The Generic Treatment of Trauma

1. James Keim, MSW, LCSW Director Bay Area Oppositional and Conduct Clinic Co-Author of the book, The Violence of Men The Generic Treatment of Trauma

2. Overview • Describe various aspects of PTSD and trauma • Discuss the natural healing of trauma outside of therapy • Apply these factors to trauma psychotherapy • Review what we know about clinical outcome and practice • Review a video of a family therapy session addressing trauma, if time a hypnosis session • Summarize generic good practice

3. The DSM Definition of PTSD Post-traumatic stress disorder (PTSD) is an anxiety disorder that follows a person's exposure to a traumatic stressor and is characterized by three clusters of symptoms: (a) re-experiencing of the traumatic event (e.g., intrusive thoughts, nightmares), (b) avoidance of stimuli associated with or generalized to the trauma, and (c) hyperarousal such as exaggerated startle response or hypervigilance (APA, 1994)

4. Prevalence A minority of persons exposed to trauma develops full characteristics (as defined by DSM-IV) of PTSD (Kessler, 2000). It is one of the most common mental disorders with an estimated lifetime prevalence of approximately 8% (Green & Kaltman, 2002; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

5. PTSD in Combat Veterans Rates of PTSD for US combat veterans who fought in Iraq and Afghanistan are up to 20% (Hoge et al., 2004).

6. The Mental Health Impact of Rape Dean G. Kilpatrick, Ph.D. National Violence Against Women Prevention Research Center Medical University of South Carolina Almost one-third (31%) of all rape victims developed PTSD sometime during their lifetime; and more than one in ten rape victims (11%) still has PTSD today. Rape victims were 6.2 times more likely to develop PTSD than women who had never been victims of crime (31% vs 5%). Rape victims were 5.5 times more likely to have current PTSD than those who had never been victims of crime (11% Vs 2%).

7. Neuro-Endocrine Interruption • Healthy processing of trauma requires repeated review of the trauma • The parts of the brain involved in processing of trauma can be “shut down” by stress hormones that seem to send blood and other assets to the parts of the brain involved in fight or flight • With PTSD, the required review of trauma is interrupted each time by the hormonal response to the trauma

8. Narrative Interruption Imagine that you are at a movie that you are really enjoying. The movie projector quits 15 minutes before the end of the movie, and you don't know how the story is completed. How do you feel? Why?

9. Narrative Interruption Not knowing the end of a story that we have an interest in, even a fictional story on a movie screen with no impact on our lives, creates a sense of agitation and frustration

10. Narrative Dimension (This refers to the importance of creating linear narratives, not to the model of therapy) • Trauma is characterized by confusion in the order of events related to the trauma, and this confusion results in interrupted interpersonal and interactional retelling • Healthy processing of trauma involves the creation of a LINEAR NARRATIVE, mainly through conversations with others, so that the story becomes retellable with a beginning, middle, and end

11. Narrative Dimension Healthy processing of trauma involves the creation of a LINEAR NARRATIVE, mainly through conversations with others, so that the story becomes retellable with a beginning, middle, and end. It seems that we can best digest trauma that has a complete narrative form and that we have trouble processing trauma that has a confused narrative form.

12. Social Support Dimension of Trauma • People process socially acceptable trauma in a healthy way without the need of therapy or medication • One of the most powerful predictors of the development of PTSD is the presence or lack of social support (see meta-analysis on next slide)

14. Digestion of Traumatic Experience • Trauma is a part of every individual's experience and is usually “digested” eventually • PTSD and other trauma related issues represent the inability to digest a traumatic experience or a series of traumatic experiences • A model of “healthy digestion” usually is one of numerous ways to harness the common factors responsible for good outcome

15. Normal Processing of Trauma • Small Group Exercise • If you would like to participate, each person should take some time to choose an experience with death of someone close to you. Your description should start with expecting or learning of the death and include the funeral and yearly rituals

16. Group Exercise – Healthy Processing of Trauma • How did this death effect you negatively at first? (sleep issues, nervousness, control over emotions, spiritual pain, mental confusion) • How did people come together to deal with this? • What rituals, conversations, and care taking of survivors was involved? How did people know how to do these things?

17. Group Exercise – Healthy Processing of Trauma Regarding the people who comforted you during the trauma processing, how important was it that they be • engaged, not detached • empathic and warm • confident that you would eventually be OK

18. Discussion Can someone provide an example of being comforted by another in a way that was authentic, connected, and helpful?

19. Exercise Remember the examples of healthy trauma response from the group exercise. • Can you imagine responding with the same degree of organization and ritual to someone being raped? • Create a list of situations that might make it difficult for a group to have a healthy response to trauma

20. Self Blame Self blame and fear of blame from others is one of the more common reasons that people are afraid to reach out to their support system

21. Generic Ingredients Identified in the Exercise Culture, family, and friends provide • training and knowledge as to how to respond including how to collaborate with others in providing support • a map of expected experience including understanding of the journey – the beginning, middle and end of the healing process

22. Generic Ingredients Identified in the Exercise • Recognition, offering, and acceptance of dignified, authentic social support • This includes allowance to assume in dignified way role of person with suffering

23. Generic Ingredients Identified in the Exercise Safe retelling and re-experiencing: • Repeated experiences of bringing up specific, individual painful memories and having them soothed, with repeated pairings of this evoke/soothe pattern • Repeated opportunities to create and tell a coherent trauma narrative, and while doing so to process, be soothed, and self-soothe. Repeated pairings of the evoke/soothe pattern.

