Result based psychotherapy

Soon I will post a few literature reviews that describes the state of the art in diagnosis and treatment of sexual assault related PTSD. The review aim is to examine the viability of a results oriented therapy method for the disorder. Results oriented management is a business practice that gives preference to efficacy over any specific process, no matter how deep and meaningful that process may sound. Or in other words: "why should I talk about my mother now???"

Result oriented therapy requires a well established construction of sexual assault related PTSD and its definition as an object of therapy, representative measures of therapy effect that can be applied continuously through the process of therapy, and a variety of therapeutic methods and technologies that can be applied alternately according to ongoing efficacy feedback from measured results. The underlying assumption is that clinician time is the bottleneck in the therapeutic process, and that methods and technologies that use clinician time more efficiently can increase therapy effect within therapy and in making therapy affordable to more potential patients.

So when a patients asks why talk about mom, while the current answer is "it's a process, it could help", a therapist with any measures of efficacy can answer: "it helps you".

The American Psychiatric Association acknowledges sexual assault as a cause for PTSD in proposed revisions to its diagnostic manual

By definition of DSM-IV (APA, 2000), PTSD always follows a traumatic event which causes intense fear and/or helplessness in an individual. Symptoms are divided into clusters that include re-experiencing the trauma, obsessive thoughts, and flashbacks, avoidance and increased anxiety. The DSM-V work group proposed a few revisions to the definition of PTSD such as specifying sexual assault as a traumatic event, and also to restructure the symptom clusters to highlight negative cognitions and mood as a cluster of its own, and adding to it moods like anger and shame, (to DSM-IV's fear and helplessness) and cognitions such as self blame (APA, 2010). These revisions seem to better describe PTSD symptomatology (Yufik, & Simms, 2010) and to take in the feminist criticism of the PTSD definition being biased against sexual assault related PTSD characteristics (Gross, & Graham-Berman, 2006).

References

APA. (2000). DSM IV TR online version. Retrieved February 17, 2011, from AllPsych Online: http://allpsych.com/disorders/anxiety/ptsd.html

APA. (2010). PTSD work group. Retrieved February 17, 2011, from DSM-5 proposed revoisions: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#

Gross, M; Graham-Berman, S A. (2006). Gender, Categories, and Science-as-Usual: A Critical Reading of Gender and PTSD. Violence Against Women , Vol 12 (4) pp. 393-406.

Yufik, T & Simms, L J. (2010). A Meta-Analytic Investigation of the Structure of Posttraumatic Stress. Journal of Abnormal Psychology , Vol. 119, No. 4, 764–776.

TeleHealth protocol: treating PTSD with PE via Skype

I like this approach. I am thinking about Therapy on Demand channels,  iphone apps etc...

2 quote from the article:

method:

"when patients had difficulty beginning in vivo exercises on their own, it was helpful for the patients to complete the exercise while talking to the clinician on a cell phone."

conclusions:

"Prolonged Exposure therapy via telehealth technology was associated with large reductions in symptoms of  PTSD and depression for veterans diagnosed with combat-related PTSD. In the current sample, telehealth PE treatment was safe and pragmatically viable. Treatment noncompletion rates, although higher than average for our clinic, were in the acceptable range."

(Tuerk et al., Journal of Traumatic Stress, Vol. 23, No. 1, February 2010, pp. 116–123)

Looks like people are doing it. skype therapy I mean...

Dr Phil is cool

I think Dr Phil is cool because:

His intro clips are a powerful therapeutic agent:

Before every spot on the show, the guest-patients see themselves on a big screen in interviews, hidden camera from home, and some dramatic illustrations. They know they have a problem, they came to the show because of it, and they describe it in the clipped interviews, usually describing the distress, along with justifying causes. Still, when he asks them how it feels to see themselves like this, they suddenly own their problem, and are ready to talk about changing their behavior. I think what happens there is that people understand TV representations of life more than they can understand life. In life they are stressed and overwhelmed, and respond out of desperation without hope. Now they suddenly see this horrible person in the clip and they have a dramatic urge to reach a solution, like on TV. 

Example:

He adds healthy common sense education to yellow talkshow media:

He exposes talkshows audience to material that is not only very personally intusive to other people's lives, but also has a didactic position with some healthy directions like: don't drink too much, don't hit your kids, don't let your husband hit you - the basics... The don't is not something you see on Ricky Lake..

Example:

As part of this he also phrases his advice in a catchy way. Reruns and compilation shows help make it stick. My favorites are how he phrased neglect, when he tells a husband he can keep his over-consuming hobbies as long as he has quality time with his wife: "it's not what you're doing that's the problem, it's what you're not doing!" Or when he tells a drinking mom who does not see this as substance abuse: "of course you drink because you enjoy it, but it's your kids who pick up the tab!".

