Rob and I have been part of a conversation on Facebook with someone who still believes that specific factors are responsible for effectiveness in psychotherapy. Facebook is usually just a place to hang out with people who think like you do, and I’m not sure if I’m just lucky but I really enjoy waking to the expansive musings of my friends and the mostly nourishing and sustaining things that they share. (American politics aside).

This last conversation reminded me of when I was 9 and in a Catholic private hospital after having my appendix out deep in conversation with a creationist of similar age who could not hear the Darwinian dogma on which I was raised. It was finally the cleaning lady who put end to the debate by declaring that God made the world. And that was that.

So I’ve been musing about beliefs, and rather than sermonising on what I think, I thought I’d share a funny story.

I don’t believe the moon landing happened. Sure, if you show me the evidence, and I judge you have the authority to know, I can get to a place where I accept it probably happened, but in my core I have the quirky experience of not believing. Don’t get me wrong, I love that JFK made it happen, and “The Dish” is one of my favourite movies, but when I look into my soul I just don’t believe.

I was just a toddler in 1969 and language was not my strong suit. Only my brother who was 2 years older could understand what I said, so I doubt I was very focused on the hoopla of the day. I was busy drawing cats and wondering why my parents couldn’t see the importance of me having one, and socializing with lizards and sugar ants in our back yard. My world was comfortably small and fascinating. It wasn’t until years later that my parents gave me a box set of Gerald Durrel books that I found someone who understood my world.

As the years passed I heard of this moon landing thing that was televised live, but we couldn’t even watch a football game live, and my Dad, who was a sports teacher, would have to wait for the recordings to be televised. I’m not sure when we got a telephone, but it had to be more than 4 years after the moon landing, and it had wires. There were no wires hanging from the moon.

I think that my lived experience was one where the moon landing could not have happened.

It’s such a quirky thing, and my husband and family who were all older think it’s funny. In fact it’s become a party trick… “Ask Gabrielle if she believes in the moon landing” and then the snickers happen, including from my own children. My brother said he would get me a telescope so I could see the flag and all the stuff left behind. I said it would be enough for me to hear that he had seen… but he hadn’t.

When I’m with a client who has a rigid belief that is keeping them stuck in their problem, I am trying to sit with it, as I do my own quirky beliefs, and notice how we can actually get to acceptance of an alternate view, without really letting go. I think that is preferable to head butting, or making wrong.

I have been inspired by Scott Millers workshop in San Diego, to tell some stories. I’ve shared these with clients who tentatively bring up such experiences, and the conversations that followed once they could trust I wouldnt judge them, were often so healing and profound, but I have not shared them publically until now.

In a slightly paradoxically tickly presentation, Scott shared research on mystery. That’s right! Just hold that thought for a moment! Something like > 80% of people believe in the spiritual/ supernatural world, and they say it is because they have had direct experience that confirms their belief. Psychotherapy has been so busy trying to give scientific certainty to Itself, that it has hidden the Magick and mystery that was strongly present in its ancestry, under a bushel. Scott Miller shared interviews with people who were NOT helped by therapists but were helped by Clairvoyants or psychic healers. What we heard was a reflection on the field’s inability to hear what a client really wants when it is outside our view of healthy psychology.

I don’t think this is limited to the supernatural. I see many people who’s world view was negated by a supposed mainstream doctor/therapist who thought they had the “truth” only to have their “patient” drop out of treatment. There are also people I know I have done this to, and my great fortune is to be amongst colleagues who I can speak to about such stuff ups so that I can learn and improve.

And so to the stories.

17 years ago, in my first marriage, when my youngest was just 10 months old, my husbands sister killed herself. We knew she had been troubled, so when we got the call that she was missing an emotion set in. An emotion I’m not sure I have felt before or since. There is some texture worth knowing, but skip the next paragraph if you don’t want to know.

We had celebrated her 35th birthday the evening before at her parents house, with her husband and three small children who were 6, 10 and 12. She and I sat on the grass and spoke about some of the shit she was dealing with. The evening wound up and they left with the usual goodbyes. I thought they had gone when she walked back into the house saying “where is she?” And walked up to me and hugged me. It felt warm in the moment, and appreciative, and that was all. I doubt I would have remembered it, if it did not turn out to be our last living contact.