24. Generic Therapy of Trauma The question is not what is the most effective model because there is no difference in bona fida models of therapy for trauma. The approach that most helps the therapist is the one that facilitates the two most important contributions – what what Gassman and Grawe called ‘resource activation’- “recruit, harvest and enlist client competencies,” and securing strong alliances (Duncan, 2010). The exercise we did was just one way that you can evoke client recruit, harvest and enlist client competencies.

25. Therapy Imitates Life Can we identify these elements from the exercise in therapy? • Provision of map of recovery Allowance to assume in dignified way role of person with suffering • Repeated telling of the story with soothing or distraction to keep flight or fight reaction in check – trauma narrative becomes a coherent linear story rather than a confused incoherent and difficult to tell story. • How does Alcoholics Anonymous do this? How does CBT do this? How does EMDR do this?

26. Videos EMDR - Start at 4:00

27. Meta-Analysis of PTSD Treatments • Benish, Imel, & Wampold, 2007 “The results suggest that despite strong evidence of psychotherapy efficaciousness vis-à-vis no treatment or common factor controls, bona fide psychotherapies produce equivalent benefits for patients with PTSD.”

28. Individual Differences between Therapists Clients of the best therapists improve at a rate at least 50 percent higher and drop out at a rate at least 50 percent lower than those of average clinicians.

29. Common Factors in Therapy • Michael Lambert's model (in T.P. Ass and M.J. Lambert, 1999, “The Empirical Case for the Common Factors in Therapy: Quantitative findings.” • 40% Client/Extra therapeutic • 30% Relationship • 15% Model/Technique • 15% Placebo, Hope, and Expectancy

32. Remember these The question is not what is the most effective model because there is no difference in bona fida models of therapy for trauma. The approach that most helps the therapist is the one that facilitates the two most important contributions – what what Gassman and Grawe called ‘resource activation’- “recruit, harvest and enlist client competencies,” and securing strong alliances (Duncan, 2010).

33. One Generic Trauma Intervention • Work from a basis of client competence by finding successful handling of past traumas. Access similar resources in people, rituals, institutions, and structure. • In collaboration with the client, find a way that the client can detach the “fight or flight” reaction from the story. • In collaboration with the client, find a way that the client can tell the story in a way that helps make it linear and comprehensible. • In collaboration with the client, find a way for this to be a story with a beginning, middle, and end.

34. Changing your Conceptualization: Outcome data seems to suggest a basic systemic idea: Successful treatment of complex problems brought to therapy resemble more the treatment of an immune system more than the treatment of a disease