Disclaimer: 

Dr Phil is also uncool, and the coolness points I gave him have limitations, the main one, is that as a showman he may be looking to pass a point, over being sensitive to how it may affect his guest-patients.

Example:

Could prolonged exposure therapy (PE) have saved Hemingway from suicide?

I explained to Ernest that the best way to get over his traumatic injury is to focus on it with full detail until the anxiety loses potency, and he gets used to the things he so far avoided. He first did not understand how this is different from his compulsion to write prose about his distress, but he was willing to try, as the seemingly brave approach seemed appropriate to him.

When first asked to rank his fears, he could not admit any fear. Later he was willing to write a list of "things he'd rather not have to face". On the bottom of the list he wrote things like sleeping with the lights off, in the middle of the list he wrote things like being trapped in a prison cell, and at the top he wrote he feared physical torture and severe injury. These things kept him anxious and awake at nights.

Explaining treatment rational took up most of the next two meetings and Ernest did not perform his homework for them. We discussed this as avoidance on his part, and agreed to move very slowly up his list of things he'd rather not face. We also agreed to start first in the therapy room, and only later at home when he was alone. 

Ernest sat in the dark without screaming after two very gradual training sessions. After three sessions I even left the room for a few minutes and found him dozing in the dark, as he was exhausted with lack of sleep. At home, he changed his working schedule from writing before dawn to writing in the late morning, and he began to catch some sleep in the dawn hours.

Therapy continued, and Ernest's most major in vivo was swimming in the deep sea, where he used to fear he would be torn to shreds by sharks. He said that being in the water cooled him even better than a Mojito. He could sleep, he was much less edgy, being more calm allowed him to function sexually and enjoy his wife's support and warmth. After 6 months follow-up he was bellow clinical level for PTSD, however, changing his working schedule to daytime made him more distracted and he did not publish additional prose.

Another disturbing image - Hemingway drinking while ready to shoot sharks:

Could cognitive processing therapy (CPT) have saved Hemingway from suicide?

Ernest is a 62 years old novel writer, suffering from PTSD (ante literam) and depression. He was wounded in his leg 40 years ago in WWI, during a bombardment of a medical evacuation point, and ever since he has suffered from many PTSD symptoms such as: insomnia and nightmares, obsessive preoccupations with death and suicide, vivid multi-sensory flashbacks, alcohol dependency, feelings of guilt and shame, and intimacy problems revolving around difficulty to trust his lovers. He came to my clinic depressed, saying that he was diagnosed with an acute liver disease caused by alcohol abuse, and that now being without alcohol, he could not escape the intensity of his war flashbacks. Although he did not believe in psychology, he felt he was unable to bare his intruding thoughts of death and suicide and came to ask for treatment.

Therapy strategy was mainly to get Ernest to talk and write about his emotions directly – stop emotional avoidance, and to move from third person fictional writing to personal writing – accept that the event occurred as it had occurred and that no alternative fictional scenarios can replace it. Ernest being a writer, he had very firm professional positions regarding these issues, and had difficulty to comply. His main subject of writing is his distress, but he only rarely writes about the traumatic event itself, and seldom writes about his emotions in intense situations. His position was that his writing should be clean of emotional import, and that laconic and concrete messages would better explain his experience than pathetic elaborations of what he felt.

On our first session I had to convince him that even though he has been writing about the subject on and on for 40 years, he has not yet processed his experience fully. What grabbed him was the explanation about synthesized emotions compared to natural emotions. He felt he had been synthesizing emotions, and that the natural ability to feel has left him, he was either numb or distressed. He wanted to continue therapy and investigate this issue.

In his first homework he wrote about the effects of his trauma. Everything he was, was described as a result from his trauma – his problematic relationships, his risk taking behaviors, his sexual difficulties. Reviewing his essay, he did not allow me to perform a therapeutic split between his healthy side and injured side.

To his second session he came after reading about blockage points, and said he acknowledges something about this. He feels that his injury wasn’t a real battle injury, that he was awarded a fake medal, he was making coffee in a shed, a kilometer behind the front when a stray shell landed near – he was no hero, so he was not really injured. He cried, and said he was pathetic. I felt this was too intense, too soon for him, so after he calmed down, I asked him only if this direction is good for him, he agreed, and we continued.

We worked on recognizing emotions. He could not mention a situation that brought up an emotion in him. We went over the cognitive model of emotions being based on interpretations of the world. He said the world was basically very hostile, and that emotions are pains he tries to burry deep inside. After elaboration, he accepted that burying deep inside, is fear.

