Posts Tagged ‘therapist’

By Allen Frances, MD

There are 3 consistent research findings that should make a world of difference to therapists and to the people they treat.

1. Psychotherapy works at least as well as drugs for most mild to moderate problems and, all things being equal, should be used first

2. A good relationship is much more important in promoting good outcome than the specific psychotherapy techniques that are used

3. There is a very high placebo response rate for all sorts of milder psychiatric and medical problems

This is partly a “time effect”—people come for help at particularly bad times in their lives and are likely to improve with time even if nothing is done. But placebo response also reflects the magical power of hope and expectation. And the effect is not just psychological—the body often actually responds to placebo just as it would respond to active medication.

These 3 findings add up to one crucial conclusion—the major focus of effective therapy should be to establish a powerfully healing relationship and to inspire hope. Specific techniques help when they enhance the primary focus on the relationship; they hurt when they distract from it.

The paradox is that therapists are increasingly schooled in specific techniques to the detriment of learning how to heal. The reason is clear—it is easy to manualize technique, hard to teach great healing.

I have, therefore, asked a great healer, Fanny Marell, a Swedish social worker and licensed psychotherapist, to share some of her secrets. Ms Marell writes:

Many therapists worry so much about assessing symptoms, performing techniques, and filling out forms that they miss the wonderful vibrancy of a strong therapeutic relationship.

Thinking I can help someone just by asking about concerns, troubles, and symptoms is like thinking that I can drive a car solely by looking in the rearview mirror. Dreams, hopes, and abilities are seen out of the front window of the car and help us together to navigate the road ahead. Where are we going? Which roads will you choose and why? It surely will not be the same roads I would take. We are different—we have to find your own best direction.

If we focus only on troubles and diagnosis, we lose the advantage of capitalizing on the person’s strengths and resources. If I am to help someone overcome symptoms, change behaviors, and climb out of difficult situations, I need to emphasize also all the positives he brings to the situation. Therapy without conversations about strengths and hopes is not real therapy.

And often most important: Does the patient have a sense of humor? Laugh together! Be human. No one wants a perfect therapist. It is neither credible nor human.

Symptom checklists and diagnoses play a role but they do not give me an understanding of how this person/patient understands his world and her troubles.

And don’t drown in manuals, missing the person while applying the technique.

People come to me discouraged and overwhelmed—their hopes and dreams abandoned. Early in our time together, I ask many detailed questions about how they would like life to change. What would you do during the day? Where would you live? What would your relationship to your family be like? What would you do in your spare time? What kind of social circle would you have? By getting detailed descriptions, I get concrete goals (eg, I want to go to school, argue less with my parents, spend more time with friends).

Almost always, working with the family is useful; sometimes it is absolutely necessary. What would be a good life for your child? How would it affect you?

Sometimes our dreams are big, perhaps even too extravagant; sometimes they are small and perhaps too cautious. But dreams always become more realistic and realizable when they are expressed. Sharing a dream and making it a treatment goal helps the person make a bigger investment in the treatment, and to take more responsibility for it. He becomes the driver and the therapist may sit in the back seat.

Because my first conversation is not just about symptoms and troubles, we start off on a basis of realistic hope and avoid a negative spiral dominated only by troubles. Problems have to be faced, but from a position of strength, not despair and helplessness.

Having a rounded view of the person’s problems and strengths enriches the therapeutic contact and creates a strong alliance.

Thanks, Ms Marell, for terrific advice. Some of the best natural therapists I have known have been ruined by psychotherapy training—becoming so preoccupied learning and implementing technique that they lost the healing warmth of their personalities.

Therapy should always be an exciting adventure, an intense meeting of hearts and minds. You can’t learn to be an effective therapist by reading a manual and applying it mechanically.

I would tell therapists I supervised never to apply what we discussed to their next session with the patient, lest they would always be a week behind. Therapy should be informed by technique, but not stultified by it.

See more at: http://www.psychiatrictimes.com/blogs/couch-crisis/magical-healing-power-caring-and-hope-psychotherapy?GUID=C523B8FD-3416-4DAC-8E3C-6E28DE36C515&rememberme=1&ts=16072015#sthash.2AOArvAW.dpuf

By Suzanne Allard Levingston

With her hair pulled back and her casual office attire, Ellie is a comforting presence. She’s trained to put patients at ease as she conducts mental health interviews with total confidentiality.