35. SNS Activation Ozbay et al (2007) note that “When the SNS is strongly activated, neuropeptide Y (NPY ) and galanin are released with norepinephrine to maintain SNS activity within an optimal activation range (reviewed by Southwick, et al. ). I ndeed, highly resilient special operations soldiers tend to have high levels of NPY in contrast to combat veterans diagnosed with PTSD who have reduced levels. The overall net effects of NE hyperactivity thus may depend on the balance between NE, NPY , and galanin. This supports the notion that resilience to stress is associated with the regulation of noradrenergic activity within an optimal window. The Heart and Soul of Change: The Heart and Soul of Change: What Works in Therapy What Works in Therapy Scott D. Miller, Ph. D. Scott D. Miller, Ph. D. Insti t tute for the Study of Therapeutic Change Change P.O. Box 578264 P.O. Box 578264 Chicago, IL 60657 Chicago, IL 60657 8264 8264 www.talkingcure.com www.talkingcure.com 1 2 • • Therapists Therapists • • Administrators Administrators • • Researchers Researchers • • Payers Payers • • Business executives Business executives • • Regulators Regulators What Works in Therapy What Works in Therapy • • “ “ Accountability, Accountability, ” ” “ “ Stewardship, Stewardship, ” ” & & “ “ Return on Investment Return on Investment ” ” the the buzzwords of the day buzzwords of the day . . • • Part of a world wide trend not Part of a world wide trend not specific to mental health and specific to mental health and independent of any particular type independent of any particular type of reimbursement system. of reimbursement system. Lambert, M.J., Whipple, J.L., Hawkins, E.J., Lambert, M.J., Whipple, J.L., Hawkins, E.J., Vermeersch Vermeersch , D.A., Nielsen, S.L., Smart, D.A. , D.A., Nielsen, S.L., Smart, D.A. (2004). Is it time for clinicians routinely to track patient ou (2004). Is it time for clinicians routinely to track patient ou tcome: A meta tcome: A meta analysis. Clinical analysis. Clinical Psychology, Psychology, 10 10 , 288 , 288 301. 301. 3 What Works in Therapy What Works in Therapy What Works in Therapy: What Works in Therapy: Question #1: Question #1: Research Research consistently shows consistently shows that treatment that treatment works works Pop Quiz Pop Quiz True True Study after study, Study after study, and studies of studies and studies of studies show the average show the average treated client is better treated client is better off than 80% of the off than 80% of the untreated sample. untreated sample. 4 Tutorial on “Effect Size” Tutorial on “Effect Size” Effect size of therapy Effect size of therapy Effect size of Aspirin Effect size of Aspirin Rosenthal, R. (June 1990). How are we doing in soft psychology Rosenthal, R. (June 1990). How are we doing in soft psychology ? ? American Psychologist, 45 American Psychologist, 45 (6), 775 (6), 775 777. 777. Duncan, B., Miller, S., & Sparks, J. (2004). Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client The Heroic Client (2 (2 .8 Marital therapy Marital therapy nd nd ed.). ed.). Jossey Jossey Bass: San Francisco, CA. Bass: San Francisco, CA. What Works in Therapy: What Works in Therapy: The Data The Data Effect Size Effect Size Treatment Treatment .8 - 1.2  Psychotherapy Psychotherapy .8  Bypass surgery Bypass surgery .8  ECT for depression ECT for depression .61  Pharmacotherapy for arthritis Pharmacotherapy for arthritis .47  AZT for AIDS mortality AZT for AIDS mortality .58  Family therapy Family therapy Lipsey Lipsey , M.W., & Wilson, D.B. (1993). The efficacy of psychological, b , M.W., & Wilson, D.B. (1993). The efficacy of psychological, b ehavioral, and educational ehavioral, and educational treatment. treatment. American Psychologist, 48, American Psychologist, 48, 1181 1181 1209. 1209. Shadish Shadish , W.R., & Baldwin, S.A. (2002). Meta , W.R., & Baldwin, S.A. (2002). Meta analysis of MFT interventions. In D.H. analysis of MFT interventions. In D.H. Sprenkle Sprenkle (Ed.). (Ed.). Effectiveness research in marriage and family therapy (pp.339 Effectiveness research in marriage and family therapy (pp.339 370). Alexandria, VA: AAMFT. 370). Alexandria, VA: AAMFT. 5 Procedure or Target: Procedure or Target: Behavioral Health (depression in adults or children, aggression, conduct disorder, bulimia, PTSD) Medicine (Acute MI, CHF, Graves Hyperthyriodism, medication treated erectile dysfunction, stages II and III breast cancer, cataract surgery, acute stroke, etc.). What Works in Therapy: What Works in Therapy: The Data The Data Aspirin as a prophylaxis for heart attacks Number Needed to Number Needed to Treat (NNT)*: Treat (NNT)*: http://www.cebm.utoronto.ca/glossary/nntsPrint.htm#table 3-7 3-7 129 129 *NNT is the number needed to treat in order to achieve one successful outcome that would not have been accomplished in the absence of treatment. What Works in Therapy: What Works in Therapy: More good news: More good news: More good news: Research shows that only 1 out Research shows that only 1 out of 10 clients on the average of 10 clients on the average Research shows that only 1 out of 10 clients on the average clinician clinician ’ ’ s caseload is not making s caseload is not making any progress. any progress. clinician’s caseload is not making any progress. Recent study: Recent study: Recent study: 6,000+ treatment providers 6,000+ treatment providers 6,000+ treatment providers 48,000 plus real clients 48,000 plus real clients 48,000 plus real clients An Example Outcomes clinically equivalent to Outcomes clinically equivalent to randomized, controlled, clinical randomized, controlled, clinical trials. trials. An Example Outcomes clinically equivalent to randomized, controlled, clinical trials. Kendall, P.C., Kendall, P.C., Kipnis Kipnis , D, & Otto , D, & Otto Salaj Salaj , L. (1992). When clients don , L. (1992). When clients don ’ ’ t progress. t progress. Cognitive Therapy and Research, 16 Cognitive Therapy and Research, 16 , 269 , 269 281. 281. Minami, T., Wampold, B., Minami, T., Wampold, B., Serlin Serlin , R. Hamilton, E., Brown, J., , R. Hamilton, E., Brown, J., Kircher Kircher , J. (2008). Benchmarking the effectiveness of , J. (2008). Benchmarking the effectiveness of treatment for adult depression in a managed care environment: A treatment for adult depression in a managed care environment: A preliminary study. preliminary study. Journal of Consulting and Clinical Journal of Consulting and Clinical Psychology, Psychology, 76 76 (1), (1), 116 116 124. 