Cognitive Therapy For Writers Part II Revenge of the Smart Brain



Raaaawr! All right. So, we've established that everyone has a Sneaky Brain, the part of you that whispers all sorts of nasty things that make you feel bad.
You know, like:

• If I don't get an agent or get published, I freaking suck as a writer.
• Because that agent/editor rejected me, I am a failure.
• I got a few rejections this week/today/in the last hour, so that means no one will ever want to represent/publish me.
• I wrote one book/chapter/page/sentence, and now I can't think of what to write next. I've run out of words FOREVAH!!!!! AAAAAAH!!!!!!!

Let's pause right here and acknowledge that not everyone who writes is going to end up a published author. Not everyone who writes is even good enough to be published. Period. That's the way it is. Language is powerful, but it can be difficult to wield. The art of storytelling adds another level of difficulty. And then there's marketability ... whoa.

SO, taking into account that I, or you, might be among those who reach as far as we can but still can't close our hands around that elusive prize, how do we keep feeling OK? How do we keep our Sneaky Brains from sapping us of whatever talent and energy and creativity we have? How do we stay on track and keep writing, keep telling the stories we want to tell?

We all have Smart Brains, too. We should use them.

Don't be afraid to fight dirty.

 1. Recognize those sneaky thoughts. Listen hard, my loves. You have to HEAR and recognize what Sneaky's saying, because those thoughts can become pretty automatic over time, meaning you stop hearing them and just skip straight to the drinking-Wild-Turkey part of the equation. Don't. Listen. What do you hear?

If you hear any of the following words, perk up and slap on those boxing gloves:

ALWAYS
NEVER
SHOULD
ONLY
FOREVER

If you find yourself thinking "sure, I had some success a year/month/day/hour ago, but THAT DOESN'T COUNT ... ", do some pushups, man, because you've got some work to do.

Or if you hear "since she rejected me, that means EVERYONE will", strap on some brass knuckles. You've got a fight on your hands.

After you've recognized what the Sneaky Brain is saying ...

2. Recognize Sneaky as a bully. Sure, it's inside your brain, but that don't mean it speaks the truth, baby. When I work with kids, we "externalize the problem". Picture me (see stick figure above) talking in funny voices with puppets strapped on my 18-inch fingers.


Just like this dude.
But probably not as ripped.

 OK, don't. Instead, picture Sneaky sitting in front of you--and see what a liar it is. Those things it's whispering are a one-way ticket to depression. Despair. Giving up. What right does it have to do that to you? What right does ANYONE HAVE TO DO THAT TO YOU?!? I don't care if the bully resides between your ears. It's still a bully.






Once you recognize that:

3. Confront the bully and talk back to it. Because, seriously, logic is not its friend.

If someone's done something to upset you, like they rejected you or gave you a bit of harsh feedback, and your Sneaky Brain is saying "it's because they hate your writing and think you're a tool", use your Smart Brain to say, "Really? 'Cuz

1. they only read a tiny sample of my writing--or only a query, or
2. they had some nice things to say, too, or
3. I got a request/compliment, etc. from this same person/similarly skilled person(s) before, or
4. they probably spent a total of 60 seconds looking at it because they had 300 other queries waiting, or
5. the idea probably just didn't float their boat, but it could float other boats ...

You get the point. Use your Smart Brain to be ... smart? Use logic. Be a skeptic. If the Sneaky Brain says you're a failure because you got one rejection, I mean, WTF? Really? How many agents and editors are out there?

If it says "you should have an agent by now" or "you always mess this up" or "you will never ..." Oh, geez. What does it know? This process is frustrating enough without Sneaky going to illogical extremes. "Always"? Yeah? Use your Smart Brain to question how that could possibly be true. If you can't, that just means your Smart Brain's out of shape, NOT that Sneaky speaks the truth.

And if it whispers "the only way to be successful and happy is to get published," your Smart Brain should be screaming, "I am more than a writer. And there are many kinds of writers. And I write for many reasons. And sometimes, the end result isn't what it's about. Sometimes, it's the JOURNEY." Then, maybe toss out some obscene hand gestures for good measure. Stupid Sneaky Brain. Gut it with a spoon, my friends. That's what it deserves.

