The Evolution of Psychotherapy conference began in 1985, ostensibly 100 years after psychotherapy itself began. Occurring every four to five years, this year was the eighth conference. Its goals are to summon those at the forefront of various psychotherapeutic disciplines to explore in a spirit of conciliation and integration, the fundamentals of psychotherapy.
Stress and health: Lessons from a wild primate
Primate researcher and Zach Galifianakis look-alike, Dr. Robert Sapolsky, delivered a keynote concerning lessons we can learn from his studies of baboons. Taking a detour from the traditional “rats in labs” approach, Dr. Sapolsky spent decades in the African bush. “If a lab rat is a good model for your emotional life, you’ve got problems,” he says, explaining his decision to leave the comforts of civilization for science.
We know that too much stress breaks down the immune system. It makes people sick. The problem is that we live in a world much different than the one in which we evolved. We get stressed for psychological reasons: trying to find parking, reactions to advertisements, pressures from family and social circles, meaningless tasks, traffic, and so on. Our stress response didn’t emerge in a world with endless psychosocial stressors. As a result, we suffer more chronic stress than our pre-civilized ancestors. While they died from bacteria, predators, starvation, and accidents, we typically die from the long-term effects of chronic stress: heart disease, stroke, cancer, and diseases due to the litany of methods we modern humans use to cope (smoking, drinking, eating bags of Oreos).
The primate studies revealed some important data that hopefully can be extrapolated to our lives. Dr. Sapolsky determined that certain baboons suffered less stress-related damage than others, even less compared with baboons of higher status and fewer aggressive encounters. What he gave us was the personality of a healthy primate.
The personality of a healthy primate
- Can discern a threat from a non-threat. In other words, doesn’t get stressed out at the smallest thing, or even not so small things. The baboons with healthy personalities only get worked up when they are seriously threatened. Yep, don’t sweat the small stuff.
- Doesn’t passively abdicate. Look at this as being assertive, not just giving in, but also not being overly aggressive.
- Winning results in bonding behavior. Some baboons after winning a fight would continue to show aggressive, out-of-control behavior. Not good. The healthy baboons would engage in grooming or other bonding behaviors after coming out on top. This would be something like showing grace after winning an argument in a meeting, rather than pettiness or rubbing the other person’s face in it.
Humans aren’t baboons, but we are much more like them socially than rats or other lab animals. If you are a Type-A person, take some tips from the healthy primates and you might live a longer, healthier life.
New, brief, respectful and effective approaches to treating post-traumatic stress disorder
This three-hour workshop led by Bill O’Hanlon wanted the audience to learn a way to treat trauma without retraumatizing the patient repeatedly with a voyeuristic exploration of all the details of their experiences of horror.
Most of the techniques center on focusing on the present and the future to help guide the client to a better existence.
- Use phrases that create expectancy, such as “yet,” “so far,” “up to now,” and “when.”
- Turn problem statements into goal statements.
- Ask people to envision a future in which the situation is better, a problem is resolved or a goal is reached. Then work backwards from that future to the present.
- Use “The Miracle Method” and ask people to imagine that the barriers to reaching the goal are eliminated by a miracle while everyone is sleeping.
- Ask people to tell you what the first signs of change will be that will indicate that they are moving in the direction of the goals, the crystal ball vision or the miracle. [Hint: The first signs may already be happening.]
- Write a letter from your future self to your current self. Looking into the future six months, one year or five years (or whatever time period you sense is appropriate). Describe where you are, what you are doing, what you have gone through to get there, and so on. Tell yourself the crucial things you realized or did to get there. Give yourself some sage and compassionate advice from the future.
Read more from this workshop
Treatment of a suicidal patient with a long history of victimization: A constructive narrative treatment approach
Cognitive-Behavioral Therapy with Donald Meichenbaum is a demonstration of arguably the most frequently used therapeutic approach by one of its cofounders. Dr. Meichenbaum uses cognitive-behavioral therapy with a constructive-narrative perspective in which he looks at the stories patients tell about themselves and considers ways that the patient could develop a different, more positive story. If this sounds more to you like narrative therapy than CBT, you aren’t alone.
In this session, Dr. Meichenbaum worked with a young woman who is depressed and anxious and has attempted suicide seven times. She has undergone multiple traumas in her life, including rape and several suicides in her immediate family. Dr. Meichenbaum accentuates the patient’s strengths, skills and support system. Then he gently confronts the patient by helping her to see that, although one of her strengths is her willingness to forgive others, she has not been able to forgive herself for the things she has done.