124. 6 What Works in Therapy: What Works in Therapy: The “Good News” The “Good News” The bottom line? The bottom line? • • The majority of helpers are The majority of helpers are effective and efficient effective and efficient most most of the time. of the time. • • Average treated client Average treated client accounts for only 7% of accounts for only 7% of expenditures. expenditures. So, what So, what ’ ’ s the problem s the problem … … What Works in Therapy: The “Bad News” What Works in Therapy: The “Bad News” • • Drop out rates average 47%; Drop out rates average 47%; • • Therapists frequently fail to Therapists frequently fail to identify failing cases; identify failing cases; • • 1 out of 10 clients accounts 1 out of 10 clients accounts for 60 for 60 70% of expenditures. 70% of expenditures. Lambert, M.J., Whipple, J., Hawkins, E., Vermeersch, D., Nielsen, S., & Smart, D. (2004). Is it time for clinicians routinely to track client outcome? A meta-analysis. Clinical Psychology, 10, 288-301. Chasson, G. (2005). Attrition in child treatment. Psychotherapy Bulletin, 40(1), 4-7. 7 What Works in Therapy: What Works in Therapy: Question #2: Question #2: Stigma, ignorance, Stigma, ignorance, denial, and lack of denial, and lack of motivation are the most motivation are the most common reasons common reasons potential consumers do potential consumers do not seek the help they not seek the help they need. need. Pop Quiz Pop Quiz False False Second to cost (81%), Second to cost (81%), lack of confidence lack of confidence in the in the outcome of the service outcome of the service is the primary reason is the primary reason (78%). Fewer than 1 in (78%). Fewer than 1 in 5 cite stigma as a 5 cite stigma as a concern. concern. http://www.apa.org/releases/practicepoll_04.html http://www.apa.org/releases/practicepoll_04.html Outcome: Outcome: How do therapists compare? How do therapists compare? In a recent survey on how much consumers In a recent survey on how much consumers trusted various professionals trusted various professionals … … . . Therapists Therapists The consumer The consumer Psychotherapy in Australia (2001). Trust in therapists? Psychotherapy in Australia (2001). Trust in therapists? 7 7 (1), 4 (1), 4 . . 8 What Works in Therapy: What Works in Therapy: • • Cognitive Therapy Cognitive Therapy • • Behavioral Therapy Behavioral Therapy • • Cognitive Behavioral Therapy Cognitive Behavioral Therapy • • Motivational Interviewing Motivational Interviewing • • Twelve Steps Twelve Steps • • Dialectical Behavioral Therapy Dialectical Behavioral Therapy • • Multidimensional Family Therapy Multidimensional Family Therapy • • Structural Family Therapy Structural Family Therapy • • Functional Family Therapy Functional Family Therapy • • Skills Training Skills Training • • Acceptance and Commitment Therapy Acceptance and Commitment Therapy • • Existential Therapy Existential Therapy Pop Quiz Pop Quiz • • Client Client centered Therapy centered Therapy • • Systemic Therapy Systemic Therapy • • Biopsychosocial Biopsychosocial Therapy Therapy • • Solution Solution focused Therapy focused Therapy • • Multimodal Therapy Multimodal Therapy • • Psychodynamic Therapy Psychodynamic Therapy • • Narrative Therapy Narrative Therapy • • Integrative Problem Integrative Problem Solving Therapy Solving Therapy • • Eclectic Therapy Eclectic Therapy • • Interpersonal Psychotherapy Interpersonal Psychotherapy • • Transtheoretical Transtheoretical Therapy Therapy What Works in Therapy: What Works in Therapy: • • Cognitive Therapy Cognitive Therapy • • Behavioral Therapy Behavioral Therapy • • Cognitive Behavioral Therapy Cognitive Behavioral Therapy • • Motivational Interviewing Motivational Interviewing • • Twelve Steps Twelve Steps • • Dialectical Behavioral Therapy Dialectical Behavioral Therapy • • Multidimensional Family Therapy Multidimensional Family Therapy • • Structural Family Therapy Structural Family Therapy • • Functional Family Therapy Functional Family Therapy • • Skills Training Skills Training • • Acceptance and Commitment Therapy Acceptance and Commitment Therapy • • Existential Therapy Existential Therapy Pop Quiz Pop Quiz • • Client Client centered Therapy centered Therapy • • Systemic Therapy Systemic Therapy • • Biopsychosocial Biopsychosocial Therapy Therapy • • Solution Solution focused Therapy focused Therapy • • Multimodal Therapy Multimodal Therapy • • Psychodynamic Therapy Psychodynamic Therapy • • Narrative Therapy Narrative Therapy • • Integrative Problem Integrative Problem Solving Therapy Solving Therapy • • Eclectic Therapy Eclectic Therapy • • Interpersonal Psychotherapy Interpersonal Psychotherapy • • Transtheoretical Transtheoretical Therapy Therapy 9 What Works in Therapy: What Works in Therapy: Question #3: Question #3: Of all the factors Of all the factors affecting treatment affecting treatment outcome, treatment outcome, treatment model (technique or model (technique or programming) is programming) is the the most potent. most potent. Pop Quiz Pop Quiz FALSE FALSE Technique makes the Technique makes the smallest percentage smallest percentage - wise contribution to wise contribution to outcome of any outcome of any known ingredient. known ingredient. What Works in Therapy: What Works in Therapy: Factors accounting for Success Factors accounting for Success Outcome of Treatment Outcome of Treatment : : • • 60% due to 60% due to “ “ Alliance Alliance ” ” ([aka ([aka “ “ common factors common factors ” ” ] 8%/13%) ] 8%/13%) • • 30% due to 30% due to “ “ Allegiance Allegiance ” ” Factors Factors (4%/13%) (4%/13%) • • 8% due to model and 8% due to model and technique (1/13) technique (1/13) 13 11 12 9 10 6 7 8 4 5 2 3 0 1 Technique Allegiance Alliance Wampold, B. (2001). Wampold, B. (2001). The Great Psychotherapy Debate The Great Psychotherapy Debate . New York: Lawrence . New York: Lawrence Erlbaum. Erlbaum. 