My son, maybe a year before, when he was 3 and he only had one sister, was in his booster seat in the car as I was driving along the narrow country road near our home. Typical of Tasmanian roads, the narrowness and poor construction was reflected in the open speed limit and use by large trucks. So we were driving at highway speed when out of the silence Liam said ” whooo” , in a giggly voice ” I just imagined that we were upside down and I was hanging upside down  in my car seat” He was still giggling but for me it was chilling and I slowed right down. As we came around that corner at slow speed we were stopped by a crash scene. A car had hit a cow, and it was stopping all traffic. Had I come around at speed I realised there would have been nothing I could do to avoid being part of the scene.

So that day, in 1999, when I collected the children from our Pat, after the call at work that my sister in law was missing, we were driving down the highway and Liam said, “whooo, I just saw Aunty Leesa on a cloud” I felt the same chilling feeling.

But that’s not the story. The next paragraph is a bit more background, so don’t read it if you don’t want to know.

We lived on 5 acres of bush. Typical Australian bush, dry, no topsoil, no green, no European plants. So the wildlife and bird life was native and used to the harsh environment. Leesa was found near our home on a vacant block, in her car, with a well researched, successfully orchestrated, efficient device to deliver carbon monoxide into the car. She was found by our local country policeman, strangely on a block owned by a friend of our Pat. She looked beautiful. She had done her makeup, and had just had her nails done. Sitting next to her on the passenger seat were cards she had written to her children.

What happened next, was what happens in families where someone they loved and was loved by dies unecessarily, but from a practical point of view there were things to be done, and her children came to us for the weekend. Enter another huge emotion, but one that I knew.

Saturday morning, one of our cats came towards us as we were out on the back deck looking at the bush, and in its mouth was a white dove. There are no white doves in the Australian bush, but there it was. The contrast of red blood on white feathers… but it was not dead. I rescued it from the jaws of the cat and all 6 children gazed upon it. I explained that birds are very fragile creatures and it had had quite a shock, but we would put it in a box and keep it quiet and see. My experience of trying to save injured birds was that it would be dead in the morning.

The next morning I opened the box and it was alive and well. I carried it outside with 6 little people milling around, helping them to be quiet and hold some care and tenderness towards it. It didn’t seem frightened so I gently put it on the rail of the back deck, where it sat, and allowed her children to stroke it, particularly allowing her 6 year old a lingering touch. I don’t remember what was said, but I will never forget watching that small child and that white dove. And then it flew. But not away. It stayed around for the whole weekend, looking in the windows so boldly that I feared the cats would get it again.

And, at the end of the weekend when the children left, I never saw it again.

I don’t remember if I made it meaningful or comforting to the children, though I hope I did, but I remember powerfully the feeling of meaning and comfort that I felt.

The collateral damage, not only to the people who knew and loved this woman, but to the police and emergency crew who attended has been profound and ongoing. I know she would see the irony if I said I have an urge to “dig her up and beat the shit out of her” for that, but it is much more useful to find a context for healing.

I have heard so many stories like this from clients over the years, and while theirs are too unique and private to share, the conversations about them provide a magical opportunity for healing to happen.

Continue reading →

We are off to San Diego for The Brief Therapy Conference next Wednesday. I’m tweaking my presentation and thinking about what other workshops I want to go to.

And here’s the dilemma again. Lots of presentations are about technique when technique is not what is responsible for effectiveness. But how do we talk about what we do without talking about the technical aspects?

And so I came back to Frank and Frank 1991, Persuasion and Healing: A comparative study of psychotherapy.

They think the biggest thing therapy does is tackle what they call the client’s demoralisation about the problem, rather than the problem itself. In our world we call that resignation, and create expectancy as it’s antidote.

They think all therapies have commonalities:

A healing relationship
A healing setting
An explanation, true or mythical, to make sense of the client’s symptoms, that the client accepts as real for them.
A ritual treatment that the client believes, or comes to believe will work, and that both client and therapist participate in.

They also think there are commonalities between all rituals (therapies)

A therapeutic relationship that survives the client sharing their demoralisation thereby combating alienation
The therapist maintains expectancy by linking hope to the process of therapy
The therapist provides new learning experiences
The client’s emotions are aroused
The therapist enhances the client’s sense of mastery or self-efficacy
The therapist provides opportunities for practice

But here’s the thing, and it’s a bit like what happened to me when I first read a theory that dogs domesticated humans, not the other way around. My whole world was tipped on its head, and of course I liked it, because that’s who I am. But the best thing was that it changed the way I am with our dogs. Our communication is more expansive. I am more likely to wonder… “How did they get me to do that”

I think an important part of successful therapy is that the therapist does not get demoralised. So I wonder if we apply the commonalities of the rituals or therapies to the therapist, not the client.

