IN THIS ISSUE:

A Note from Jack
5th annual Western Canadian Conference
Tools, not Schools, of Therapy by David Burns, MD
Register for a workshop online and save!
Drugs of Abuse: A Complimentary Identification Guide

A Note from Jack:

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5th annual Western Canadian Conference - November 12 - 14, 2008

The 5th annual Western Canadian Conference on Addictions and Mental Health is on its way! This yearly event draws addiction and mental health professionals from across North America for advanced clinical training. This year, the Western Canadian Conference features a youth-focused concurrent session each afternoon.

Keynote speakers for 2008 include Dr. Cardwell Nuckols, Ph.D.; Dr. Marc Schuckit, M.D.; Dr. Dennis Daley, Ph.D.; Dr. John Preston, Ph.D.; Bill O'Hanlon, M.S.; Dr. Graeme Cunningham, M.D.; Dr. Andrea Barthwell, M.D.; and Dr. Gregory Boothroyd, Ph.D. Concurrent sessions will also be led by Dr. Allen Berger, Ph.D.; Dr. Joe Solanto, Ph.D.; Dr. Ross Laird, Ph.D.; and Wedlidi Speck.

The Conference will be held at the newly renovated Best Western Richmond Inn, just 10 minutes from Vancouver International Airport and 30 minutes to downtown Vancouver. The hotel is located in the heart of the bustling multicultural city of Richmond. If you’re planning on coming to the Western Canadian Conference, book your room at the Best Western before October 11 to take advantage of our corporate room rate. Gold sponsors for the event include the Sunshine Coast Health Centre, Cedars at Cobble Hill, Edgewood Treatment Centre, Orchard Recovery, Thorpe Recovery Centre, and Bellwood Health Services. The Avalon Women’s Centre is the Conference’s non-profit affiliate.

The Western Canadian Conference is organized by Jack Hirose & Associates in partnership with HealthQuest and Dr. Ray Baker, M.D.

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Tools, Not Schools, of Therapy— Integrating Twelve Treatment Models
by David Burns, M.D.

Copyright © 2008 by David D. Burns, M.D. Any reproduction, electronic or otherwise, is strictly prohibited without expression written permission of the author.

If you’ve attended my workshops, you know that I’m not a huge fan of schools of therapy, such as Psychodynamic / Psychoanalytic Therapy, CBT, EMDR, DBT, ACT, TFT, and so on. There are currently hundreds of these schools of therapy, and they function much like competing cults or religions. Usually there’s a guru / founder who believes that he or she has discovered the true cause of or the most effective treatment for some specific emotional disorder, such as depression, shyness, PTSD, marital problems, or Borderline Personality Disorder, or even for mental illness in general.

I believe that a systematic scientific approach will eventually dominate the behavioral sciences, just as science has come to dominate biology, physics, and chemistry, fields that were also dominated by religious, non-scientific, thinking for hundreds of years. The transformation of our field to a true science of human behavior may be several decades in the future. I am disheartened by the fact that politics, not science, still seems to have an enormous impact on the way people think and practice.

Still, the schools of therapy aren’t entirely bad. Most of them have useful insights about human nature along with a number of methods that can be valuable in the treatment of certain kinds of problems or disorders. I believe we can integrate the best features of a number of schools of therapy into a systematic treatment approach. In my research and psychotherapy training, I emphasize 12 vitally important models of therapy. Each model, when understood and mastered, can be tremendously healing and exciting. The main danger is grabbing onto one of these models and trying to use it with all of your patients, as if it’s “the answer.” This type of reductionism has plagued our field for the past 100 years.

These are the 12 models that I use every day in my clinical work and teaching:

1. The Measurement Model
2. The Empathy (Rogerian) Model
3. The Motivational Model
4. The Cognitive Model
5. The Behavioral Model
6. The Exposure Model
7. The Hidden Emotion Model
8. The Interpersonal Model
9. The Acceptance (Spiritual) Model
10. The Role-Playing (Gestalt) Model
11. The Psychodynamic Model
12. The Relapse Prevention Model

The first three models—the Measurement, Empathy, and Motivational Models--will be important in the treatment of every patient. They set the foundation for good therapy. If you master them and use them skillfully, your therapeutic efforts will be vastly more effective, and patients will recover far more quickly, often in just a few sessions. However, learning these techniques is harder than it might seem. Training and practice will be necessary. In this article, I’ll focus on these three models and provide you with some information on how to incorporate them into your practice.