You don't have to be the only one who talks back to Sneaky. I'll bet you have friends or family or beta-readers or intriguing-strangers-you-meet-in-a-coffee-shop who can help you. Listen to their encouragement and don't discount it. But know this: no voice will ever pack a punch as powerful as your own Smart Brain.

So ... confession time. I'll be going on submission in the new year. And you know what? I'm going to be using every single one of these strategies every single day to stay calm and sane and happy. I know it won't always be easy. I know my Smart Brain won't win every round. BUT, I also know my Smart Brain is pretty damn smart. No matter what happens, I'm going to be OK. I'm going to be successful. And I'm going to define what that means for myself--I won't let anyone, including my own Sneaky Brain, define it for me.

That shapeless lump is my vanquished Sneaky Brain.

What about you? What challenge are you facing now? What's that Sneaky Brain telling you? And just how do you plan to kick its a$$??

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder Part II

At the end of Part I of this post of September 12, 2012, I mentioned that doing psychotherapy outcome studies is diabolically difficult, and promised to discuss the reasons why in this post. In fact, because of the literally infinite numbers of uncontrolled variables in studies of human beings both individually and in relationship to other human beings, psychotherapy outcome research can never be the only standard by which the "science" of human behavior-change technology should be measured.  In fact, it's not even the gold standard.  

In order to better understand ourselves and what leads us to change our behavior, we must use ALL available sources of information. We have to look at the widespread clinical experience of psychotherapists who use a variety of techniques and theories with a variety of clinical populations. We have to look for potential biases in both clinical studies and within an individual therapist's anecdotes and the conclusions that we draw from them. In forming conclusions about both anecdotal and controlled-trials data, we have to look at a wide variety of possible explanations, as well as for any information and experiences that would seem to contradict those explanations.

We also have to look at the experience of marketers who have been able to induce a large numbers of people to buy a product or vote for a politician (many of whose very powerful techniques have been discussed in previous posts on this blog). We have to look at the social psychology literature, which shows that people behave very differently when interacting with different groups of people and with different individuals than they might do in a therapist's office. 

We have to look at historical and sociological trends. We have to look at new knowledge from the neurosciences that might account for findings that are difficult to explain or reconcile with other beliefs.  We must look at evolutionary biology. We must examine our own beliefs for logical inconsistencies. We have to be honest about thinking about ourselves what makes us tick personally.

What follows is a list of some of the difficulties psychotherapy outcome researchers encounter, as well as the reasons they may overstate their results.  A fuller discussion of each of them can be found in my book, How Dysfunctional Families Spur Mental Disorders.

1.  The Problem of the “False Self”

People do not act the same way in all social contexts.  They do not act or speak the same way around a boss that they do when they are alone with a lover. A man’s behavior in a strip club is very different than his behavior when he is playing with his children. We have different “faces” or masks which we apply to ourselves in different environments.  Not infrequently, these masks are meant to manipulate others to get them to do what we want them to do. 

I never cease to be amazed at how mental health professionals and researchers seem to believe that they really know what is going on in a patient’s or a research subject’s life based solely on the self report of the patient, or solely on the reports of the patient’s intimates, or even on the reports of people like teachers who observe the behavior of children in only one context that includes thirty other distracting students. If these professionals were asked if they believe that people often act differently in public than they do behind closed doors, they would of course say yes, but they seem to develop amnesia for this fact in discussions and in studies. 

A patient’s family members may be just as motivated to give a distorted view of a patient as is a patient.  Parents, for example, may prefer to believe that their child has some sort of mental defect, so as not to experience as much of their own covert guilt about their parenting skills. Conversely, some may actually prefer to blame the child’s behavior completely on themselves, in order to let their “perfect” child off the hook. Most mental health practitioners do not make home visits to watch patients and family members interact in their natural environment. Even if they did, unless they had a camera operating twenty four hours a day as in the movie The Truman Show, they could still be easily deceived.

2.       Double Blinding

When it comes to psychotherapy treatment outcome studies, we cannot do double blind placebo controlled comparisons of two different types of psychotherapy treatments. This is true because, in a sense, the therapist – or more correctly the relationship between the patient and the therapist – is the treatment. If the study were to meet the criteria for being double blind, that would mean that the therapists who administer the treatment would have to not know what they were doing. 