10 What Works in Therapy: What Works in Therapy: Current State of Clinical Practice Current State of Clinical Practice Nonetheless, in spite of the data: Nonetheless, in spite of the data: • • Therapists firmly believe that the Therapists firmly believe that the expertness of their techniques leads to expertness of their techniques leads to successful outcomes; successful outcomes; • • The field as a whole is continuing to The field as a whole is continuing to embrace the medical model. embrace the medical model. • • Emphasis on so Emphasis on so called, called, “ “ empirically empirically supported treatments supported treatments ” ” or or “ “ evidence based evidence based practice. practice. ” ” • • Embracing the notion of diagnostic groups. Embracing the notion of diagnostic groups. Eugster, S.L. & Wampold, B. (1996). Systematic effects of parti Eugster, S.L. & Wampold, B. (1996). Systematic effects of parti cipants role on the evaluation of the cipants role on the evaluation of the psychotherapy session. psychotherapy session. Journal of Consulting and Clinical Psychology, 64 Journal of Consulting and Clinical Psychology, 64 , 1020 , 1020 1028. 1028. What Works in Therapy: What Works in Therapy: Research on the Alliance Research on the Alliance • • Research on Research on the alliance the alliance reflected in over reflected in over 1000 research 1000 research findings. findings. Bachelor, A., & Horvath, A. (1999). The Therapeutic Bachelor, A., & Horvath, A. (1999). The Therapeutic Relationship. In M. Hubble, B. Duncan, & S. Miller (eds.). Relationship. In M. Hubble, B. Duncan, & S. Miller (eds.). The Heart and Soul of Change The Heart and Soul of Change . Washington, D.C.: APA . Washington, D.C.: APA Press. Press. Goals, Goals, Meaning or Meaning or Purpose Purpose Client Client ’ ’ s s Theory of Change Theory of Change Client Client ’ ’ s View of the s View of the Therapeutic Relationship Therapeutic Relationship Means or Means or Methods Methods 11 The Client The Client ’ ’ s Theory of Change: s Theory of Change: • • When treatment of people diagnosed as schizophrenic When treatment of people diagnosed as schizophrenic was changed to accord their wishes and ideas: was changed to accord their wishes and ideas: • • More engagement; More engagement; Empirical Findings Empirical Findings • • In the Hester, Miller, Delaney, and Meyer study: In the Hester, Miller, Delaney, and Meyer study: • • A difference in outcome was found between the two groups A difference in outcome was found between the two groups depending on whether the treatment fit with the client depending on whether the treatment fit with the client ’ ’ s pre s pre treatment beliefs about their problem and/or the change process. treatment beliefs about their problem and/or the change process. • • Higher self Higher self ratings; and ratings; and • • Improved objective scores. Improved objective scores. Hester, R., Miller, W., Delaney, H., & Meyers, R. (1990). Hester, R., Miller, W., Delaney, H., & Meyers, R. (1990). Effectiveness of the community reinforcement approach. Effectiveness of the community reinforcement approach. Paper presented at the 24 Paper presented at the 24 annual meeting of annual meeting of the AABT. San Francisco, CA. the AABT. San Francisco, CA. Duncan, B., & Miller, S. (2000). The client Duncan, B., & Miller, S. (2000). The client ’ ’ s theory of change: Consulting the client in the integrative pro s theory of change: Consulting the client in the integrative pro cess. cess. Journal of Psychotherapy Integration, 10 Journal of Psychotherapy Integration, 10 (2), 169 (2), 169 187. 187. Priebe Priebe , S., & , S., & Gruyters Gruyters , T. (1999). A pilot trial of treatment changes according to sc , T. (1999). A pilot trial of treatment changes according to sc hizophrenic patients hizophrenic patients ’ ’ wishes. wishes. Journal of Nervous and Mental Disease, 187 Journal of Nervous and Mental Disease, 187 (7), (7), 441 441 443. 443. Kelin Kelin , E., Rosenberg, J., & Rosenberg, S. (2007). Whose treatment is , E., Rosenberg, J., & Rosenberg, S. (2007). Whose treatment is it anyway? The role of consumer preferences in mental healthcar it anyway? The role of consumer preferences in mental healthcar e. e. American Journal of American Journal of Psychiatric Rehabilitation, 10 Psychiatric Rehabilitation, 10 (1), 65 (1), 65 80. 80. What Works in Therapy: What Works in Therapy: An Example An Example Dennis, M. Godley, S., Diamond, G., Dennis, M. Godley, S., Diamond, G., Tims Tims , F. Babor, T. Donaldson, J., , F. Babor, T. Donaldson, J., Liddle Liddle , H. , H. Titus, J., Titus, J., Kaminer Kaminer , Y., Webb, C., Hamilton, N., Funk, R. (2004). The , Y., Webb, C., Hamilton, N., Funk, R. (2004). The cannibas cannibas youth treatment (CYT) study: Main findings from two randomized t youth treatment (CYT) study: Main findings from two randomized t rials. rials. Journal of Journal of Substance Abuse Treatment, 27, Substance Abuse Treatment, 27, 97 97 – – 213 213 . . th th 12 What Works in Therapy: What Works in Therapy: An Example An Example • • 600 Adolescents marijuana users: 600 Adolescents marijuana users: • • Between the ages of 12 Between the ages of 12 15; 15; • • Rated as or more severe than adolescents seen in routine clinica Rated as or more severe than adolescents seen in routine clinica l l practice settings; practice settings; • • Significant co Significant co morbidity (3 to 12 problems [83%], alcohol [37%]; morbidity (3 to 12 problems [83%], alcohol [37%]; internalizing [25%], externalizing [61%]). internalizing [25%], externalizing [61%]). • • Participants randomized into one of two arms (dose, type) Participants randomized into one of two arms (dose, type) and one of three types of treatment in each arm: and one of three types of treatment in each arm: • • Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Support Network (12 Support Network (12 wks)+MET+CBT wks)+MET+CBT ; ; • • Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks). Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks). What Works in Therapy: What Works in Therapy: An Example An Example Cannabis Youth Cannabis Youth Treatment Project Treatment Project • • Treatment approach accounted for little more than 0% of Treatment approach accounted for little more than 0% of the variance in outcome. the variance in outcome. • • By contrast, ratings of the alliance predicted: By contrast, ratings of the alliance predicted: • • Premature drop Premature drop out; out; • • Substance abuse and dependency symptoms post Substance abuse and dependency symptoms post treatment, treatment, and cannabis use at 3 and 6 month follow and cannabis use at 3 and 6 month follow up. up. Tetzlaff Tetzlaff , B., Hahn, J., Godley, S., Godley, M., Diamond, G., & Funk, R. , B., Hahn, J., Godley, S., Godley, M., Diamond, G., & Funk, R. (2005). Working alliance, (2005). Working alliance, treatment satisfaction, and post treatment satisfaction, and post treatment patterns of use among adolescent substance users. treatment patterns of use among adolescent substance users. Psychology of Addictive Behaviors, Psychology of Addictive Behaviors, 19(2), 199 19(2), 199 207. 