1. The Measurement Model. There are two major aspects. First, it’s important to do a comprehensive initial evaluation of each patient and make accurate diagnoses according to DSM-IV criteria. However, performing a structured, systematic diagnostic interview is so complicated, time-consuming, and frustrating, that most clinicians skip this step, and simply scribble some waste-basket diagnosis in the chart, such as “Adjustment Disorder with symptoms of Depression.” There are many problems with this, not the least of which is the fact that you’re likely to overlook many problems that can make a significant impact on your understanding and treatment strategies. My colleagues and I have developed a new approach that we’re excited about. You can use the new EASY Diagnostic System at the initial evaluation to assess the patient’s problems in multiple dimensions, using DSM-IV diagnostic criteria. The latest version of the EASY screens for 60 Axis I disorders and all 10 Axis II disorders. This only requires a few minutes of your time and will provide you with a wealth of information about each new patient. In our experience, most inpatients and outpatients will have between 10 and 15 probable or definite diagnoses. The EASY also helps you screen for relationship problems, including feelings of anger and violent urges, motivation level, depression severity, suicidal urges, and honesty in completing the survey.

Second, you can measure the severity of symptoms, including depression, suicidal urges, anxiety, anger, and relationship satisfaction at the start and end of each therapy session. At the end of the session, we also measure the patient’s perceptions of therapeutic empathy, helpfulness, satisfaction with the session, and positive and negative feelings during the session, using brief, sensitive and accurate scales. The process takes only 15 seconds out of the therapy session, since patients complete the scales in the waiting room just before and after each session. You will see, for the first time, exactly how effective you were during each session, and how you came across to your patient. This type of information, which has never before been available to clinicians (or even researchers), allows you to modify your therapeutic methods and style to be maximally effective for each patient. It’s much like having the world’s greatest psychotherapy supervisor at every session for the rest of your life—because our clients, after all, are the greatest experts in what works, and what doesn’t work, for them.

2. The Rogerian (empathic alliance) Model. Karl Rogers believed that a warm, accepting alliance was the necessary and sufficient condition for change in therapy. This turned out to be incorrect. Still, research and clinical experience indicate that empathy, warmth, and acceptance are necessary for good therapy. If the patient doesn’t like and trust you, all the skill and techniques in the world will be ineffective.

Most therapists believe that they are reasonably sensitive and caring, with good empathy skills. However, the Empathy Scale I have developed is exceedingly sensitive to failures of the alliance, and nearly all therapists receive failing grades from most of their clients at every session when they first use this instrument. The good news is that these failures of the alliance can lead to a deepening of the therapeutic relationship if you discuss them skillfully and non-defensively with your client.

Of course, that’s often easier said than done. Most therapists become defensive when confronted with patient criticism. That’s why I’ve developed specific training tools for therapists, including the Five Secrets of Effective Communication, as well as the empathy role-playing exercise many of you have seen in my workshops. These tools will help you improve your ability to communicate with your patients—as well as your colleagues, friends, and family members. If you have determination, humility, and the willingness to practice these techniques consistently over a period of weeks, the odds are high that you will observe dramatic increases in your empathy scores, along with an improvement in the quality of your clinical work.

3. The Motivation Model. Empathy, of course, is not enough. Many of our patients have one foot in the water and one foot on the shore. There is apart of them that wants to change, and a part of them that’s forcefully committed to the status quo. So how do you deal with an ambivalent or unmotivated patient who yes-buts you and keeps “forgetting” to do the psychotherapy homework between sessions? Agenda Setting is the mother of all motivational techniques. When you set the agenda, you make the patient accountable to focus on a specific problem and explore the many reasons why the patient may not want to change. There are eight common patterns of resistance, including four types of Outcome Resistance and four types of Process Resistance.