Of course, they cannot administer psychotherapy without being aware of what techniques they are using. If they could, that would mean that they were incompetent.  Not a fair test of a treatment!  The fact that the therapy relationship is one of the basic aspects of the treatment also makes placebo or “sham” treatments difficult, because any relationship has some effect on an individual. Does this mean we should give up on evaluating psychotherapy treatment scientifically and rely exclusively on clinical anecdotes?  Of course not.  Studies are still important.  We just have to understand their limitations.  

3.       Randomized Clinical Psychotherapy Trials 

One strategy used in therapy studies is to compare the outcomes of two different, presumably active types of psychotherapy treatment techniques with each other, rather than with placebo, on similar groups of patients, without the benefit of double blinding.   These studies are referred to as randomized clinical trials, or RCT’s. 

A large number of different schools of psychotherapy have different approaches to the understanding of and methodology for changing a patient’s repetitive dysfunctional habits.  Most of these therapy schools were designed by charismatic and creative individuals who based their ideas on clinical anecdotes. These innovators are highly invested emotionally in their own personal theories, and want them to look good in comparative psychotherapy outcome studies.

This leads to a so-called allegiance effect in RCT’s. The preferred psychotherapy school of the researcher is likely to be delivered more enthusiastically and with more rigor to subjects in the study than is the competing therapy treatment. One survey study examined 29 RCT outcome studies that compared one type of therapy to another and found a correlation of .85 between researchers’ therapy allegiance and outcome. That is, the researcher’s preferred treatment came out ahead 85% of the time. Just as in sponsored drug studies, this number is too way high to discount the presence of a significant bias in the studies.

When differences are found between two therapies, they are often statistically but not clinically significant. They show that one therapy is slightly more advantageous than the other, but that the actual improvement of the subjects was so minimal as to be inconsequential. 

When both groups of therapists who are providing the treatment in the study are equally committed to the paradigms they are delivering, comparative psychotherapy outcome studies almost always result in a tie. In psychotherapy research circles, it is known as the “dodo bird verdict.”  This refers to a character from Alice in Wonderland, the dodo bird, who in one passage said “Everybody has won, and all must have prizes.”

4.       Treatment as Usual 

Lately, many researchers engaged in psychotherapy RCT’s have employed a control group called treatment as usual (TAU), which really stacks the deck in favor of their pet psychotherapy school. Lining up practitioners of a different school from the researcher’s to act as therapists for a comparison group is often difficult.  Additionally, if the researcher were able to do so, the study might not show his or her therapy to be superior to another type. For these reasons, the use of TAU control groups has become almost epidemic in psychotherapy RCT’s. 

Subjects randomly assigned to the TAU condition, which serves as a comparison group to the group of subjects receiving the researcher’s therapy model, are simply released back into the community to get whatever other treatments are already out there. Some may see practitioners from other therapy schools, some may get medications, some may get both, and many others may get neither.  Both the TAU group and the experimental group are followed up at equal time intervals and given all the same outcome measures.  The psychotherapy methodology that serves as the investigated treatment always seems to beat TAU.

The reader should understand that within any widely-practiced therapy model, both good therapists and bad therapists can be found, just as practicing physicians can be either good or bad psychopharmacologists. For the subjects in the TAU condition who receive treatment, the results of the good clinicians in the community are probably cancelled out by those of the bad ones. TAU subjects may also be seen less frequently. Some, as I mentioned, are getting no treatment at all. Meanwhile, the experimenter’s group is usually getting a lot more individualized attention by therapists who are highly committed to the particular treatment model. These factors may be the real reasons their patients do better than those receiving TAU. 

The experimenter’s therapy is provided by uniformly well-trained and enthusiastic therapists under very well controlled conditions. The psychotherapy that is provided is applied with rigor and consistency, and is scrutinized by other observers through the use of videotapes of the sessions. Therapists who make errors are supervised almost immediately.  On top of this, research therapists often have caseloads that are very much smaller than those of folks out in practice, allowing them to spend more time deciding how to approach the clinical issues they face.  I cannot recall a single instance of a study in which TAU beat another therapy delivered in such a manner. If it did, I would have to wonder how the experimenter could have possibly accomplished such an unlikely feat.