207. Shelef Shelef , K., Diamond, G., Diamond, G., , K., Diamond, G., Diamond, G., Liddle Liddle . H. (2005). Adolescent and parent alliance and treatment . H. (2005). Adolescent and parent alliance and treatment outcome in MDFT. outcome in MDFT. Journal of Consulting and Clinical Psychology, Journal of Consulting and Clinical Psychology, 73(4), 689 73(4), 689 698 698 . . 13 What Works in Therapy: What Works in Therapy: Question #4: Question #4: Pop Quiz Pop Quiz Research shows Research shows that some treatment that some treatment approaches are approaches are more effective more effective than than others others FALSE FALSE All All approaches approaches work equally well work equally well with some of the with some of the people some of the people some of the time. time. What Works in Therapy: What Works in Therapy: An Example An Example • • No difference in outcome No difference in outcome between different types of between different types of treatment or different treatment or different amounts of competing amounts of competing therapeutic approaches. therapeutic approaches. Godley, S.H., Jones, N., Funk, R., Ives, M Godley, S.H., Jones, N., Funk, R., Ives, M Passetti Passetti , L. (2004). Comparing , L. (2004). Comparing Outcomes of Best Outcomes of Best Practice and Research Practice and Research Based Outpatient Treatment Based Outpatient Treatment Protocols for Adolescents. Protocols for Adolescents. Journal of Psychoactive Drugs. 36 Journal of Psychoactive Drugs. 36 (1), 35 (1), 35 48. 48. 14 What Works in Therapy: What Works in Therapy: Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? • • The research says, The research says, “ “ NO! NO! ” ” • • T T he lack of difference cannot be he lack of difference cannot be attributed to: attributed to: • • Research design; Research design; • • Time of measurement; Time of measurement; • • Year of publication; Year of publication; • • The differences which have been The differences which have been found: found: • • Do not exceed what would be expected by Do not exceed what would be expected by chance; chance; • • At most account for 1% of the variance. At most account for 1% of the variance. Rosenzweig, S. (1936). Some implicit common factors in diverse Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. methods in psychotherapy. Journal of Journal of Orthopsychiatry, 6 Orthopsychiatry, 6 , 412 , 412 15. 15. Wampold, B.E. et al. (1997). Wampold, B.E. et al. (1997). A meta A meta analysis of outcome studies comparing bona fide psychotherapies: analysis of outcome studies comparing bona fide psychotherapies: Empirically, Empirically, "All must have prizes." "All must have prizes." Psychological Bulletin, 122 Psychological Bulletin, 122 (3), 203 (3), 203 215. 215. What Works in Therapy: What Works in Therapy: Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? •Meta-analysis of all studies published between 1980-2006 comparing bona fide treatments for children with ADHD, conduct disorder, anxiety, or depression: •No difference in outcome between approaches intended to be therapeutic; •Researcher allegiance accounted for 100% of variance in effects. Miller, S.D., Wampold, B.E., & Varhely, K. (2008). Direct comparisons of treatment modalities for youth disorders: A meta-analysis. Psychotherapy Research, 18(1), 5-14 15 What Works in Therapy: What Works in Therapy: What Works in Therapy: Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? •Meta-analysis of all studies published between 1960-2007 comparing bona fide treatments for alcohol abuse and dependence: •No difference in outcome between approaches intended to be therapeutic; •Approaches varied from CBT, 12 steps, Relapse prevention, & PDT. •Researcher allegiance accounted for 100% of variance in effects. Imel, Z., Wampold, B.E., Miller, S.& Fleming, R.. (in press). Distinctions without a difference. Psychology of Addictive Behaviors. What Works in Therapy: What Works in Therapy: What Works in Therapy: Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? •Meta-analysis of all studies published between 1989-Present comparing bona fide treatments for PTSD: •Approaches included desensitization, hypnotherapy, PD, TTP, EMDR, Stress Inoculation, Exposure, Cognitive, CBT, Present Centered, Prolonged exposure, TFT, Imaginal exposure. •Unlike earlier studies, controlled for inflated Type 1 error by not categorizing treatments thus eliminating numerous pairwise comparisons; Bemish, S., Imel, Z., & Wampold, B. (in press). The relative efficacy of bona fide psychotherapies for treating psttraumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review. 16 What Works in Therapy: What Works in Therapy: What Works in Therapy: Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? Do Treatments vary in Efficacy? •The results: •No difference in outcome between approaches intended to be therapeutic on both direct and indirect measures; •D = .00 (Upper bound E.S = .13) •NNT = 14; (14 people would need to be treated with the superior Tx in order to have 1 more success as compared to the “less” effective Tx). Bemish, S., Imel, Z., & Wampold, B. (in press). The relative efficacy of bona fide psychotherapies for treating psttraumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review. What Works in Therapy: What Works in Therapy: Question #5: Question #5: Pop Quiz Pop Quiz Consumer ratings of Consumer ratings of the alliance are better the alliance are better predictors of retention predictors of retention and outcome than and outcome than clinician ratings. clinician ratings. True True Remember the Alamo! Remember the Alamo! Remember Remember Project MATCH Project MATCH 17 What Works in Therapy: What Works in Therapy: Project MATCH and the Alliance Project MATCH and the Alliance • • The largest study ever conducted on the treatment of The largest study ever conducted on the treatment of problem drinking: problem drinking: • • Three different treatment approaches studied (CBT, 12 Three different treatment approaches studied (CBT, 12 step, step, and Motivational Interviewing). and Motivational Interviewing). • • NO NO difference in outcome between approaches. difference in outcome between approaches. • • The client The client ’ ’ s rating of the therapeutic alliance the best s rating of the therapeutic alliance the best predictor of: predictor of: • • Treatment participation; Treatment participation; • • Drinking behavior during treatment; Drinking behavior during treatment; • • Drinking at 12 Drinking at 12 month follow month follow up. up. Project MATCH Group (1997). Matching alcoholism treatment to cl Project MATCH Group (1997). Matching alcoholism treatment to cl ient heterogeneity. ient heterogeneity. Journal of Studies on Alcohol, 58 Journal of Studies on Alcohol, 58 , 7 , 7 29. 