The therapist must first believe that their particular ritual can help the client. But what if the client helps that happen.

So if we turn those 6 points on their head:

The client generates expectancy in the therapist by sharing their demoralisation and letting them think they can help.
The client engages in the therapy that the therapist believes in so that the therapist feels hopeful.
Hope in the therapist is increased by the client sharing that they are learning new things.
The therapists emotions are aroused, as they are connected to their passion for their work.
The Client shares their mastery and self efficacy So the therapist feels validated in what they are doing, thereby improving their own sense of mastery and self efficacy.
The client returns with more scenarios for the therapist to practice their therapy.

What do you think?

Todays obsession with the brain as a pseudoscientific tag line for all things drives me nuts. Yes, we have a brain. Do we really know how it is involved in our conscious, cognitive, behavioural and emotional selves. No.

Insert rant… more eloquently done by Ana Todorovic in her blog “Do psychologists need a brain”

Would knowing more about the brain change anything? I’m not convinced. Just like understanding muscles might make some tiny difference to elite athletes but hasn’t helped in muscular dystrophies.

It seems fairly straight forward to me, that if I go to the gym and do arm curls my biceps will get bigger. And so it follows that if we recurrently practice something, the bit of our brain we are working with will get developed.

I went looking for a study I heard about in the ’80’s when I was at medical school. This study found that London taxi drivers had an overdeveloped part of their brain responsible for spatial awareness. As I embarked on this search I tried to recall if we even had CT scans in the 80’s and braced myself for some macabre post mortem study.

What I found was something much more recent, and my confession is that I found it interesting and thought provoking, raising useful questions for doing therapy.

The study:

Talent in the taxi: a model system for exploring expertise. Katherine Woollett et al 2009

They studied London taxi drivers and found that people of average IQ can develop expertise to an exceptional level, and this was associated with developing more grey matter in their posterior hippocampus, an area related to spatial awareness and navigation. The down side, as seen with autism where there can be exceptional abilities at the expense of social cognition and executive functions, and some expert musicians who suffer focal dystonia, the taxi drivers performed poorly on tests of spatial memory and delayed recall, as well as acquiring and retaining other types of new information. They also lost grey matter in their anterior hippocampus associated with worse anterograde associative memory.

Interestingly both the positive and negative grey matter changes began to revert after the drivers retired.

London bus drivers, in comparison, had no hippocampal changes, and this was explained by the different expertise required to follow prescribed bus routes versus being required to learn the layout of all 25,000 streets  and thousands of places of interest in London.

A follow up study in 2011: Acquiring “the Knowledge” of London’s Layout Drives Structural Brain Changes tracked individuals of average IQ over the time of their training and found that those who qualified demonstrated a structural increase in grey matter in their posterior hippocampus and concomitant changes to their memory profile, but there were no changes in those who failed the test, or those in the control group.

Some useful questions for working with clients:

One of the most reproducible findings for structural brain changes in PTSD is reduction in hippocampal volume. This has also been found in major depression, schizophrenia, and in bipolar where a correlation with verbal memory deficit has been shown.

Most people who are stressed or depressed report poor memory. I wonder if you practiced being stressed or depressed you could shrink your hippocampus.

What if reversing those changes were as simple as retiring from taxi driving?

Is it just a matter of use it or lose it?… or better still, lose it or use it…

What we practice we get good at. What are we practicing if we are depressed, anxious, obsessed, paranoid…

What could we practice instead?

What do you think?

I started this blog with enthusiasm, as a way of sharing my thoughts as I was exploring what we know about how people diagnosed with mental illness get better. I hoped that by getting clear I would find a focus and direction for developing and improving in my work, and that by sharing a summary, this clarity might also help other practitioners. This blog has been languishing while I have been lost in the metaphoric Amazon, but here’s an update.

Unlike many other areas of medicine, where such a pursuit is a relatively simple journey with well marked sign posts and a road well travelled, this journey has been a murky, muddy, poorly lit path with lots of scrub bashing required.

I have discovered that despite millions of dollars spent on research in the last 50 years, we are no better at treating mental illness now, than we were then.

Gene studies, Neuroscience and exploration about how the brain works has been fascinating, but it has made no difference to patient outcomes.

