathos. You can disagree if you like but remember, you won’t get paid for your time.

 

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The War of evidence-based psychotherapy: part two

 

Turnaround is fair play. That’s what it seems like when the champions of psychodynamic models like Jonathan Shedler caricature their CBT counterparts. As I’m no more in their offices as they are in mine, I don’t really know what they do or don’t do in their interventions, but I glean. I don’t glean that my CBT colleagues use workbooks like cookbooks, offering rote interventions that they either memorize or read from a sheet. Nor do I think that most CBT therapists interrupt when a client is speaking of family of origin material; that they scoff at such unstructured navel-gazing and inform clients that exploring the past is a waste of time. Many believe in a structured approach, one that mimics a teaching paradigm to some extent: passing out information worksheets, assigning homework…educating. I recall working in an agency that made copious use of defense analysis worksheets. Clients were meant to read along in a group or in one-on-one meetings, examples of typical defense mechanisms matched to illustrative phrases. They were meant to reflect and say, “I think I do that”, and so on, presumably so they’d learn to not exercise those habits in the future. I’d give lectures to groups on defense mechanisms, codependency—a host of topics I liked expounding upon—delivered bullet-point style, to individuals who appeared to lap up didactic material, to learn if not wholly integrate into their minds, because the learning they need isn’t academic. It simply isn’t. Anyway, the promulgaters of structured approaches think it necessary to, as they sometimes put it, set the limb (with information) before they encourage the broken patient to walk (meaning, explore). It was/is a catchy turn of phrase and powerful use of metaphor, only it doesn’t really work. The mind isn’t like a limb.

But ultimately, it doesn’t matter, this debate between proponents of CBT versus the range of psychoanalytically-derived therapies. It doesn’t matter because the establishment that drives mental health treatment has made its choice, based upon economics (the supposition that CBT is a more cost-effective approach), but justified publicly by invoking evidence-based research. Meanwhile, adherents of psychodynamic models ever hold space for a deeper, longer-lasting, sometimes abstruse and painful descent. Students of these models are on the workplace fringe unless working independently. They sometimes meet, in apparent secrecy, in ‘forums’ in hospital basements, Saturday morning church halls, to discuss their older theories like freemasons keeping one step ahead of orthodoxy. Analyst Wilfrid Bion wrote half a century ago that the role of the mental health provider was to be a container for the pathological patient who attacks his or her mind, and to operate without memory or desire so that an unfettered examination of projections and introjections can occur. His approach wouldn’t fly in most mental health agencies, psychiatrist offices today. He ethos is going to sound a lot different on a treatment plan than, say, “Client will use tools to reduce behavior X over the ensuing 90 days”, or “Take 30mgs of Effexor each day”.

The Bion line wouldn’t go on a treatment plan. It would scarcely enter a ‘team’ meeting, or a consult with a fellow professional. And it’s not because professionals don’t think there’s value in the approach of analysts like Wilfrid Bion or his latter day followers. That’s why the debate doesn’t matter, because it’s not really about which approach is better, but rather which approach is more plainly understood; about what can be quantified, studied, measured, published and disseminated widely so that insurance companies, program clinical directors, and possibly consumers—all looking to varying degrees for ‘evidence’ of what works or doesn’t work—can point to something tangible and say, “hey, this looks like it has substance to it.” It’s about what’s utilitarian, more readily conveyed across channels, such that teamwork, professional fusion—that popular if suspect notion of ‘being on the same page’—can transpire.

When I was a clinical supervisor in a mental health agency, back in the day, I used to assuage interns with non-conformist leanings that the external voices of what is evidence-based are not ‘in the room’ with them (though some try to be or think they are ‘in the room’). This ambiguous freedom comes with responsibility, to decide what’s right for a patient, which often means what ‘feels’ right for a patient, when in the dense meaning of a therapeutic moment. Those patients, the consumers of mental health services, rely upon a sage and flexible approach, and they stand to lose if providers simply conform to that which is prescribed. The notion of ‘what works’ in mental health is quasi scientific, semi-observable; the phenomena of desired outcomes in mental health tend to be thinly defined, and observable only over short durations, which doesn’t speak to the lasting and unknown changes that the consumer seeks.

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The War of Evidence-Based Psychotherapy

  Work in a hospital or a community health agency of any kind and you’re likely to hear the term ‘evidence-based’ at some point, fairly early actually. Also, as a consumer of services you’re l…

Source: The War of Evidence-Based Psychotherapy

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The War of Evidence-Based Psychotherapy

 

Work in a hospital or a community health agency of any kind and you’re likely to hear the term ‘evidence-based’ at some point, fairly early actually. Also, as a consumer of services you’re likely to have heard this term applied to clinical practices of various kinds, medical and not. In the field of mental health, this term, borrowed from medical science, has largely served as the cudgel of Cognitive Behavioral Therapy (CBT) advocates eager to promote their methods and mostly derivative theories to practitioners and third party payers (i.e: insurance companies). Since the late eighties, the ‘evidence-based’ tag has been used to assert or at least imply the superiority of cognitive behavioral therapy over traditional, insight-oriented or psychodynamic approaches to mental health. The strategy has been so successful that when people speak of ‘talk therapy’, the assumption (contrary to that of, say, two generations ago) is that a psycho-educational or cognitive-behavioral approach is being referenced.