She draws you into conversation: “So how are you doing today?” “When was the last time you felt really happy?” She notices if you look away or fidget or pause, and she follows up with a nod of encouragement or a question: “Can you tell me more about that?”

Not bad for an interviewer who’s not human.

Ellie is a virtual human created by scientists at the University of Southern California to help patients feel comfortable talking about themselves so they’ll be honest with their doctors. She was born of two lines of findings: that anonymity can help people be more truthful and that rapport with a trained caregiver fosters deep disclosure. In some cases, research has shown, the less human involvement, the better. In a 2014 study of 239 people, participants who were told that Ellie was operating automatically as opposed to being controlled by a person nearby, said they felt less fearful about self-disclosure, better able to express sadness and more willing to disclose.

Getting a patient’s full story is crucial in medicine. Many technological tools are being used to help with this quest: virtual humans such as Ellie, electronic health records, secure e-mail, computer databases. Although these technologies often smooth the way, they sometimes create hurdles.

Honesty with doctors is a bedrock of proper care. If we hedge in answering their questions, we’re hampering their ability to help keep us well.

But some people resist divulging their secrets. In a 2009 national opinion survey conducted by GE, the Cleveland Clinic and Ochsner Health System, 28 percent of patients said they “sometimes lie to their health care professional or omit facts about their health.” The survey was conducted by telephone with 2,000 patients.

The Hippocratic Oath imposes a code of confidentiality on doctors: “I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.”

Nonetheless, patients may not share sensitive, potentially stigmatizing health information on topics such as drug and alcohol abuse, mental health problems and reproductive and sexual history. Patients also might fib about less-fraught issues such as following doctor’s orders or sticking to a diet and exercise plan.

Why patients don’t tell the full truth is complicated. Some want to disclose only information that makes the doctor view them positively. Others fear being judged.

“We never say everything that we’re thinking and everything that we know to another human being, for a lot of different reasons,” says William Tierney, president and chief executive of the Regenstrief Institute, which studies how to improve health-care systems and is associated with the Indiana University School of Medicine.

In his work as an internist at an Indianapolis hospital, Tierney has encountered many situations in which patients aren’t honest. Sometimes they say they took their blood pressure medications even though it’s clear that they haven’t; they may be embarrassed because they can’t pay for the medications or may dislike the medication but don’t want to offend the doctor. Other patients ask for extra pain medicine without admitting that they illegally share or sell the drug.

Incomplete or incorrect information can cause problems. A patient who lies about taking his blood pressure medication, for example, may end up being prescribed a higher dose, which could send the patient into shock, Tierney said.

Leah Wolfe, a primary care physician who trains students, residents and faculty at the Johns Hopkins School of Medicine in Baltimore, said that doctors need to help patients understand why questions are being asked. It helps to normalize sensitive questions by explaining, for example, why all patients are asked about their sexual history.

“I’m a firm believer that 95 percent of diagnosis is history,” she said. “The physician has a lot of responsibility here in helping people understand why they’re asking the questions that they’re asking.”

Technology, which can improve health care, can also have unintended consequences in doctor-patient rapport. In a recent study of 4,700 patients in the Journal of the American Medical Informatics Association, 13 percent of patients said they had kept information from a doctor because of concerns about privacy and security, and this withholding was more likely among patients whose doctors used electronic health records than those who used paper charts.

“It was surprising that it would actually have a negative consequence for that doctor-patient interaction,” said lead author Celeste Campos-Castillo of the University of Wisconsin at Milwaukee. Campos-Castillo suggests that doctors talk to their patients about their computerized-record systems and the security measures that protect those systems.

When given a choice, some patients would use technology to withhold information from providers. Regenstrief Institute researchers gave 105 patients the option to control access to their electronic health records, broken down into who could see the record and what kind of information they chose to share. Nearly half chose to place some limits on access to their health records in a six-month study published in January in the Journal of General Internal Medicine.

While patient control can empower, it can also obstruct. Tierney, who was not involved as a provider in that study, said that if he had a patient who would not allow him full access to health information, he would help the patient find another physician because he would feel unable to provide the best and safest care possible.

“Hamstringing my ability to provide such care is unacceptable to me,” he wrote in a companion article to the study.

Technology can also help patients feel comfortable sharing private information.