Outcome Resistance means that the patient would not want to be “cured,” even if she or he only had to press a magic button on the desk, with no work involved, and would walk out of the session in a state of euphoria. Outcome resistance differs for depression, anxiety disorders, relationship problems, and addictions—hence, the four types. For example, I recently treated a woman from San Francisco who’d suffered from Borderline Personality Disorder and ten years of severe, intractable depression following an abortion at age 19. The thought that triggered her intense self-loathing and shame was: “I murdered my baby, so I deserve to suffer forever.” Her previous therapists had all attempted to “help” her with pills or psychotherapy, but she resisted these interventions and the therapy failed. Before you can connect with her, you have to consider Outcome Resistance—what are the possible reasons she might not want to change?

There could be many reasons. Her suffering shows that she is a very moral person with a strong value system. You could even say that her depression has a spiritual component. Her suffering also allows her to remain connected to the baby she lost. She thinks about him all day, every day, and has not yet grieved or let go. Her depression is an expression of her love, and keeps her baby alive in her mind. In addition, there may be other problems in her life, involving her marriage for example, that her depression distracts her from dealing with. Her suffering and self-loathing may be an important part of her identity. She may fear that without the self-hatred, she’d be a nothing. And finally, her suffering is a kind of protest, because no one has empathized with her pain. When she shares her pain with her husband or with her parents, they tell her to cheer up and say that an abortion is not the same as murder. They encourage her to let go of the self-criticism, but are secretly annoyed with her. No one, including her therapists, have given her the opportunity to vent and to let those painful feelings out, and to feel accepted.

Of course, every patient will be different, but each person will have his or her reasons not to change. When you use Paradoxical Agenda Setting, you become the voice of the patient’s resistance, and verbalize all the reasons why the patient should not change. If you do this in a sincere, warm, and accepting manner, the patient may paradoxically suddenly let go of the resistance.

For example, after you’ve empathized for a period of time, without trying to “help,” you might say this to Janice: “Janice, I can see that you’ve been suffering tremendously since your abortion, and I can’t even imagine how horrible it must be to feel that you’re a murderer and that you killed your baby. And I can imagine how frustrating it’s been, and perhaps even irritating, to have people always trying to cheer you up, and never really listening or acknowledging how you feel inside, and the hell you’ve been living in. I want you to know that some negative feelings are relatively easy to treat, and some are difficult. Guilt and shame, on average, are among the easier feelings to treat. Furthermore, I have more than 50 powerful tools, any of which would have a good chance of helping you. And if we work together, and try many of these tools, I have no doubt we’d be successful, and your depression would disappear. But to be honest with you, Janice, I am very reluctant to use these tools in your case. Don’t get me wrong, I do want to work with you, and I have great respect for you. But I’m not sure it would be the right thing to do.”

Janice was surprised by this response, and protested. She wanted to know why I was reluctant to help her, after so many years of failed treatments, since I had the tools she needed to overcome her depression.

In response to her protest, I explained that her depression was not only a psychological problem, but also a spiritual problem, and that her suffering showed me what a wonderful person she was, and how much she loved the baby who died, and that in a sense her love was still keeping that baby alive. And that before I could consider using such powerful tools to make her guilt and shame and self-hatred disappear, I would have to hear from her what the justification would be from a spiritual perspective.

Notice what’s just happened. I have now become the voice of her subconscious resistance, and I’m saying, “You have to persuade me to work with you.” But I’m not doing this in a rejecting or pessimistic way—I’m also conveying to her that we can and will be successful, and have plenty of power to defeat her depression. But before we can do that, she has to persuade me that she’s ready, willing, and able to do that.

If you’re interested, I’ll be happy bring more of these treatment models to life in the subsequent editions of the Newsletter. Let me know if this type of writing is interesting or useful to you, as well as what you might enjoy reading about. You can email me directly at: david@feelinggood.com.

Thanks!
David Burns, M.D.
Adjunct Clinical Professor Emeritus, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine

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