The scope of this article cannot detail all of the differences between the apparently warring factions, though I will point in what I think is the right direction. First of all, a negative suggestion: ignore Psychology Today. It dilutes issues, in my opinion, versus opening the reader’s mind. It does advertise my practice capably enough, however, so that’s all I’ll say about PT for now. Second: besides combing through the one hundred and twenty plus unheralded yet worthy blog entries on this site, readers might seek out the writings of one Jonathan Shedler, psychology professor at The University of Colorado and perhaps the foremost crusader of the last decade for the restoration of the psychodynamic therapy’s public and professional image. For at least that long Shedler has been an outspoken critic not only of CBT, but of its advocates’ tactics in marketing their method to providers, third party payers, and consumers. In Working Through Rehab, my 2013 excoriation of adolescent drug treatment, I cite Shedler’s 2010 American Psychologist article, “The Efficacy of Psychodynamic Psychotherapy”, which outlines the essential features of a psychodynamic (BTW: an umbrella term for psychoanalytically-derived models) treatment, and offers comprehensive evidence for its efficacy, contrary to the dismissive claims of CBT supporters. In his latest paper, “Where is the Evidence for Evidence-based treatment”, Shedler ups the ante with scathing condemnations of research practices of CBT advocates, more or less mocking their claims. The result makes for some entertaining reading, which I shall review here.

Tracing the history of the evidence-based (movement?), Shedler calls out the National Institute of Mental Health (NIMH) as the biggest culprit of ‘evidence-based’ misinformation, starting in the late eighties. Citing research that began a decade earlier than that, he points out that studies pertaining to treatment of anxiety and depression (the two most prominent conditions presenting in MH), indicate only minor differences between experimental CBT-treated samples and control groups on outcomes measured by the Hamilton depression scale; differences that carry statistical meaning (as in not the result of chance) but, as Shedler explains, lack significance in clinical terms, as in discernible contrasts in symptoms, presenting problems. Examining a recent study by Driessen et al. (2013), Shedler derides a method wherein 341 patients were subject to 16 sessions of manualized CBT. Though the method was proclaimed as effective, Shedler points out that only 22% indicated remission of symptoms, based upon assessments taken the day treatment ended. Shedler then points to studies suggesting that even such improvements evaporate after a short period of time and that 50% of CBT recipients seek treatment again after 6 months. And these findings beg other questions: what happened to the other 50% of patients? Did they improve significantly? Did they not improve and then give up on psychotherapy?

Moving on, Shedler generalizes his observations: the average patient receiving manualized CBT is still significantly depressed after a time-limited treatment episode; that benefits assessed after laughingly short intervals after treatment typically evaporate quickly; that most ‘evidence-based’ studies are ‘shams’, suppressing evidence that doesn’t fit preconceived agendas, publication biases extolling what he calls a “master narrative”; that criteria for patients’ participation in studies excludes those who present with more than one diagnosis, or those with personality pathology, to which (I think) most therapists would respond: wait…those are the people we see. Furthermore, Shedler complains that the so-called control groups don’t accurately represent alternative models of treatment; that while prominent or even celebrity practitioners administer the CBT treatment that is studied, psychodynamic methods are carried out by graduate students given minimal training, rendering a comparison of technique unfair. Finally, there exists in research circles what Shedler calls the ‘File drawer’ effect: the phenomenon of studies, or data within studies being suppressed, as in not published, and thereafter shelved (side note: like my Tommy article between 2012 and 2014). The missing data can be inferred from what is called a funnel effect of data, wherein small samples yield a wide range of values, versus large samples which yield a narrower range. The data is then plotted on a graph which resembles a funnel. Shedler demonstrates that gaps appear on such graphs pertaining to manualized CBT research, indicating ‘invisible’ data.

Incidentally, the term ‘manualized’ used and mocked by Shedler merits some comment, as does the rest of Shedler’s arguments, of course, though I’ll shelve most of my comments until part two of this essay, likely a week hence. Anyway, Shedler’s reference to ‘manualized’ treatment is a snide rebuke of therapies that appear to make use of workbooks, often co-written by practitioners and academics. I admit that I have a few of these manuals adorning my bookshelves, though I rarely use them. They contain examples of questions posed to patients about their conditions, designed to challenge problematic thinking; suggestions for a ‘reframing’ of a problem, or examples of homework assignments given—CBT chestnuts, I guess. The comedy in Shedler’s writing—his dismissal of ‘cookbook’ technique—verges on the nasty, but what’s significant is the background context: psychodynamic or psychoanalytic therapies/methods have been taking it on the chin for some time now; dismissed as “that Freud stuff” by pedestrian instructors, psychiatrists, peddlers of psychotropic medication, or ignoramuses positioned at various nodal points in the industry; people who pull the purse strings, or who have those peoples’ collective ear(s), who have been willing to stereotype, quite ruthlessly, the forefathers of our profession. Jonathan Shedler is one of the people at last bothering to fight back. So It’s 2016 and everyone and thing has its advocates. Including the unconscious, it seems.

 

  • I shall refrain from a list of references for this article, though each can be found via Shedler’s 2015 article, “Where is the Evidence for Evidence-Based Therapy”, available online

 

 

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