In the Room

Boys Own Empathy Drug

Interesting little snippet in New Scientist this week. A quick snort of Oxycontin improves your empathy but only if you are male.

The trust hormone, it seems, is also the mind-reading hormone. A sniff of oxytocin, which underpins social attachment among animals, also turns out to improve men's ability to read other people's emotions.

Two years ago, researchers reported that oxytocin increases trust. Now a team led by Gregor Domes at Rostock University, Germany has investigated one of the basic components of trust: emotional recognition.

The researchers sprayed oxytocin up the noses of 30 men and tested how well they could read the emotions conveyed by photographs of eyes taken in real-life situations. Twenty of them performed significantly better on the test after sniffing the hormone (Biological Psychiatry, vol 61, p 731). Domes suggests that oxytocin could be investigated as a treatment for people with autism, who struggle to read the emotions of others.

Read the original article here.

Is CBT Just a Load of B?

What if you could just forget about all that complex cognitive challenging, understanding of logical fallacies and the mental demand this asks of the clinician working in the room? A new paper out in the latest Clinical Psychology Review suggests that maybe you can. Richard Longmore and Michael Worrell have a provocative paper (can't make a link) entitled: Do we need to challenge thoughts in cognitive therapy?

..... is the direct, explicit modification of maladaptive cognitions a necessary or sufficient intervention in CBT? Hayes (2004) identified three empirical anomalies in the CBT outcome literature. First, component analyzes do not show that cognitive interventions provide added value to the therapy. Second, CBT treatment is often associated with a rapid, early improvement in symptoms that most likely occurs before the implementation of any distinctive cognitive techniques. Third, measured changes in cognitive mediators (the thoughts and beliefs held by the cognitive model to underpin disorder) do not seem to precede changes in symptoms.

Longmore and Worrell take us through a range of depressive and anxiety disorders including OCD and provide research showing that behavioural components are as effective if not more effective than the CT component. In other words leaving out cognitive challenging doesn’t make a lot of difference to outcome. I would have to say the paper appears pretty convincing and it will be interesting to see what scholarly refutation to this is raised. Studies on behavioural activation by Jacobson et al in the mid nineties raise some interesting questions.

Jacobson et al. (1996) study has potentially serious implications for both the theory and practice of CBT for depression. In practical terms, behavioral activation is simpler and more cost effective, both in the training of therapists and delivery to patients. Further, they suggest that efficacy of behavioral interventions in the trial must lead to doubt regarding the significance of cognitive factors in the etiology and maintenance of depression.

This study is currently being replicated and preliminary results suggest:

Here, it is stated that Behavioural Activation proved as effective as antidepressant medication, and that both produced superior outcomes to cognitive therapy, which was no more effective than the pill placebo condition. Given that the Washington University study purports to be the largest outpatient therapy trial for depression yet undertaken, these would appear to be perplexing results for the proponents of cognitive therapy as a treatment for depression. However, putting aside the comparison with BA, the Washington results would seem to contradict many previous studies which have shown CT to be equally effective as pharmacotherapy as a treatment for moderate depression and severe depression. Therefore, it will be necessary to wait for the publication of the study's data before its full implications can be assessed.

More on Working with Borderline Clients

A plug for this book, just out from one of my clinical colleagues in Sydney.

Guidelines for the Management and Treatment of Borderline Personality Disorder.

This is a very practical hands on book focussing on what to do and how to respond to this complex client group.  It promotes a strong  Linehan model (dialectical behaviour therapy).  The newer Transference Focussed and Schema Focussed don’t get much of a mention. It has good chapters on working with other health profession and managing risk.  I definitely recommend it. If you are in Australia or even if you are not in Australia and want to know about this book contact Julia Shearsby at Bankstown Mental Health.

What if you had to Pass an Empathy Test?

How long before we are doing therapy with our clients in an MRI scan. Interesting news just out today on neurophysiological measures of empathy in both clients and clinicians. Hat tip: Eureka. As a total aside Eureka is one of the best news feeders I have found for keeping up to date with breaking science news.

There is now converging evidence that, during moments of empathic connection, humans reflect or mirror each other’s emotions, and their physiologies move on the same wavelength.

I suppose it is not surprise really to think that we mirror physiologically as much as psychologically with our patients but this seems to be a first step in actually beginning to be able to measure it. Actually measuring empathy is something new. Is this yet another of the clinician’s arts falling to science. The idea of therapists having to pass an “empathy test” to practice in the future is an interesting and scary thought.

