How could I forget this distinguishing characteristic or practitioners who get the best results??? In Atul Guwande’s study of effective medical practitioners, he found that those achieving the best and most consistent results (with cystic fibrosis) were very ambitious, putting pressure on themselves and their patient to get the very best response to treatment possible. They were not satisfied when the patient achieved 80% lung capacity. They would motivate, pressure and cajole the patient to go for as close to 100% as possible. In ISTDP we have very ambitious goals – not just to reduce symptoms or help people cope, but to seek complete resolution of conflicts. We hope to remove all symptoms and pathological defenses and to see them REPLACED with something healthy. This clearly has an impact on process and outcome!read more
As promised, I want to write about the most potent, but understudied, variable is psychotherapy outcome – the person of the therapist. Research by Duncan and Miller (as well as others) suggest that the top 15-20% of therapist get consistently better outcomes that the other 80% combined. Atul Guwande has written about the bell shaped curve when it comes to all medical practitioners. He concluded that, if you have an average problem, then going to see an average practitioner will be just fine. But, if you have a complex disorder – like somatization, a personality disorder or treatment resistant depression, for example, then who you see makes all the difference. Finding what Duncan and Miller refer to as a “super shrink” is required to get positive results in these cases.
So what qualities do these “super shrinks” possess? They tend to have a combination of qualities that are more powerful than the particular techniques they use – though they all tend to be passionate about what they do and how they do it. This may seem like a paradox. Randomized clinical trials repeatedly reveal that most therapies are effective, but none more than others. However, when we look at the super shrinks and their outstanding results, it turns out they are all passionate about their method (whether it is CBT or ISTDP) and apply their methods in a systematic but FLEXIBLE manner, given the needs and capacities of the patient. This combination of passionate engagement and flexibility, with an openness to learning and feedback are hallmarks of this group of clinicians. They are humble, admit mistakes, and change when given useful feedback. They are confident and approachable, and are masters at dealing with relationships, especially in handling negative feelings and conflict. Therapists who avoid these negative feelings get poor results, and their patients often drop out. In fact, other than the expense involved in therapy, the number one reason for dropping out of therapy was the patient’s lack of faith in the therapist. Other therapist variables that contribute to NEGATIVE outcome are being defensive, authoritarian, rigid and dominant.
We also know that the best therapists create and maintain a focus in their therapies, while lack of focus is the hallmark of those who tend to produce poor outcomes. Research suggests that most therapists are not very accurate in their self appraisal and could benefit a great deal from seeking feedback from patients on a routine basis.. Since the average drop out rate in psychotherapy is 47%, most of us fit in this category!
As a trainer and supervisor, I always keep in mind two central commitments – to teaching specific skills and techniques to enhance therapeutic effectiveness, while facilitating the personal development of the therapist. Especially when it comes to the emotionally intense work required in ISTDP, helping therapists to deal with their own anxiety and mixed feelings without resorting to defenses, is essential. In my view, we need to practice what we preach and make our best effort to “be the change” we seek to facilitate in our patients.
In my next post, I will write about the unconscious alliance, with an emphasis on the contribution of both patient and therapist to the development of this powerful force for healing.
Hope you are all enjoying your summer. Write and join the discussion!
These are exciting times in our field. There is increasing agreement from different areas of study, including developmental research, neuroscience and psychotherapy outcome studies, that we are emotional creatures, making most of our decisions on an emotional, rather than rational or logical basis. The cognitive revolution appears to be dead, now that our understanding of human functioning suggests that we are wired for emotion and for emotional connection with others. This emotional activation happens at lightening speed and is essentially an unconscious process. Not only have behavioral scientists come to understand this, but economists, market researchers, and the general public are now on to this new idea. David Brooks has just written a book for the general public called The Social Animal, which lays out the evidence for the public.
Within our field, there is also increasing agreement about the centrality of emotional awareness and regulation for both emotional and physical health and well being. Accumulating evidence suggests that the link between emotions and health is enormous. James Pennebaker has been researching this link for decades. The results clearly suggest that those who are aware of their emotions and allow themselves to experience and express them freely are happier, more productive, and healthier than their repressive cohorts. It seems that those who chronically repress their emotions simultaneously suppress their immune system, rendering them vulnerable to all kinds of illnesses. Conversely, those who focus on their feelings, especially regarding the most troubling and traumatic experiences of their lives, get a boost in immune functioning.
Even the pioneers of Cognitive Behavior Therapy, most notably, David Barlow, have come to conclude that we only need one therapy for all psychological disorders; namely a unified treatment that focuses on the awareness and regulation of emotion.In the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (2011), Barlow writes, “individuals with emotional disorders use maladaptive emotional regulation strategies – namely, attempts to avoid or dampen the intensity of uncomfortable emotions – which ultimately backfire and contribute to the maintenance of their symptoms” (pg.17). Given this, he suggests that our treatment efforts be designed to “help patients learn how to confront and experience uncomfortable emotions, and to respond to their emotions in more adaptive ways”. This is what psychodyanmic theory has always proposed, and what Intensive Short Term Dynamic Psychotherapy has been designed to facilitate.
Why re-invent the wheel? Those who have been educated in the study of unconscious processes and dynamic psychotherapy clearly have an advantage here. Studies by Allan Abbass substantiate the view that Intensive short term Dynamic Psychotherapy is both cost effective and clinically effective. The data indicate that physical health improves markedly, in alignment with emotional health and well being.
I look forward to a wide and spirited discussion about these issues.
Patricia Coughlin, Ph.D.
March 31, 2011read more