A study conducted by the Veterans Health Administration found that some patients used secure e-mail messaging with their providers to address sensitive topics — such as erectile dysfunction and sexually transmitted diseases — a fact that they had not acknowledged in face-to-face interviews with the research team.

“Nobody wants to be judged,” said Jolie Haun, lead author of the 2014 study and a researcher at the Center of Innovation on Disability and Rehabilitation Research at the James A. Haley VA Hospital in Tampa. “We realized that this electronic form of communication created this somewhat removed, confidential, secure, safe space for individuals to bring up these topics with their provider, while avoiding those social issues around shame and embarrassment and discomfort in general.”

USC’s Ellie shows promise as a mental health screening tool. With a microphone, webcam and an infrared camera device that tracks a person’s body posture and movements, Ellie can process such cues as tone of voice or change in gaze and react with a nod, encouragement or question. But the technology can neither understand deeply what the person is saying nor offer therapeutic support.

“Some people make the mistake when they see Ellie — they assume she’s a therapist and that’s absolutely not the case,” says Jonathan Gratch, director for virtual human research at USC’s Institute for Creative Technologies.

The anonymity and rapport created by virtual humans factor into an unpublished USC study of screenings for post-traumatic stress disorder. Members of a National Guard unit were interviewed by a virtual human before and after a year of service in Afghanistan. Talking to the animated character elicited more reports of PTSD symptoms than completing a computerized form did.

One of the challenges for doctors is when a new patient seeks a prescription for a controlled substance. Doctors may be concerned that the drug will be used illegally, a possibility that’s hard to predict.

Here, technology is a powerful lever for honesty. Maryland, like almost all states, keeps a database of prescriptions. When her patients request narcotics, Wolfe explains that it’s her office’s practice to check all such requests against the database that monitors where and when a patient filled a prescription for a controlled substance. This technology-based information helps foster honest give-and-take.

“You’ve created a transparent environment where they are going to be motivated to tell you the truth because they don’t want to get caught in a lie,” she said. “And that totally changes the dynamics.”

It is yet to be seen how technology will evolve to help patients share or withhold their secrets. But what will not change is a doctor’s need for full, open communication with patients.

“It has to be personal,” Tierney says. “I have to get to know that patient deeply if I want to understand what’s the right decision for them.”

Few concepts in popular psychology have gotten more attention over the last few decades than self-esteem and its importance in life success and long-term mental health. Of course, much of this discussion has focused on young people, and how families, parents, teachers, coaches, and mentors can provide the proper psychological environment to help them grow into functional, mature, mentally stable adults.

Research shows that low self-esteem correlates with poorer mental health outcomes across the board, increased likelihood of suicide attempts, and difficulty developing supportive social relationships. Research also shows that trying to raise low self-esteem artificially comes with its own set of problems, including tendencies toward narcissism, antisocial behavior, and avoiding challenging activities that may threaten one’s self-concept.

This division in the research has led to a division amongst psychologists about how important self-esteem is, whether or not it’s useful to help people improve their self-esteem, and what the best practices are for accomplishing that.

In one camp, you have people who believe improving self-esteem is of paramount importance. On the other side of the fence are those who feel the whole concept of self-esteem is overrated and that it’s more critical to develop realistic perceptions about oneself.

But what if we’ve been asking the wrong questions all along? What if the self-esteem discussion is like the proverbial finger pointing at the moon?

New research is suggesting this may indeed be the case, and that a new concept — self-compassion — could be vastly more important than self-esteem when it comes to long-term mental health and success.

Why the Self-Esteem Model Is Flawed

The root problem with the self-esteem model comes down to some fundamental realities about language and cognition that Acceptance and Commitment Therapy (ACT, pronounced all as one word) was designed to address.

The way psychologists classically treat issues with self-esteem is by having clients track their internal dialog — especially their negative self talk — and then employ a number of tactics to counter those negative statements with more positive (or at least more realistic) ones. Others attempt to stop the thoughts, distract themselves from them, or to self sooth.

Put bluntly, these techniques don’t work very well. The ACT research community has shown this over and over again. There are many reasons that techniques like distraction and thought stopping tend not to work — too many to go into all of them here. For a full discussion, see the books Acceptance and Commitment Therapy or Get Out of Your Mind and Into Your Life. For the purposes of our discussion here, we will look at one aspect of this: How fighting a thought increases its believability.

