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Learn about the importance of talk therapy in addressing the mental health crisis in America, including rising rates of depression and anxiety, and explore the qualities and personalities of excellent talk therapists. Discover if therapy can be taught and the impact of life experiences and education on therapists. Challenge common beliefs about treatment approaches and understand the essential ingredients of effective psychotherapy.
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Interpersonal Wisdom Allowing your natural gifts to flourish in talk therapy
Mental Health Crisis in America • Depression and Anxiety on the increase. • 2/3 of women report extreme stress. • Middle aged men in deep despair. • Crisis of resilience on college campuses. • Drug abuse up. • Mass shootings way up. • Faith in government way down. • Trust in each other way down. • Pharmaceutical use way up.
Are excellent Talk Therapists born or bred? • Are there natural Healers? • What qualities do they possess? • Is there a Talk Therapy personality type? • Are there bad shrink personalities? – people that should not be therapists. • Why do people become therapists?
Born or Bred continued • Can great therapy be taught? • Does our current educational process cultivate great therapists? • Does clinical supervision cultivate great therapists? • Which life experiences cultivate great therapists?
Does graduate education work?Source – Miller and Hubble, The Road to Mastery, Psych Networker (May 2011) In a comparative study of licensed doctoral-level providers, pre- doctoral interns, and practicum students that appeared in the Journal of Counseling & Development, Scott Nyman, Mark Nafziger, and Timothy Smith found “the extensive efforts involved in educating graduate students to become licensed professionals result in no observable differences in client outcome.”
Interpersonal Wisdom The everyday excellent talk therapist capacities, which are a constellation of skills, attitudes, behaviors, beliefs, and some difficult to describe ways of being.
Superiority Complex? Despite common counseling folklore, there is little or no difference in outcome between treatment approaches. No model has proven to be any better than any other model. All approaches work about equally well (Wampold, Miller).
CBT off its pedestal Socialstyrelsen, the National Mental Health Board in Sweden has officially ended the CBT mandate. Providers are now encouraged to be flexible and offer their clients choices.
What we think we know Demographic factors (race, gender, age, cultural background), professional identity (counseling vs. psychology vs. social work) and even professional experience (defined as years of practice) are unrelated to counseling outcome (or at least overrated in the therapeutic relationship).
What this means Matching of clients and counselors on these dimensions (e.g. client and counselor of same race working together) does not (necessarily) result in increased efficacy.
End psychiatry monopoly? Allen Frances, MD New York Times (May 2012) The psychiatrist who lead the DSM - 4 Task Force now says he believes psychiatrists should not be the only professionals given the right to determine what is or is not a mental illness.
What he did not say There is little evidence to suggest that a particular psychiatric diagnosis guides the practitioner toward the selection of a particular treatment.
Essential psychotherapy ingredients-Frank • An emotionally–charged confiding relationship with a helping person. • A healing setting. • A rationale, conceptual scheme, or myth. • A ritual or procedure.
Jerome Frank Creed • Psychotherapy achieves its effects largely by directly treating demoralization and only indirectly treating overt symptoms of covert psychopathology.
Inspiration from Carl Whitaker “ Psychotherapy is by its very nature a counter-cultural enterprise.” “All great psychotherapy involves risk.”
Ways we professionals get in trouble • Distancing ourselves from others’ pain (therapeutic defense or burnout). • Acting like an “expert” unless they want us to act like an expert. • Hiding behind our roles. • Poor differentiation. • Ego investment in others’ recovery. • Sticking to a manual – more later.
Talk Therapy works • The average treated psychotherapy client is better off than 80% of the untreated sample (Wambold, 2001). • The average psychotherapy client does 4 times better than the untreated client. • But there is a great range of effectiveness among clients and therapists.
Hot off the PressesDoes Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials - Elllen Driessen , Steven D. Hollon, Claudi L. H. Bockting, Pim Cuijpers, Erick H. Turner - September 30, 2015 • The efficacy of psychological interventions for depression has been overestimated in the published literature, just as it has been for pharmacotherapy. • Both are efficacious but not to the extent that the published literature would suggest. • Published literature overestimates the effects of the predominant treatments for depression. Studies with poor outcomes are omitted from the literature. In other words, researchers lie.
Good News from this new study • Psychotherapy was found clearly superior to a variety of placebo and no-treatment controls, including treatment-as-usual, pill-placebo, and non-specific control conditions. • No differences in outcome were found between treatment approaches • No differences in outcome were found between psychological treatments and anti-depressant medication. • Finally, the effect of psychotherapy plus medications was superior to anti-depressant medication alone.
Perceptions • The least effective therapists often believe they are as effective as the most effective therapists. (Duncan, 2006) • Consumers have a very low perception of the therapy profession, rating us below car salesman and just above lawyers. (CR) • How can we change that?
Are providers interchangeable? In most effectiveness studies it is assumed that the therapist can be an independent variable that can apply the specific model ingredients with absolute fidelity.
Not PC Therapy Truths • All Models Work! (Dodo) • The alliance is king. • It’s the Therapist Stupid! • General Effects Prevail. • Allegiance Effects - Critical.
Talk Therapy Truths continued • Between Therapist Differences exceed Between Treatment Differences. • Therapy is: • 4 X as Effective as No Treatment. • 2 X as Effective as Placebo. • 25% of Clients Improve Before Therapy. • 50% Change after 7-9 Sessions. • 50% Recover After 7-9 Sessions.
Debunking a myth Past Treatment Failures do not predict whether the client will have a bad outcome in a current encounter. -Wambold
Common Factors Radicalism • Extra-therapeutic Factors. • Relationship Factors. • Hope and Expectancy. • Model and Technique.
Treatment approach • Accounts for a small portion of the variance in client outcomes – in some studies zero. • Setting and Therapist factors have a significantly higher positive effect.
Shrink Relationships Matter In one study the top third of psychiatrists had better outcomes even with a placebo than the bottom third psychiatrists with an SSRI. Apparently the person of the psychiatrist makes a difference in the response to anti-depressant medication. McKay, Imel, and Wampold, Journal of Affective Disorders (2006)
It’s the Relationship Interpersonally wise talk therapists recognize that their ability to balance allegiance to an approach, boldness (especially early in treatment), empathy, and responsiveness creates the best opportunity for a healing alliance.
What do clients want? • When clients are asked after the conclusion of therapy what made it work for them, most people say, “I could tell my therapist liked (respected) me”. • Therefore, if you cannot like (respect) your client refer her/him to someone else.
Being in alliance • Determining and aligning with the client’s stage of change (MI, P and D, and De Shazer). • Applying Rogerian principles. • Working with goals. • Working with tasks. • Seeking regular feedback. • Continuously maneuvering within the evolving relationship.
Client-Direction Bring your relational complexity to the process and “feel out” how that fits with what that client likes and needs. - Barry Duncan 2006
Supershrink qualities (Scott Miller) • Have lower initial SRS scores • Non-conventional people • Supervisors and other therapists could not tell which therapists were super.
Model infidelity • Not Model Fidelity • The erroneous EST mythology. • If we can’t measure it then it does not exist. – What? • We need courageous therapists that practice outside the box.
Documentation Nightmare • In clinic settings, therapists spend up to 50% of their time doing paperwork. • Research shows that a high documentation to clinical service ratio leads to higher rates of: • Burnout and job dissatisfaction among clinical staff. • Fewer scheduled treatment appointments. • No shows, cancellations, and disengagement among consumers.
Caring the right amount - Providing some direction AND containment when needed.