29. Babor, T.F., & Del Boca, F.K. (eds.) (2003). Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK. Cambridge University Press: Cambridge, UK. Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and and its relationship to alcoholism treatment participation and outcome. outcome. Journal of Consulting and Clinical Psychology, 65 Journal of Consulting and Clinical Psychology, 65 (4), 588 (4), 588 98. 98. What Works in Therapy: What Works in Therapy: Question #6: Question #6: The bulk of change in The bulk of change in successful treatment successful treatment occurs earlier rather occurs earlier rather than later. than later. Pop Quiz Pop Quiz True True If a particular approach, If a particular approach, delivered in a given delivered in a given setting, by a specific setting, by a specific provider is going to work, provider is going to work, there should measurable there should measurable improvement in the first improvement in the first six weeks of care. six weeks of care. 18 What Works in Therapy: What Works in Therapy: Project MATCH and Outcome Project MATCH and Outcome Babor, T.F., & Babor, T.F., & DelBoca DelBoca , F.K. (eds.) (2003). , F.K. (eds.) (2003). Treatment Matching in Alcoholism Treatment Matching in Alcoholism . United Kingdom: Cambridge, 113. . United Kingdom: Cambridge, 113. What Works in Therapy: What Works in Therapy: More Research on Outcome More Research on Outcome Cannabis Youth Treatment Project Cannabis Youth Treatment Project Approach Approach Dose Dose http://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdf http://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdf 19 What Works in Therapy: What Works in Therapy: Pop Quiz Pop Quiz Last Question! Last Question! The best way to insure effective, The best way to insure effective, efficient, ethical and accountable efficient, ethical and accountable treatment practice is for the field to treatment practice is for the field to adopt and enforce: adopt and enforce: • • Evidence Evidence based practice; based practice; • • Quality assurance; Quality assurance; • • External management; External management; • • Continuing education requirements; Continuing education requirements; • • Legal protection of trade and Legal protection of trade and terminology. terminology. The Medical Model: The Medical Model: Evidence Evidence based based Practice Practice The Contextual Model The Contextual Model Practice Practice based based Evidence Evidence False False What Works in Therapy: What Works in Therapy: A Tale of Two Solutions… A Tale of Two Solutions… • • Diagnosis Diagnosis driven, driven, “ “ illness model illness model ” ” • • Prescriptive Treatments Prescriptive Treatments • • Emphasis on quality and Emphasis on quality and competence competence • • Cure of Cure of “ “ illness illness ” ” • • Client Client directed (Fit) directed (Fit) • • Outcome Outcome informed (Effect) informed (Effect) • • Emphasis on benefit over need Emphasis on benefit over need • • Restore real Restore real life functioning life functioning 20 What Works in Therapy: What Works in Therapy: First Step First Step • • Formalizing what Formalizing what experienced therapists do experienced therapists do on an ongoing basis: on an ongoing basis: • • Assessing and adjusting Assessing and adjusting fit for maximum effect fit for maximum effect . . Duncan, B.L., Miller, S.D., & Sparks, J. (2004). Duncan, B.L., Miller, S.D., & Sparks, J. (2004). The Heroic Client The Heroic Client (2 (2 Ed.). San Ed.). San Francisco, CA: Francisco, CA: Jossey Jossey Bass. Bass. What Works in Therapy: What Works in Therapy: Integrating Formal Client Feedback into Care Integrating Formal Client Feedback into Care The O.R.S The O.R.S The S.R.S The S.R.S Download free working copies at: Download free working copies at: http:// http:// www.talkingcure.com/index.asp?id www.talkingcure.com/index.asp?id =106 =106 nd nd 21 What Works in Therapy: What Works in Therapy: Integrating Formal Client Feedback into Care Integrating Formal Client Feedback into Care • • Cases in which Cases in which therapists therapists “ “ opted out opted out ” ” of assessing the of assessing the alliance at the end of alliance at the end of a session: a session: • • Two times more likely Two times more likely for the client to drop out; for the client to drop out; • • Three to four times more Three to four times more likely to have a negative likely to have a negative or null outcome. or null outcome. Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February , 2005). The Partners for , 2005). The Partners for Change Outcome Management System. Change Outcome Management System. Journal of Clinical Psychology, 61 Journal of Clinical Psychology, 61 (2), 199 (2), 199 208. 208. What Works in Therapy: What Works in Therapy: Integrating Formal Client Feedback into Care Integrating Formal Client Feedback into Care Baseline Baseline Outcome Feedback Outcome Feedback Miller, S.D., Duncan, B.L., Sorrell, R., Brown, G.S., & Chalk, M Miller, S.D., Duncan, B.L., Sorrell, R., Brown, G.S., & Chalk, M .B. (2006). Using .B. (2006). Using outcome to inform therapy practice. outcome to inform therapy practice. Journal of Brief Therapy, 5 Journal of Brief Therapy, 5 (1), 5 (1), 5 22. 22. 22 Percent Percent “ “ recovered recovered ” ” 12 13 10 11 7 8 9 3 4 5 6 0 1 2 50 40 45 35 20 25 30 10 15 What Works in Therapy: 0 5 What Works in Therapy: DO DO A Question of Focus A Question of Focus B B E E L L I I E E V V E E C C a a n n Y Y o o u u R R e e l l a a t t e e ? ? Technique Allegiance Alliance Outcome What Works in Therapy: What Works in Therapy: More Research on Feedback More Research on Feedback 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Outcome-Informed Clinic Standard Practice Lambert, M.J., Lambert, M.J., Okiishi Okiishi , J.C., Finch, A.E., Johnson, L.D. Outcome assessment: From con , J.C., Finch, A.E., Johnson, L.D. Outcome assessment: From con ceptualization to ceptualization to implementation implementation . . P P rofessional Psychology: Research and Practice. rofessional Psychology: Research and