Empathy is well known to be an important component of the patient-therapist relationship, and a new study has revealed the biology behind how patients and therapists “connect” during a clinical encounter. In the February Journal of Nervous and Mental Diseases, researchers from Massachusetts General Hospital (MGH) report the first physiologic evidence of shared emotions underlying the experience of empathy during live psychotherapy sessions. The researchers found that, during moments of high positive emotion, both patients and therapists had similar physiologic responses and that greater levels of similarity were related to higher ratings of therapist empathy by patients.

As part of an ongoing study of the role of empathy in psychotherapy, the MGH researchers videotaped therapeutic sessions of 20 unique patient-therapist pairs. The patients were being treated as outpatients for common mood and anxiety disorders in established therapeutic relationships. The participating therapists practiced psychodynamic therapy, an approach that uses the therapeutic relationship to help patients develop insight into their emotions.

Throughout the therapy sessions, patients and therapists were “wired up” to record their physiologic responses using skin conductance recordings. Skin conductance is a commonly used measure of the activity of the sympathetic nervous system, which controls human arousal and provides a physiologic context for emotional experiences. Following the sessions, the videotapes were edited to focus on moments of high and low physiologic concordance – that is, when patients’ and therapists’ levels of nervous system activity were most and least similar. Independent observers, blinded to the study’s goals and methods, reviewed randomly presented video segments to identify the types of emotions being expressed by both patients and therapists.

The observers' data showed that both patients and therapists expressed significantly more positive emotions during moments of high physiologic concordance than during low concordance. In addition, patient’s ratings of therapist empathy corresponded to levels of physiologic concordance during the therapy sessions. Overall, the findings suggest that shared positive emotions and shared physiologic arousal contribute to an empathic connection during psychotherapy.

"We were pleased to find evidence for a biological basis to that feeling of connection,” Marci says. “Taken together with current neurobiological models of empathy, our findings suggest that therapists perceived as being more empathic have more positive emotional experiences in common with patients during the therapy session.” He adds another finding not reported in the published report – that there was much less physiologic concordance when therapists were talking than listening. “That suggests it is hard for clinicians to be empathic when they are talking.”

One of the things that comes to mind is that you could utilise this as a biofeedback mechanism to help clinicians improve their empathy. The other interesting note was that when we talk we become less empathetic. I wonder is this is even when we are making an empathic statement? The other question to wonder about is, will we see the same physiological correlates to empathy when clinicians are delivering other sorts of therapy?

Therapeutic Oxymoron Laid to Rest

Posting has been a little light lately as I discover, like 60 million bloggers before me, the inverse relationship between blogging and work.

In the mail this week is Paul Gilbert and Robert Leahy’s new book titled: The Therapeutic Relationship in the Cognitive Behavioral Therapies.

I’ve been holding the book up to everybody who comes to my office over the week with a range of responses from “unbelievable” to “about time". I have to say I was delighted to see this title which I see as a sign of the rounding out and maturing of cognitive approaches to therapy.

I know my headline will invoke some criticisms from the Cognitive Therapists. However looking through all the books on cognitive therapy in our clinic (and we have a lot) I could not find one that had a chapter on the therapeutic relationship except for the more in-depth DBT and Schema Therapy books.

…….there may be a grain of truth in the observation that many of us who utilize CBT could do a better job of understanding and working with the therapeutic relationship.

A full review in a week or two when I have had time to read it through.

Easy and Cheesy: Simple Techniques from the Happiness Research

I like the happiness stuff, how can you not. It is simple, positive and easy to apply. Sometimes I like a break from all the deep stuff that demands so much more from me both as a person and a therapist. It has certainly seen rapid growth both in research and commercial exploitation.

I must admit I find some of the research confusing. I remember reading a New Scientist article (can’t find the link now) on happiness indicating that most of your happiness is genetically determined, around about a whopping fifty percent. The next biggest contributor off the block at two per cent (yes only two per cent) was marriage. This is actual marriage (ring on the finger stuff) not just living together.

At the same time there is some compelling research on the use of very simple techniques that appear to make significant differences to both people’s levels of depression and their perceived levels of happiness. This research challenges those therapeutic ideas that the harder and deeper the work the longer lasting and more real the change. Marty Seligman and others published a good review, in the American Psychologist, on the current state of happiness research with a focus on demonstrating the utility of some very specific and simple techniques. They identify two techniques as being particularly effective over the long term (six months).

Three good things in life: Participants were asked to write down three things that went well each day and their causes every night for one week. In addition, they were asked to provide a causal explanation for each good thing.

Using signature strengths in a new way: Participants were asked to take our inventory of character strengths online at Authentic Happiness and to receive individualized feedback about their top five signature strengths. They were then asked to use one of these top strengths in a new and different way every day for one week.