5.       The Choice of Outcome Measures 

Another huge controversy in psychotherapy RCT’s is the question of which outcome measures should be used, because the different psychotherapy schools target different aspects of the patient's problems. What should we measure, exactly?  Symptom relief?  Whether or not the patient continues to meet criteria for a specific DSM disorder?  Whether they stop engaging in chronic repetitive dysfunctional behavior?  Whether they experience fewer conflicted emotions?  Whether they have improved and more satisfying relationships? Whether they can hold a good job?

In their November 1995 issue, Consumer Reports published a large survey on the public’s experience with psychotherapy. In response to the survey, satisfaction with their experience was reported widely by those who had been in therapy. Furthermore, longer term therapy was rated higher than therapy limited in duration by managed care, and satisfaction with psychotherapy was rated about equally by those who had therapy alone and those who were given a combination of therapy and medication.

In surveys of this sort, the question of selection bias arises - whether or not the sample of people polled is representative of the general therapy population. The respondents in this case were almost all middle class and educated, so we have to limit our conclusions to that population rather than the population of the United States as a whole.  Nonetheless, the study was the most extensive study of its type on record. Should opinions expressed by patients evaluating psychotherapy outcomes for themselves count as science?  Many in the field would say no.  

But one must consider, however, that psychotherapy target's a patient’s subjective sense of personal well being. That is, we want to know whether patients feel better mentally about their lives. By this measure, assuming that the survey respondents were being somewhat honest with their answers, we would have to say it should count.  A paradox about the “science” of psychotherapy is that we are attempting to be objective about subjectivity, two concepts which are usually defined as antonyms.

6.       Funding Issues

Another big issue for the field concerns which psychotherapy treatment outcome research studies get funded.  If a scientist cannot get money for a project, it will rarely get off the ground, because these types of studies are very expensive to mount. Most successful psychotherapy RCT’s have employed CBT because of the predominance of this model in professional psychology training programs, and because most CBT treatments aim primarily for symptom reduction, which is relatively easy to measure, rather than personality change, which is not. 

7.       Problems with Generalizability of Study Results

Another big problem with all psychotherapy RCT’s is that most studies require that the subject population be homogeneous, meaning that the subjects in the study must be very similar in the nature of the disorder they exhibit, and in how severe it is. This requirement means that patients who have more than one DSM disorder or psychological problem are often excluded from studies.  In contrast, most patients seen in practice, at least by psychiatrists, have more than one disorder (co-morbidity). This fact alone limits what is termed the generalizabilityof the study’s finding. We do not know from a study using patients who have only one disorder if the treatment employed in the study would work as well with patients who have multiple problems.

Because studies need subjects who will stick with the treatment until the end of the research project, some subjects who have certain characteristics that are common in clinical practice tend to be excluded. This problem further limits the generalizability of the study.  For instance, most studies of treatments for depression exclude patients who are suicidal!  Another problem with RCT’s is that many subjects drop out of a study or are removed from a study as it proceeds because they do not completely cooperate with the treatment in some way. CBT studies, as do many others, tend to have a fairly high dropout rate. The subjects who end up completing the study are usually the most motivated to change, and would therefore be expected to do better than those who lack this motivation. This all makes the treatment method look much better than it would be if it were employed in a typical clinical practice setting. 

8.       Treatment Manuals

Another big issue in psychotherapy outcome studies is that, in comparing different treatments for different behavioral problems, researchers need to have some way of knowing that all the therapists employed in the study are doing mostly the same things. In early psychotherapy studies, the methods section of a journal report might say that such and such number of patients was “given psychoanalytic therapy,” with no description of what the therapists actually did. This was clearly unacceptable.

The solution to this problem that has been employed most frequently is the use of treatment manuals, as well as manuals that measure the study therapists’ competence in and their adherence to the treatment paradigm.  Treatment and adherence manuals specify exactly what the therapist should be doing under a variety of circumstances. Tapes of psychotherapy sessions of patients in the studies are reviewed to make sure that the therapists are employing the same interventions. A “rater” will count the times the therapist did the right thing and the times the therapist strayed from the procedures specified in the manual. This process assures that all patients are getting approximately the same treatment. 