Therapy continued, and Ernest also rephrased his intimacy issues as trust issues, and his trust issues as fear of abandonment, based on his feelings that he was "not man enough". After 12 sessions, Ernest could recognize the blocking effect of the trauma on his cognitions, and the way they jammed his emotions in a state of fear. He recognized that feeling like a fake hero lead him to feel pathetic, unmanly and undeserving of emotions, that his third person characters were made up to deserve more than he did. He got a chance to cry during therapy, and noted how this was much better than drinking, really. His PTSD symptoms inventory was bellow clinical level after 5 months follow-up, but his laconic realism was badly damaged and he could not write prose again.

The obsessive compulsive style (Shapiro, 1965)

In his chapter "obsessive compulsive style," David Shapiro (1965) describes the characteristics of obsessive compulsive (OC) people, beginning with the rigidity of thought which is clinically observed with compulsive characters. Shapiro depicts this characteristic as limited, very focused attention; an unwillingness to divert from an interest or a position or listen to other parties in conversation.

            Shapiro then depicts a second major characteristic as a mode of action. He refers to OC people as work prone, work invested, workaholics – not necessarily over-productive, but treating every life situation as a productive process that requires effort on their side – even enjoyment. Effort is described as mental effort of preoccupation about an issue, not necessarily making evident pragmatic efforts towards it. Shapiro connects this to a damaged sense of autonomy, attuned to a sense of should over a sense of will, with demanding impulses that threaten the cores of intent and control; then awareness becomes their struggle, and all human behavior becomes an issue to preoccupy with – an effort. Their struggle is to keep from madness.

            If a keyhole attention and a troubled soul aren’t enough, Shapiro adds a loss of the sense of reality to the mental dynamics of the obsessive compulsive people. The authentic position is replaced with a logical perspective. The logical perspective is maintained by the narrowing attention, and its maintenance is an effort. Spontaneous right and wrong are missing from their judgment and they mediate their experience with rational criticism instead.

            In view of DSM-IV-TR's criteria list for OCD and OCPD, I believe Shapiro is describing the dynamics of an obsessive compulsive personality disorder. His emphasis is on obsessions, and less on the very evident compulsions and rituals expected in an OCD by the manual. Furthermore, Shapiro's everyday register and empathic description of psyche dynamics may tell us that this phenomenon is on the clinical doorstep, not yet inside the madhouse.

It is said that Cameron Diaz suffers from OCD!

Jessica Alba too.

Classic CBT VS ACT

Classic CBT (cognitive behavioral therapy) aims to modify maladaptive cognitions by supplying more adaptive alternatives, while ACT (acceptance and commitment therapy) assumes the mind to be a meaningless chatterbox that should be habituated, not focused on, or manipulated.

For example, when a patient is afraid of flying, the classic CBT approach would be to teach him more realistic risk evaluation, which is minimal in this case, a manageable way to interpret his physical over-arousal, as expectation of danger – not actual danger, and behavioral exposure as means to learn that there is no real danger.

The ACT approach would not argue with the patient's risk assessment in flying and in his panic, claiming that these serve avoidance, and that the patient should just listen passively to the arguments in his mind like they were an open channel radio with other people talking, until the volume fades, and he can just go through the motions, just do what he should do, disregarding his anxious thoughts and feelings.

If we put aside the contradictory theoretical frameworks, we can find that a pragmatic similarity would be the behavioral "just do it," and the difference is whether to tackle specific maladaptive cognitions or circumvent them. A combined practice could be to direct the patient to exposure, tackling the grossly maladaptive cognitions that lead to avoidance, and circumventing debates where cognitive debating is a cause for avoidance. Alternatively we could use CBT when we can offer a more adaptive cognition and ACT when the cognition is sensible but nevertheless distressful. Another distinction can be to tackle the ego-ayntonic cognitions, which the patient tries to justify with arguments, while circumventing the ego-dystonic cognitions, which admits have no sense behind them.

In my view, psychotherapy's curative effect is replacing dogmatic responses with a soft dissonance that allows variability of response – not providing a more adaptive response but facilitating adaptivity itself. Classic CBT should not provide a right answer - "you know flying is 10X less dangerous than driving" - but provide the patient a grain of salt to his preconceptions - "did you ever question your conception that flying is dangerous?" - show him that another way is possible. In that way, ACT should not ask the patient to give up the meaning of his thoughts ("what were the numbers? You see? Meaningless, and you're stuck with them!") as much as it should alleviate intensity of the patient's internal debate regardless of the arguments - "where does all this thinking lead you?" – show that it can be harmful by itself. If the mutual goal of mental agility can be established, the therapist can vary his practices, being attuned to the patient's field of preoccupations, and estimating the patient's capacity to loosen up a variety of dogmatic mental structures. The combined practice can be focusing on specific cognitions as a start, and then generalizing the same principle to the entire internal discourse, giving the patient room for air. Unifying these practices under one goal could also allow us to measure their effects comparatively, and use them more appropriately.