This signature strength exercise has similarities with some of the values based exercise from the Acceptance and Commitment Therapy as well as some of the behavioural activation techniques.

The outcomes for these techniques are graphed below. Remember participants only did the exercise for one week.

Bring out your Blogs

Discovering stuff and blogs in the blogosphere is an interesting experience. Googling or Dogpiling, as I prefer, for psychology blogs provides a limited list of the more well known blogs. However I like the way the discovery of many new blogs come through the author commenting on my postings or email in my inbox or a new listing on the blogroll of the other psychology blogs I read.  There is a personal connection element to blogging I have discovered I really like.

A recent comment sympathising with my posting about creeping commercialisation in the blog world is a case in point. Annette is an Irishwoman with a psychodynamic focus on organisations. She has a very professional looking blog called: Interactions. She is living proof that Freud was wrong. Sigmund is quoted as saying the following about the Irish.

This is one race of people for whom psychoanalysis is of no use whatsoever.

Hat Tip: Modern Psychoanalysis.

While her blog focuses more on the business world she has interesting posts from time to time on psychotherapy.

Another site is not really a blog I spend a reasonable amount of time at is the Behavior Online Forums particularly the Cognitive Behavioral Therapy forum.

This is set up as a discussion forum which is quite different from a blog setup. Topic headings are provided in a listing and you can dip into whatever takes your fancy. This forum has been around for quite a few years; however I only discovered it last year. For anyone using a CBT approach it keeps you up to date and thinking about things. James Pretzer who moderates the forum is very knowledgeable on CBT and keeps the postings regularly updated.

To Blogroll or not to Blogroll

If I list every blog of interest that comes my way, my blogroll can get out of hand. You see some sites where the blogroll disappears down the right column into the ether and beyond.

This makes for some interesting decisions at times about who to put on the roll. Recently the author of All About Forensic Psychology approached me to let me know about his site. In my private practice outside of the university I do mainly forensic work and this site is an excellent one in that regard and one I read regularly. At the same time it is somewhat outside the area of psychotherapy technique and as a result I have not listed it.

Similarly I received an email from Oxford University Press about their blog. This appears to have some good psychology stuff on it but not all that regular (actually only on Mondays). There was a nice interview with Stephen Hinshaw recently about his book: The Mark of Shame, however not quite enough psychotherapy material to list.

Today I get an email from the Australian Institute of Professional Counsellors about exchanging listings. This is what started this particular posting and I suppose the advantage of writing a blog is that when things get up your nose you can bitch about it. The email is addressed to “The Blog Editor” and goes on to tell me about the organisation and the many thousand of people they have accessing their website and all the benefits of mutual link exchanging and what a wonderful opportunity this will be for me. It then tells me if I list them they will list me (but I have to first). When I go to the front page of the blog most posts link back to something commercial. The vast majority of psychology and psychiatry blog do not push their own products or skills commercially in their posts. Many of them have advertising around the side but that is about it.

What got my goat on this email was firstly the impersonal marketing approach. Anyone who reads my blog can see clearly who I am. Secondly is the commercial nature of it. They would be making money off my link in exchange for one more notch for me up the Technorati ladder. Thirdly was the fact that for them to list me, I had to list them.

Nonetheless they are a psychotherapy website who also have some interesting general articles of psychotherapy and case studies in their library. I can’t deny the narcissistic pleasure of writing a blog and having lots of people read it or my own competitive nature and certain desire to be in the top 100 000 on Technorati. Do I list them? I am still thinking.

It seems to me that the creeping commercialisation of the blogosphere is even reaching psychology. Organisations and publishers are beginning to realise that many of the higher ranked psychology blogs access far more people than most professional journals.

How Many of you are in There: The Concept of Multiple Selves

The latest Journal of Clinical Psychology (sadly no free access) has the whole journal devoted to exploring ideas around the internal multiplicity of the self. Basically this is the idea that the self has or consits of multiple parts, aspects, object or persons rather than that the self is some type of unitary concept.  Dimaggio and Stiles offer a very lucid and easy to udnerstand overview of this concept in the opening paper.

Internal multiplicity is present, if not always acknowledged, in most systems of psychotherapy. It is expressed in such cognitive-behavioral concepts as automatic or intrusive thoughts and self-talk or self-statements. Self-criticism and self-blaming, for example, are forms of self-to-self relationships in which a harsh part of the self criticizes or blames another part that is submissive or inferior. Multiplicity is also assumed in such psychodynamic concepts as internal objects and states of mind and in the humanistic focus on contradictory aspects of self and unrealized potentials. Multiple internal voices are central to dialogical accounts of the self , as therapists try to distinguish from what positions patients speak and to understand what parts of the self are suppressed and prevented from expressing themselves. Multiple I positions are deliberately used in the service of therapy, in the facilitation of reflective thinking, in the analysis of reciprocal role procedures in cognitive analytic therapy, in empty chair work and two-chair work in experiential therapies, in archetypal psychology, and in narrative psychotherapy.