Unfortunately, a good therapist has to be flexible and employ a variety of different strategies in ways that are tailored to the proclivities and sensitivities of the patient in front of them. Generic interventions may not only fail to work, they may backfire and make matters worse. Verbal interventions must often be phrased differently to different patients in order to reduce the patient’s defensiveness. Treatment and adherence manuals take away a lot of this flexibility, so that the therapy as performed in an RCT is not always similar to the way that clinicians out in the field practice it. Creating treatment manuals can itself be a daunting task. I heard a respected researcher tell a group of other researchers that his team was having trouble designing such a manual because the founder of the treatment they wanted to study was observed to perform psychotherapy completely differently than his own wife, who supposedly was a practitioner of the same model of therapy.

Anecdotal Evidence and Inductive Conclusions in Psychiatry Part II

Cherry picking: pointing to individual cases or data that seem to confirm a particular position, while ignoring a significant portion of related cases or data that may contradict that position

In part I of this post, I discussed the issue of inductive reasoning, and how it can be a source of quite valid scientific evidence. This brings up the question of what is a valid conclusion based on inductive reason versus an invalid conclusion based on one person’s personal experience.

The following comes from my book, How Dysfunctional Families Spur Mental Disorders.

Anecdotal evidence in medicine is often misleadingly defined as evidence based on only one clinician’s personal experience with a treatment or diagnosis in question. If that is the standard that is to be used, clearly many reasons exist to question the validity of inferences drawn from these experiences. Individuals are well known to have various biases that color their observations and the conclusions they draw from them. 

They may have blind spots because of their own emotional conflicts. They may ignore evidence that is contradictory to their point of view. Their observations may be limited by their pet theories about the phenomena in question. 

Perhaps even more importantly, they may be seeing unusual cases that are not representative of more “typical” cases in one way or another – a so-called selection bias.

An obvious case of selection bias was illustrated by a statement I heard made at a conference by a family therapy pioneer, the late Jay Haley. I had always admired Mr. Haley for many of his fascinating and utilitarian ideas and observations. However, in this case he betrayed some ignorance. He stated that he did not believe antidepressant drugs were ever effective because none of the patients referred to him had ever responded to them.

Of course, his being a well-known family therapist who did not believe in medication had a tremendous effect on exactly who would be referred to him. Not everyone does respond to drug treatment. Anyone who had responded to an antidepressant would, in all probability, rarely if ever darken his door. Hence, with his sample, he would be misled into thinking that the medicines were not effective for anybody. This form of bias is very common and can be quite subtle. For example, it can affect one’s beliefs about such matters as racial stereotypes or a determination of how trustworthy members of a city’s police department are.

Do these types of biases invalidate all clinical experience? Hardly. First of all, we have to distinguish between the descriptions of the actual events contained within specific anecdotes, and the conclusions or inferences which are drawn from these events. 

Let us first examine the descriptionsof what actually happened. A specific anecdote may be accurately observed and described, or not so accurately. If important details are altered or left out entirely, the anecdote may indeed be worthless. However, the exact same thing can be said about empirical studies.

Important details may not even be known to an observer. Particularly with observations of family behavior within a practitioner’s or researcher’s office, important information is almost always hidden, either by design or unwittingly. In addition to the fact that one does not see the whole picture in any single context, there is also a basic problem inherent in the nature of interactions between intimates.

With verbal behavior, for instance, linguists refer to a quality called ellipsis. What this means is that in conversations among people who have known each other for a while, certain information is not spelled out verbally because the other person already knows it. Strangers such as therapists who are listening in and who have not been privy to these prior experiences may think they know what the family is talking about, but they may in reality be completely clueless.

Let us now consider the separate issue of conclusions that are drawn from anecdotes, as opposed to their description. The questions raised by an accurately-described clinical observation can be quite valid, but the answers inferred from it can be completely wrong. Conclusions based on clinical “anecdotes” exist on a continuum from relatively accurate ones to those that are extremely biased to those that are based on spectacular inferential or logical leaps of faith.