36. Recovery from PTSD related to long-term exposure to high stress environments involves the recovery of certain parts of the brain which are known to be grow in response to meditaion and psychotherapy. The researchers found significant evidence that PTSD among study participants was associated with smaller volume in both the left and right amygdala, and confirmed previous studies linking the disorder to a smaller left hippocampus. The differences in brain volumes between the two groups were not due to the extent of depression, substance abuse, trauma load or PTSD severity - - factors the researchers took into account in their statistical model. Rajendra Morey Duke University Nov. 5, 2012, Archiv es of General Psychiat ry

37. By comparing the distribution of brain injuries between the PTSD group and the non-PTSD group, the researchers found two regions where damage was rarely associated with PTSD: the amygdala, a structure important in fear and anxiety, and the ventromedial prefrontal cortex (vmPFC), an area involved in higher mental functions and planning Jordan Grafman, Ph.D. Senior investigator at the National Institute of Neurological Disorders and Stroke (NINDS)

38. Newberg AB, Wintering N, Waldman MR, Amen D, Khalsa DS, Alavi A. Cerebral blood flow differences between long-term meditators and non-meditators. Conscious Cogn. 2010 Dec;19(4):899-905. Epub 2010 Jun 8. AB The purpose of this study was to determine if there are differences in baseline brain function of experienced meditators compared to non-meditators. All subjects were recruited as part of an ongoing study of different meditation practices. We evaluated 12 a.dvanced meditators and 14 non-meditators with cerebral blood flow (CBF) SPECT imaging at rest. Images were analyzed with both region of interest and statistical parametric mapping. The CBF of long-term meditators was significantly higher (p<.05) compared to non-meditators in the prefrontal cortex, parietal cortex, thalamus, putamen, caudate, and midbrain. There was also a significant difference in the thalamic laterality with long-term meditators having greater asymmetry. The observed changes associated with long-term meditation appear in structures that underlie the attention network and also those that relate to emotion and autonomic function

39. The Extratherapeutic Factor Let's define our aspects healthy recovery from trauma as prime examples of extratherapeutic factors Part of the art of therapy is connecting people to these people, rituals, and knowledge

40. What does the “evidence” touted by proponents really tell us? Treatment is on average four times more effective than no treatment and twice as effective as placebo. So when an evidence based approach, for example, reports in one study that the no treatment group had a 41% recidivism rate, while FFT achieved 9%, that’s great but nothing more than would be expected. Any approach systematically applied by individuals believing in what they are doing will be similarly better than no treatment. FFT has never demonstrated that it is better than any other model of treatment.