Imagine a young person has the thought, “There is something wrong with me.” The classic rhetoric of self-esteem forces this person to take the thought seriously. After all he or she has likely been taught that having good self-esteem is important and essential for success in life. If they fight against the thought by countering it, however, that means the thought is confirmed. The thought is itself something that is wrong with the individual and has to change. Every time they struggle against it, the noose just gets tighter as the thought is reconfirmed. The more they fight the thought, the more power they give it.

This is a classic example of why in ACT we say, “If you are not willing to have it, you do.”

The simple fact is, we can’t always prevent young people from experiencing insecurity and low self-esteem. Heck, we can’t eliminate those feelings in ourselves. All people feel inadequate or imperfect at times. And in an ever-evolving, ever-more complex world, there is simply no way we can protect our young people from events that threaten their self-esteem — events like social rejection, family problems, personal failures, and others.

What we can do is help young people to respond to those difficult situations and to self-doubt with self-compassion. And a couple of interesting studies that were recently published show that this may indeed offer a more useful way forward not only for young people, but for all of us.

What Is Self-Compassion?

Before we look at the studies, let’s take a moment to define self-compassion.

Dr. Kirstin Neff, one of the premier researchers in this area, defines self-compassion as consisting of three key components during times of personal suffering and failure:
1. Treating oneself kindly.
2. Recognizing one’s struggles as part of the shared human experience.
3. Holding one’s painful thoughts and feelings in mindful awareness.

Given this context, the negativity or positivity of your thoughts isn’t what’s important. It’s how you respond to those thoughts that matters. Going back to the example above — “There is something wrong with me” — instead of fighting against that thought or trying to distract yourself from it, you could notice this thought without getting attached to it (become mindful), understand that it is common to all humans and part of our shared experience as people, and then treat yourself kindly instead of beating yourself up.

Does this approach really work better than simply improving self-esteem?

It seems it does.

A just-published longitudinal study that followed 2,448 ninth graders for a year found that low self-esteem had little effect on mental health in those who had the highest levels of self-compassion. That means that even if they had negative thoughts, those thoughts had minimal impact on their sense of well-being over time as compared to peers who didn’t have self-compassion skills.6

This suggests that teaching kids who suffer from self-esteem issues to be more self-compassionate may have more benefit than simply trying to improve their self-esteem.

The question is: How do we do that?

As it turns out, this is exactly where ACT excels.

Using ACT to Enhance Self-Compassion

Knowing that enhancing self-compassion has been shown not only to mitigate problems with self-esteem, but also impacts other conditions including traumatic stress. Jamie Yadavaia decided to see in his doctoral project if we could enhance self-compassion using ACT.

The results were promising.

A group of 78 students 18 years or older was randomized into one of two groups. The first group was put in a “waitlist condition” which basically means they received no treatment. The other group was provided with six hours of ACT training.

As anticipated, ACT intervention led to substantial increases in self-compassion over the waitlist control post-treatment and two months after the intervention. In this group self-compassion increased 106 percent — an effect size comparable to far longer treatments previously published. Not only that, but the ACT treatment reduced general psychological distress, depression, anxiety, and stress.

At the heart of all these changes was psychological flexibility, this skill seemed to be the key mediating factor across the board, which makes sense. After all, learning how to become less attached to your thoughts, hold them in mindful awareness, and respond to them with a broader repertoire of skills — like self-kindness, for example — has not only been posited in the self-compassion literature as a core feature of mental health but proven time and again in the ACT research as essential for it.

Taken together these studies have an important lesson to teach all of us.

It’s time for us to put down the idea that we have to think well of ourselves at all times to be mature, successful, functional, mentally healthy individuals. Indeed, this toxic idea can foster a kind of narcissistic ego-based self-story that is bound to blow up on us. Instead of increasing self-esteem content what we need to do is increase self-compassion as the context of all we do. That deflates ego-based self-stories, as we humbly accept our place as one amongst our fellow human beings, mindfully acknowledging that we all have self-doubt, we all suffer, we all fail from time to time, but none of that means we can’t live a life of meaning, purpose, and compassion for ourselves and others.

http://www.huffingtonpost.com/steven-c-hayes-phd/is-selfcompassion-more-im_b_6316320.html