Dr. Meichenbaum, in speaking with the woman, tapped into what is meaningful for her, including her concern for the step-father who raped her as teen, because he’s all the family she has left. It’s situations like this where the clinician can be tested in profound ways. Of course, our instinct is to want to create space between our patient and her victimizer, but if she is suicidal and he is truly the only family member left in her life, do we try to take that away and then watch her succumb to her daily suicidal ideation? The answers are troubling and seeing Dr. Meichenbaum handle the situation gracefully and gently showed that CBT has a heart bigger than it’s given credit for having.
Read more from the handout
Masculine/feminine: Then and now
In this talk, Dr. Marilyn Yalom and Esther Perel discussed how masculine and feminine appear in their clinical settings. Much of it had to do with how gender identity is more commonly presenting as a topic of concern. They also discussed the dynamics in gay couples where gender roles are clearly not based upon sex, but are still present and contribute to problems in the relationship.
Developing an atlas of emotion
Dr. Paul Ekman and daughter, Eve, presented on their work sponsored by the Dalai Lama. The goal of the project is to map emotions so that we can better develop a calm mind. According to the Dalai Lama, calm mind is destroyed by fear, anger, suspicion, lust, greed, and ambition. For example, even if one possesses the entire world, if one is filled with greed, he will be restless and still want Mars and the moon. The Dalai Lama states that to have a calm mind, one must possess self-confidence and psychological health.
Why a calm mind and not a joyful mind? Ecstatic joy isn’t stable. We need to cultivate awareness to have a calm mind, according to the Dalai Lama. Emotions are fleeting and complex, and facial expressions alone ignore the rich inner world that happens along with emotions. This is why the Dalai Lama engaged the Ekmans to produce “The Atlas of Emotions.” Check it out at The Ekmans’ Atlas of Emotions
Why some psychotherapists are more effective
Dr. Don Meichenbaum, part detective Columbo and part comedian, ( OK?! ) entertained a packed room with his take on what it takes to be the best healer you can be. While he delivers a one-liner every minute or two during his presentations, Dr. Meichenbaum takes his work seriously. His handout for the conference came in at 352 pages.
First, he told us that the psychotherapy alliance is five times more important than any approach or orientation. Then he self-deprecatingly sold us CBT because “being a CBT therapist decreases depression for the therapist.” He also let us know that the only thing that increases for most therapists after graduation is their confidence and bill rate, not their outcomes. In fact, he showed us data that beginning therapists have lower confidence, but better outcomes than more experienced therapists. Why? Because for most therapists the deliberate practice they undertook for years as a student comes to an end once the diploma is in hand. Dr. Meichenbaum advises, “love yourself as a person, doubt yourself as a therapist.” The point being that research shows that those therapists with a positive sense of self, but uncertainty about how to best deal effectively with a patient, have the best outcomes.
As an extension of this humility, Dr. Meichenbaum asks us to have patients provide two-minutes of assessment and feedback on each session. He also let us know that the only way to improve is to maintain deliberate practice. This can’t be undertaken alone. It must be done within a practice group or community of practitioners who are seeking to grow as therapists. “Attending workshops doesn’t change performance or improve skills,” he says, encouraging us to do the hard work throughout the year, not just during a long weekend retreat.
He also provided a list of specific behaviors that detail exactly what helpful and unhelpful therapists do according to their clients–you know, the experts on whether treatment was successful or not.
Helpful psychotherapists did the following
“Listened respectfully and took me seriously.”
“Believed my story.”
“Helped me see if I was still in danger and explored with me how I could deal with this situation.”
“Helped me see my strengths.”
“Helped me understand the impact of traumatic events on myself and on others.”
“Helped me plan for change.”
Unhelpful psychotherapists did this instead
“Did not listen and did not have an accepting attitude.”
“Questioned and doubted my story.”
“Dismissed or minimized the seriousness of my situation.”
“Gave advice that I did not wish to receive.”
“Blamed or criticized me.”
Finally though, he left us with one more juicy bite to chew on. Delivered using classic Dr. Meichenbaum humor, he advised us that if we really want to succeed as a therapist, the most important thing we can do is to choose our clients. And the ones we might prize most are YAVIS’s: Young, attractive, verbal, intelligent, and successful. “They are going to get better with or without your help.”
Read more from the handout
The initial interview
Three heavyweight names in therapy joined this panel: Dr. Otto Kernberg, Dr. William Miller, and Dr. Michael Yapko. The purpose of the panel was for each clinician to discuss the way they conduct the first session with a new patient. Their approach to the initial interview were strikingly different.