The value in this journal issue is not just a discussion of a theoretical concept but a range of papers directly outlining the use of this sort of model in actual therapy with specific clients. Papers are presented from range of therapies using individual case studies to illustrate the value of the multiplicity concept.

For me this multiplicity of selves has always been inherent in my therapy particularly with borderline clients. One of my favourite sayings to my interns who are working with these clients is that working with borderline clients is like doing family therapy inside somebody’s head. To work effectively with a family you must get everybody in the room and this is usually the first task in working with borderline clients, getting all aspects of the self acknowledged and making it safe enough for each of them to express their point of view and problems.

Clinicians who recognize the self’s multiple aspects may be more empathic with their patients’ internal struggles and acute ambivalence. They may exhibit more attunement or responsiveness, thus being more effective as patients present different facets in different sessions or within one session.

To me this is critically important in the delivery of empathy. Neutrality becomes more of a balancing act in ensuring that each aspects of the self is given some attention and understanding rather than a stricter technical neutrality usually demanded in a psychodynamic approach. While it is usually not possible to offer a single empathic statement that acknowledges all aspects of the self it is useful to think at least in terms of responding to which ever dyadic aspects of the self are in the forefront at the time. In virtually all therapies including CBT there are at least two self aspects present.

As respect and empathy are offered to each voice individually, conflicting internal voices can hear and begin to understand each other, a crucial step toward developing internal meaning bridges. On hearing conflicting expressions, a therapist can reflect  rather than try to encompass multiple voices in an omnibus reflection. Reflections that address only one voice may facilitate elaboration by the voice that was reflected, or, alternatively, they may stimulate an opposing response from a voice that was not reflected. Either client response may be productive. Trying to encompass multiple voices with one reflection, on the other hand, is likely to lead to confusion, as it is unclear which voice should respond. Accurate empathy can thus be understood as facilitating conversation and hence mutual understanding among the client’s internal voices as well as between client and therapist.

Book Review: Suicide Risk Management A Manual for Health Professionals

Suicide Risk Management: A Manual for Health Professionals, by Stan Kutcher and Sonia Chehil is a good introduction to the subject of suicide assessment. This book in my view is geared to the beginning mental health professional. It is only 109 pages of well spaced text some of which is repeated in different layouts. Overall it is an extremely practical book which is written in easy to read language.

The book divides up into roughly four sections. The first section backgrounds and provides an  understanding of suicide. It has helpful little sections such as common myths about suicide. It covers a spectrum of disorders and situations where suicidal behaviour may be more prevalent and does a good job of covering and discussing a range of risk factors.

The second section looks directly at suicide risk assessment. They provide a practical four step process with a structured Suicide Risk Assessment Guide (SRAG) complete with flow diagrams to help you visualise each stage of this assessment process. I found this section quite useful even as an experienced clinician. Because I don’t deal with suicide on a daily basis in my practice it is easy to forget things and Kutcher and Chechil use of simple acronyms is very helpful. They emphasise the need to ask “the question” and provide a number of good ways to do this. Bottom line is you need to call a spade a spade but in a gentle and empathic way. Their suggestions include"

• Have you ever thought about harming yourself?
• Have you ever tried to do anything to yourself that could have seriously harmed you or killed you?
• Have you been thinking about killing yourself lately?

The third section deals with commonly encountered problems. This is one of the weaker sections in the book. It is only a few pages long and deals with complex issues such as countertransference and self harm or repeated low lethality clients in a brief and glib manner. Advice such as, avoid common traps such as manipulation and exploitation with no suggestion on how do this, is not helpful in my view.

The last section of the book focuses on what they call “Bringing it all together” and introduces a summary assessment tool on which to rate potential risk. Again they provide a nice structured way of doing this with their Tool for the Assessment of Suicide Risk (TASR). This is essentially a rating from for collating the information gathered with the Suicide Risk Assessment Guide (SRAG). Some practice using this with a range of vignettes is provided.

Overall a practical easy written book geared to the beginning professional. It is certainly a book I could recommend to my interns. Personally I would have liked more meat on the bones but then I don’t think I am necessarily this book's target market.

Received from the publisher 18^th December 2006.