Relatively unbiased clinical conclusions based on anecdotes by mental health professionals have many things in common: 

·   They are based on a sample that one has a reasonable expectation is at least somewhat representative of a larger population.

·    They make use, not just the practitioner’s observations, but of the observations of other professionals whom one knows to be reliable and open minded. These clinicians should also be ones known to take the time with their patients necessary to take a complete history. Widespread clinical experience by competent clinicians is something upon which someone can make a very valid inductive conclusion, and is not just “anecdotal evidence.” In fact, conclusions drawn from this source tend to be more accurate that those drawn from so called “empirical” studies. Many dangerous side effects from drugs that did not show up in the initial drug studies have been discovered in this manner.

  

·     They make use of other informants besides the patient when possible.

·     They take into consideration that people and their family members behave quite differently behind closed doors than they do in public, and therefore if at all possible include observations of patient behavior when patients are unaware that they are being observed.

·    They are based on longitudinal observations. That is, the patients on whom conclusions are based have been seen on multiple occasions over an extended period of time.

·     They are not contradicted by commonly observed examples of behavior in everyday life related to the behavior in question.

·      The person proposing the conclusion acknowledges potential biases, such as a financial stake in a certain drug or allegiance to a specific school of therapy, and acknowledges his or her limitations. What former president of the Society of Clinical Psychology, Gerald C. Davison, calls “ex cathedra statements based upon flimsy and subjective evidence,” a hallmark of some psychotherapy gurus, are always highly suspicious. In fact, charlatans are relatively easy to spot. They have a tendency to sidestep challenges. I will give an example of this shortly.

  

·     The conclusions reached should lead to predictions of patient behavior under certain circumstances that prove to be accurate in a significant number of cases. This is called predictive validity. Of course, human behavior being as unpredictable as it is, at times the predictions will not be completely accurate even if the conclusions are valid, and so this fact must also be taken into account.

·     Conclusions based on anecdotes about treatment efficacy or the reasons for certain observed behavior should consider several alternate possible explanations for the observations. If several explanations are possible, one must make a judgment about which ones are more likely and which are less likely based not on the anecdote alone, but on all sources of data available. These sources include empirical studies, but also include observations from everyday life, as well as material seen in some relatively reliable media such as reputable newspapers.

Now of course stories in the media also do not tell the whole story or may be biased, so one needs to realize again that one can be fooled, and take this into account as well. I used to believe the common myth, for example, that in nature under certain conditions the animals called lemmings would follow each other off a cliff and commit mass suicide.

I was surprised when I learned that this was untrue because I had as a child in 1958 seen a film clip of said mass suicide that was part of a Disney “True Life Adventure” nature movie called White Wilderness. I later learned that, because the Disney crew could not find a real example, they had from behind the scenes driven the group of lemmings off the cliff for the cameras.

On the other hand, many people believe that men have never been to the moon and that films of the moon landings were made in a movie studio using special effects. I must say, I tend to believe that those film clips are real, but few know for certain.

·   If other anecdotes about similar patients and treatments seem to contradict the conclusions based on a given anecdote, an attempt should be made to account for this difference.

As an illustration of the latter point and an example of a the “quick step side step” in scientific presentations. I once heard an expert present new evidence from neuroscience that certain capabilities of which human brains are capable seem to develop only at certain times during early childhood development. This brain development could be adversely affected by a baby’s early social environment. Of course, that is somewhat true.

Like psychoanalysts will, however, the expert went on to conclude that if the adverse early experiences had taken place, the child had no chance of growing up to be normal. I raised my hand and asked about those children who come from horribly adverse backgrounds, are adopted away at an age past the alleged crucial developmental time, and yet still turn out wonderfully. The expert then changed the subject without ever addressing my question.  

If the data doesn't fit your pre-conceived conclusions, just change the subject!

Remember, there are NO empirical, placebo-controlled, double blind controlled studies on whether parachutes reduce the incidence of deaths or injuries after falling out of airplanes. Or that appendectomies are effective in preventing complications and deaths from appendicitis. And yet we all take those things for granted.