Dr. Kernberg treats many types of patients, including severely mentally ill patients. He takes a detailed clinical approach that requires the patient to complete many intakes questions and interviews. He said depending upon the patient, it may take up to four hours. He wants to know as much as he can up front: how the patient is doing at work, sex, love, and other important areas of life and functioning. His theory is that the patient wants to feel their problem has been understood. Immediately digging into the tiny details of a patient’s life is how Dr. Kernberg hopes to make a patient feel their problem has been heard.
Dr. Yapko, a CBT-oriented practitioner, went next. He wants to find out each client’s strengths and availability to resources. He also want to know how each client is keeping their symptoms at bay. He also wants to find out what the client wants. He cynically, if not accurately, mocked the web sites of many psychotherapists concerning what they will give people coming to them, “clients never come in and say, ‘I want to go on a journey.’” They want help with a specific problem or problems.
Dr. Yapko and Dr. Miller clearly had some disagreements that they were working out through the panel. As you likely know, Dr. Miller is the father of Motivational Interviewing. Early in Dr. Yapko’s explanation of his approach he made the statement, “It doesn’t matter how motivated people are, without skills, they can’t accomplish goals.”
Of course, Dr. Miller wasn’t going to let this slide and in his portion of the panel, he made it clear that “people already have a lot of skills and we overestimate the extent to which clients need our time.” His approach encourages the therapist to consider first contact very important. He wants to create a welcoming environment and to give a client something useful during the very first session. He said we shouldn’t bog down the first session with tons of questions, an opposing stance to Dr. Kernberg’s very formal intake. He also took a parallel tack to Dr. Yapko in diminishing the role of motivation, but contrasted with a different therapeutic element–hope. Dr. Miller said, “If you create motivation, but no hope, you haven’t done anyone any favors.”
The clinical application of mindfulness and compassion
“Any man who can drive safely while kissing, is simply not giving the kiss the attention it deserves.”
Dr. Jack Kornfield led us on a live application of using mindfulness in a therapeutic session. First, he led the entire room through a guided meditation, which is how most of his sessions begin. “I just want to give them the experience of quieting down,” he said.
He spoke for some time before bringing up a volunteer and doing a mindful, compassionate session with her. He was very gentle and sweet. He held her hand for much of the session. His approach was so tender and soft, that I wonder what approach he takes with men, who would certainly not be so receptive to the approach he demonstrated with the older woman.
Much, perhaps all, of his philosophy is Buddhist, although Dr. Kornfield promises that using his approach “doesn’t have to be a weird, spiritual, religious way of teaching quiet.” He emphasized that mindfulness isn’t passive. By using loving awareness, we become a loving witness to our experience and learn to bring a receptive quality to what is present.
His most powerful statement, “We do all of these things to manage what we cannot bear,” illuminated with deep compassion the suffering, maladaptation, and inconsistency we bring forth as humans when confronted with situations that we can’t face directly.
Hexadancing: A demonstration of the liberating impact of process-focused evidence-based therapy
Is it a bit long of a title? Yes, but watching one of my psychotherapy heroes, Dr. Steven C. Hayes, actually perform his Acceptance and Commitment Therapy live on-stage was worth every syllable. Seeing his slender, bald, nervous-but-confident presence on the stage got me very excited. It was the first talk where I made sure to find a seat in the front row.
But what the heck is a hexadance and why would I want to see it? ACT involves six core-processes that makeup the psychological flexibility model. These six are: Acceptance, cognitive defusion, being present, self as context, values, and committed action.
ACT is an approach to psychological intervention defined in terms of certain theoretical processes, not a specific technology. In theoretical and process terms we can define ACT as a psychological intervention based on modern behavioral psychology, including Relational Frame Theory that applies mindfulness and acceptance processes, and commitment and behavior change processes, to the creation of psychological flexibility. Association for Contextual Behavioral Science
ACT’s roots are behavioral, but far more rich philosophically. ACT shares common philosophical roots with constructivism, narrative psychology, dramaturgy, social constructionism, feminist psychology, Marxist psychology, and other contextualistic approaches, but its unique goals leads to different qualities and different empirical results than these more descriptive forms of contextualism. Association for Contextual Behavioral Science
Dr. Hayes wanted to demonstrate how flexible the psychological flexibility model is by having each of the six processes individually displayed on a presentation slide. Every thirty seconds the slide would automatically change and he would work on that particular aspect of the model with a volunteer sitting with him on stage. The end result would be a brief therapy session driven by random slides as Dr. Hayes hexadanced with two different volunteers.
The manifestation was not jarring. He smoothly glided from one facet to the next, using metaphors, visualizations and more to pry loose the stuck wheels of the client. This approach requires more talking than many other approaches. It also requires a lot of creativity in delivering metaphors that can help shift the perspective of the client.
The cognitive roots of this approach come out in questions like, “What stops you? What thought stops you from taking that step?” when a client states clearly what they want to commit to, but still can’t.