The promise of medications that work like antibiotics to cure a complaint, is a bubble that has well and truly burst, with placebo being the biggest winner. The strategy of throwing every new drug at every condition to see what happens has been pretty interesting, and probably been driven more by the practitioners desperation and anecdotal observations than any decent science. The result has arguably put the biggest dent in the rationale for diagnostic categories. If you say you can observe benefits of antipsychotics in depressed patients and vice versa… well isn’t that like saying antihypertensives have some effect in Influenza??? You’d have to wonder if we are trying to cobble some therapeutic effect from a side effect, rather than an explainable physiological biochemical intervention. As studies emerge with concerns for long term follow up, particularly of children who were exposed prenatally, we will likely see the pendulum swing in the benefit/risk debate about when to treat.

What has gone wrong? Where is the hard science? The indisputable ground on which to make decisions about patient care.

Well, as Deep Thought famously said: “I think the problem, to be quite honest with you, is that you’ve never actually known what the question is.”

I myself am just sitting with that one, and don’t claim to have had a bolt of lightening about the question. The experience I have in the face of this though, is like working with a family where all the logical attempted solutions to say a child’s behaviour have actually become part of the problem and there’s a big tangly mess of action and reaction, and the best thing to do is to down tools and start again, and a big part of this is to help the individuals give up their certainties about how and why the problem began.

In starting again, there are some things we can say about psychotherapy with certainty:

That the therapeutic alliance is of primary importance, but that the qualities the therapist brings to this alliance are vastly under researched.
That no one model is superior to another when put under scrutiny that controls for quality of study design, therapist allegiance to the model being tested, and comparison to a bona fide treatment.
That therapist allegiance has a robust influence on effective outcome, but is vastly under researched.
That most therapists do not improve with years of experience, implying that their education and continuing professional development, must not be currently focussed on what is responsible for effectiveness.

That feedback is a good starting point, but we need to know more about what to do with that feedback.

The difference between a good therapist and an average therapist is far greater than the perceived difference between models that has been exhaustively investigated, but we know very little about what the good therapist is doing that the average therapist isn’t.

Theres still a lot we don’t know about. We know almost nothing about people who get worse with treatment. The only things I’ve seen written about this phenomenon, generally follows a demeaning, paternalistic bent around the fact that these people are not psychologically minded or sufficiently cognitively sophisticated to be helped by therapy.

We don’t know much about people with severe mental illness who do actually get better. The people who are literally “cured”. It is usually said that they can’t really have had that severe diagnosis in the first place. Then they are dismissed.

I think that we need to think differently about the whole issue, and to start asking different questions…. but what? What do you think?

I have been preparing my talk for The Brief Therapy Conference in San Diego in December and I’ve just discovered an awfully big problem.

Responding to feedback from my last presentation… People want evidence.

So I looked for evidence for the major points I want to make and I can find it. Some of the studies I could use to support what I am saying are even pretty well designed, but here’s the thing. After my exploration this year, I now know that they are meaningless. You can actually find anything you are looking for in the social sciences and psychology research.

Most of the time researchers are honestly passionate about what they are exploring and don’t see the biases and allegiances they bring, and some of the time affiliations to industry, pharma, or just getting published and keeping your job or earning a crust let the rot creep in.

Even if you find a good study with seemingly none of this, it won’t be reproducible, because none of them are, and for a finding to have any scientific rigor it has to be reproducible.

And there’s another funny thing which I discovered when speaking to my brother who is a scientist. Chemistry is his thing. I could barely understand the title of his PHD, let alone what it was about.. He has embodied the science machine and chemistry has behaved itself appropriately. Being analytical has worked well for him, and I value his clarity and experience.

He is, however, also an athletics coach,  most recently an official Olympic coach. Pretty amazing achievement to manage in his spare time. Inspiring. I have spoken to him about doing the landmark forum, as I think the distinctions and experiential learning would open a whole new world for him in his coaching. He is reluctant, and would expect to walk out not being able to manage the hoopla. But here’s the thing, feedback from 2.5 million participants of the forum show that 95% get a major life altering transformation. This is way better than any therapy or coaching process. Then my brother started telling me how impressed he is with neurofeedback for coaching. Ho hum. We know that Neurofeedback, CBT, or any of the other hundreds of models are all the same. But there’s the thing… Neurofeedback is very palatable for the scientific mind and The Landmark forum is not.

And I think that’s it. We put these studies up on a slide to make what we are saying palatable to our audience. If you really see that, most presentations are like persuasive writing. We are more like journalists than serious contributors to our field.

It’s actually quite funny when you think of all the criticism Erickson got from his Ocean Monarch Lecture, when people discovered he was speaking to generate an experience so that learning could actually happen, and some people felt manipulated. If only people would get offended by the attempted manipulation anytime someone used research to make their point.

Holy toledo! What now?