Tag Archives: cognitive behavioral therapy

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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Sex Offender Treatment: Just Say No to the Dodo


Talk about reductionist thinking: try this corner of the mental health industry. It’s a dark little corner, where the journeymen and women of our profession go…because someone has to, supposedly. Not that therapists are wanted, necessarily. As in the treatment mileus depicted in my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, administrators and directors of SO treatment programs, or the “supervising officers” (euphemism for correctional officers) that are actually in charge of the three-headed mon–sorry–treatment team, want straightforward instructors for implementing of program protocols. They want containment based upon a structured approach designed to elicit successful behavioral outcomes–a teleological perspective.
       Recidivism: the repetition of offending behavior. That’s the operative concept in sex offender treatment: the standard by which this entire arena of care is judged, or will be judged, if it is indeed on trial. And why not? you may ask. Surely the problem of sexual abuse needs to be addressed as aggressively as possible, with a behavioral lens front and center; with recidivism the criteria for assessing everyone in the process, participants and providers alike.
       The problem is with the research, and thereafter with the spinning upon said research for anxious listeners. At a recent presentation of sex offender treatment protocols at a CCOSO (California Coalition on Sex Offending) conference, I listened to program officials assert the need to implement a structured treatment program consisting of an RNR (Risk Needs Responsivity) model, in conjunction with Cognitive Behavioral Therapy (CBT), and that unstructured psychotherapy (unclear what that was referring to–perhaps the aforementioned “Freud stuff”) was contra-indicated (meaning, ill-advised), because its methods were not associated with a significant decrease in recidivism. By RNR model, presenters were alluding to the work of criminologists Don Andrews and James Bonta, who outlined what are termed dynamic risk factors central to treatment, alongside corresponding so-called criminogenic needs. The list of factors include some of the following: antisocial personality, antisocial cognitions, social support for crime (meaning, friends or family with criminal attitudes), impulsive behavior, family dysfunction–again, such as criminality, low education. Other factors of ancillary importance are early childhood negative experiences, family of origin stressors, age, gender, and ethnicity. Spot the issue yet? Well, the likes of Ward, Melser, and Yates (2007) did, opining that the RNR etiological theory was too general to explain criminal conduct, and as a result, was unfalsiable–meaning, not especially useful.
        As for recidivism, the research here is generally thin and unconvincing. According to Duwe and Goldman (2009), a reduction of 18% in sexual recidivism existed for one in-prison treatment program. But researcher Stephen Brake, who in 2010 published his examination of 37 studies of sex offender treatment outcomes conducted over a quarter century, found that only 41% of such studies indicated reductions in recidivism, with 37% not significantly reducing recidivism, and a remainder of studies indicating mixed, partial evidence based upon different factors (violent versus non-violent recidivism, for example). Overall, it’s been known since the early 90s (via federal reports) that sex offenders exhibit among the lowest recidivism rates (4-12%–tracked over 5 years), compared to other criminal profiles. But it’s unclear whether such findings can be attributed to specific treatment models. The authors of another meta-analysis study, Losel and Schumacker (2005), concluded that there is a significant effect of treatment on recidivism, but the studies they examined indicated treatment programs that featured not only CBT methods, but also surgical castration. Pardon me while I imagine the principals of each intervention strategy arguing over whose method worked best.
       Several critics point out basic problems with research into sex offender treatment: findings that indicate as much effect upon recidivism for no-treatment versus treatment; inadequate control groups; the fact that sex crimes are the least reported types of crimes (thus confounding statistics on recidivism). Add to this discrepancies in study designs, outcome measurement protocols, time-frames for follow-up, and what researchers have is a messy globule of information that strains against the community’s desire for straightforward action. Critics of the RNR model point out its limitations: the opinion that attention to criminogenic needs is insufficient, and that attention must be paid to individual needs, self-esteem issues, personal distress; that treatment alliance is an unassailable factor in positive treatment outcomes. Amen, I say. However, these are borderline heresies for those presenting on the topic of sex offender treatment, for sex offenders aren’t really allowed to talk about personal distress and low self esteem–at least, not until they’ve admitted to all of their crimes and then said they were sorry…like, really sorry. And so, with all this in mind, I wade into this dodgy realm of care, becoming a ‘certified’ provider of sex offender treatment. Why? because I have some clients who fit the profile, and because they are people about whom I care. I’ll nod my head at the pronouncements of those looking to codify practices and reign in the unconscious. I’ve got my eye on the Dodo.
* Stephen Brake (2010) The Effectiveness of Treatment for Adult Sex Offenders.