By the end of each demonstration, each volunteer had a lot of movement with their problem. The first young man committed to calling his father and being honest with him about his feelings even knowing that his father might not reciprocate. A married woman decided she was going to pursue an opportunity for career advancement against the demand of her husband that she not and instead support him in his schooling.
When the talk was over, I made sure to stick around to have a chance to ask Dr. Hayes a question and take a photo with him.
Going off the deep end: Rediscovering our magickal roots in healing and psychotherapy
“Focus more on healing and less on psychotherapy,” said Dr. Scott Miller. His point is that we have become so caught up in our theories, models, and research that we have forgotten what resonates in our clients. People still crave magick.
Six dimensions of magick
- Symbol - Connects people with core archetypes. Think Jung. Think deep human subconscious and the hero’s journey (if you are a writer).
- Use of space - How the environment is shaped
- Voice - tone, rhythm, and words
- Movement - Structure and form
- Drama - a narrative tension and release
- Wonder, amazement, and surprise
Much of Dr. Miller’s work relates to treatment outcomes. Most people who need help don’t seek it. Many who do don’t come back after their first visit. “After meeting with us, people decide ‘I’d rather be mentally ill,’” he says. His research, including a large longitudinal study (see references) found that many psychotherapists don’t improve over time. That’s right. They don’t get better with experience and in fact, they get slightly less effective as they gain experience.
After burning the state of lethargy and disconnect in many practitioners, he encouraged us to connect more with the people in front of us. “Your clients want you to succeed in helping them. They will help you to be observant. Whatever presents to you in the office, you really ought to use,” he says. Psychics and other non-psychotherapeutic healers are in an industry worth billions that grows bigger economically each year. They only observe the person before them and give them advice based upon what they are seeing and experiencing in the other person. They keenly transmit all of the information the person in front of them is transmitting back to the person. He wants therapists to do learn from that.
“We are like islands in the sea – separate on the surface but connected in the deep.”
The purpose of his talk is to get us to reconnect with the core of our humanity, the one that emerged before civilization and science. He encourages us to be sensitive to the vibrations in the other person. If we are, the connection we will feel will serve to transmit what we need to know to help the other person. Connect with the other person, not our theories and models.
“It’s all about empowering the patients to believe in the magick within them,” he says.
Read the handout from Dr. Miller’s related talk on training new therapists
Positive psychology, positive interventions and positive education
Dr. Martin Seligman of positive psychology fame explored our current situation regarding suffering and well-being. Since the gains of the 20th century, we have reached an upper-limit in decreasing suffering but we have yet to increase happiness. We are very comfortable, unhappy creatures.
Dr. Seligman wants us to realize that well-being is something over and above the absence of misery. “Why are our kids unhappy when the objective world has never been better?” he asks. Schools don’t teach well-being as they should. His research has shown that in schools in various world regions, where a program of well-being was implemented, not only did well-being increase but also standardized test scores.
The model for well-being is contained in the acronym PERMA.
- Pleasant emotions
- Engagement “flow” (me sitting for hours at the computer writing this in a joyful state without time)
- Relationships that are positive and supportive
- Meaning and purpose in life (think Viktor Frankl)
- Accomplishment for its own sake (not money, ambition, fame)
He also wants us to realize that pessimism is bad for our health. Cardio-vascular disease’s biggest risk factor is chronic negativity. To counter the negativity in our society, Dr. Seligman suggests resilience training. “We can be positive creatures,” he declares.
love is a place
love is a place
& through this place of
(with brightness of peace)
yes is a world
& in this world of
– E. E. Cummings
And then we will find out for the very first time, what kind of creature we truly are
“We will go out into the world and plant gardens and orchards to the horizons, we will build roads through the mountains and across the deserts, and terrace the mountains and irrigate the deserts until there will be garden everywhere, and plenty for all, and there will be no more empires or kingdoms (…) no more slavery and no more usury, no more property and no more taxes, no more rich and no more poor, no killing or maiming or torture or execution, no more jailers and no more prisoners, no more generals, soldiers, armies or navies, no more patriarchy, no more caste, no more hunger, no more suffering than what life brings us for being born and having to die.”
– Kim Stanley Robinson, The Years of Rice and Salt
Read more from the handout
Goldberg, S. B., Miller, S. D., Nielsen, S. L., Rousmaniere, T., Whipple, J., Hoyt, W. T., & Wampold, B. E. (2016). Do Psychotherapists Improve With Time and Experience? A Longitudinal Analysis of Outcomes in a Clinical Setting. Journal Of Counseling Psychology, 63(1), 1-11. doi:1O.1037/cou0000131