* Ward, Melser, and Yates (2007) Aggression and Violent Behavior, 12, 208-228.

* Losel and Schumacker (2005) The effectiveness of treatment for sexual offenders. Journal of Experimental Criminology, 1, 117-146.

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

Shedler’s comprehensive research informs us that psychodynamic practices are not only effective, but arguably more so than its rival models. The effect sizes he reports following numerous meta analyses are consistently higher than those attributed to cognitive behavioral therapy, and furthermore, the effect sizes linked to psychodynamic approaches increase over time; that is, from short-term follow up studies to longer-term follow up studies. This suggests that in-depth psychodynamic therapy sets in motion a set of changes for people that acquire momentum over time, and are ongoing.

Yet these findings don’t speak to the issues that I presented to that frozen audience in the community mental health setting–that audience, comprised as it was with overworked souls more typcially compelled to hear rote trainings in which smug pedogogues pitch bullet-pointed treatment manuals: the evidence-based droning about quantifying treatment goals and codifying methods. The irony, Shedler asserts, is that many who work under the banner of CBT actually practice methods at least derived from psychoanalysis. In my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, I allude to this curious trend. Writing anecdotally, I reference several terms, like “splitting”, “denial”, “failure to thrive”, and “containment”, which are used regularly in settings purportedly driven by a CBT philosophy, but which have a psychoanalytic pedigree. Shedler implies that many practitioners are unwittingly using psychodynamic language and methods; which sounds a bit like rock musicians who aren’t aware of the blues roots of their craft. He cites a study by Ablon and Jones (1998), who interviewed experts in CBT and psychoanalysis, asking them to define their models such that use of objective tools like the so-called Q-sort assessment (blind raters, listening to audio tapes of sessions, tracking specific interventions) could be understood. The psychoanalytic experts cast the umbrella psychodynamic process as follows: allowing for an unstructured dialogue, the identification of recurrent themes, linking feeling states to past experiences, and giving attention to intrapsychic defenses, and to “unacceptable” feelings. I can see in my mind the disdainful head shakes of those who think this a waste of time; something only the privileged might pay for. The CBT experts in the study emphasized a more specific focus in therapy–a process actively structured by therapists taking on didactic, teacher-like roles. They give advice, discuss goals, and focus generally on current life stressors or (in the case of those mandated into tx.), objectives assigned externally: far more popular with industry onlookers looking to streamline methodology.

But get this: the investigators measured therapist adherence to models without regard to what therapists believed they were applying: Beck’s treatment model, apparently. Upon reading verbatim transcripts, investigators of this study tracked the following variables: quality of therapeutic alliance; addressing cognitive distortions by patients; patients’ experience of emotion; gaining awareness from previously implicit meanings and feelings. The thing is, only one of these variables truly belongs to the canon of cognitive behavioral therapy–addressing cognitive distortions. Therapeutic alliance and the importance of establishing therapeutic alliance is a concept that has been written about in psychoanalytic literature for decades. Implicit process? Practically synonymous with the unconscious. And BTW: only one of these variables, focus on cognitive distortions, was associated with poorer treatment outcomes. Oops! Regarding the ambiguous term “experiencing”, there is a fascinating breakdown of meaning by researchers: Shedler refers to the experiencing of feelings to distinguish it from a defensive expression of feeling, or an absence of feeling. A person can, for example, be speaking of him or herself and their life, and be doing so truthfully, but also intellectually; that is, without emotion. Also, a person can be speaking emotionally, but focused upon external phenomena, and thus be blocked from learning how events relate to self. The premises of psychodynamic treatment call for people to integrate thought and emotion, reflect upon self and other, and to recognize needs and viewpoints of self and other in such a manner that holds each in equilibrium–neither subordinate to the other, ultimately.

These were among the things I hoped to stir in my patients/clients when I worked in community mental health. They were the variables of treatment success I suggested to newer therapists as I later became a clinical supervisor. Roughly, and anecdotally speaking, these were the outcomes that were clearly sought by the consumers of all this dross we call therapy.

* Ablon, J., Jones, E. (1998) How expert clinicians’ prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive behavioral therapy. Psychotherapy Research, 9, 71-83.

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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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