Psychologist Philip Zimbardo knows a thing or two about tough guys. In 1971, his notorious Stanford prison experiment, originally planned for two weeks, had to be shut down after only six days when college students acting out roles as prison guards started to play a little too rough with their mock inmates. In 2007, he tried to understand the military abuses at Abu Ghraib prison in his book The Lucifer Effect: Understanding How Good People Turn Evil. Now he turns his attention to a different kind of prisoner: the average American male shackled by the constraints and demands of societal expectations.
In a new eBook titled The Demise of Guys: Why Boys Are Struggling and What We Can Do about It, Zimbardo and his coauthor psychologist Nikita Duncan paint a dire picture of dudes in this country, asserting that boys are increasingly failing to measure up academically, socially, and sexually. The blame, they say, lies with the Internet, television, and video games. According to their view, a new Lost Generation has grown up, addicted to arousal and constantly seeking stimulation and novelty through digital means: “The excessive use of video games and online porn in pursuit of the next thing is creating a generation of risk-averse guys who are unable (and unwilling) to navigate the complexities and risks inherent to real-life relationships, school and employment.” More young men are supposedly languishing in their parents’ basements, aimless, asocial, and out of touch.
The signs of the decline, they say, are everywhere: falling test scores, violent video gaming, and a buxom pornography industry. Zimbardo describes a “social intensity syndrome” in which men are driven to engage in intense, male-dominated social interactions leading to an endorphin rush that the rest of their dull daily lives just can’t match. During a popular TED talk, Zimbardo said “Guys would rather be in a bar with strangers, watching a totally overdressed Aaron Rodgers of the Green Bay Packers, than Jennifer Lopez totally naked in the bedroom.”
Boys aren’t the only ones struggling, suggests psychiatrist Boadie Dunlop, director of the Mood and Anxiety Disorders Program at Emory University. With the economic downturn’s hitting men particularly hard, they’re relying more heavily on women as the primary household earners. While traditionally female-populated fields like healthcare and social services are experiencing burgeoning demand, “manly” occupations like construction and manufacturing are being scaled back and reorganized for greater efficiency. Many men are finding themselves outsourced, obsolete, and out of work. “Compared to women, men attach greater importance to their roles as providers and protectors of their families,” Dunlop says, “and men’s failure to fulfill the role of breadwinner may lead to greater depression and marital conflict.”
Zimbardo and Duncan may be sounding an alarm about masculinity in crisis, but concerns about the death of manhood have been around for decades, if not centuries. Pornography isn’t new, even if it’s now more accessible on the Internet. Many video gamers would protest that gaming is more interpersonally interactive today than ever, and our wired world is used much more for social networking than social detachment. Are entertainment addictions really a more pervasive societal concern for men than rising housing costs and ballooning student loan bills? Is the fact that men are living with their parents longer and postponing marriage and childrearing a sign of “Arma-guy-ddon” or just a smart social adaptation to an economic “man-cession”? Only time will tell.
Manpocalypse: http://www.demiseofguys.com; British Journal of Psychiatry 198, no. 3 (March 2011): 167-68.
By W. Robert Nay
It’s one thing to help an easily incensed individual learn to manage a too-easily-aroused temper. It’s entirely another thing to help partners in a troubled relationship deal with the kind of anger that gets triggered primarily when they’re with each other. Yet therapists often focus too narrowly on helping individuals manage their personal anger, rather than helping partners reduce the anger that repeatedly arises between them.
In chronically angry couples, differences of opinion rapidly become arguments, which escalate to raised voices, raised blood pressure, and sometimes raised fists. Repeatedly, the anger itself, rather than the initial disagreement, becomes the issue, shooting back and forth, intensifying with each volley. As the emotion rises, and as ordinary inhibitions fall away, the likelihood of verbal abuse and/or physical aggression grows. Aggressive feelings drown out any attempt at addressing the underlying conflicts or problems in the relationship.
Partners riding this merry-go-round of anger almost inevitably blame each other for the problem. Typically, one or both portray the other as having “started it,” ignoring the fact that their conflict occurs within a system of two. The partners pass the anger back and forth like a shared virus.
My Way or the Highway
Adam and Sarah sought my help after what Sarah called “years of fighting over nothing,” which had sapped the life from their marriage. Sarah, 38, told me her anger was triggered only by Adam’s temper. “I’m fine with other people,” she said, adding that the only time she got mad was when she felt Adam had invaded her space. “With him, it’s always ‘my way or the highway.’ He gets extremely loud, intense, and sarcastic when we don’t do what he wants, when he wants it.”
When I asked her how she usually reacted when Adam got angry, she looked embarrassed. “Lately, I’ve been telling him off,” she admitted. “I can’t take any more of his loudness and aggression. Last week, I screamed at him to ‘shut the hell up’ in front of our children. I don’t want to act this way, or for them to turn out like him!” I asked her if she’d be willing to be a part of the treatment, even though she believed Adam’s anger was the main problem. Although she wasn’t sold on this idea, she agreed when I told her that she needed to learn to change the way she reacted to Adam’s anger to help defuse it early, and to feel better herself.
Adam, 41, informed me right away that he’d do anything to save his marriage. He came from a family of shouters, he said, and often listened to his parents argue well into the night. While he’d vowed not to be like them, he found himself all too often “losing it” with Sarah—yelling and saying things he later regretted. But he saw his wife as a big part of the problem: “If she’d just leave me alone when I get stressed out, I wouldn’t get so mad. She needs to learn to back off.” He blamed much of his anger on stress resulting from long hours working for a demanding boss at a large insurance company. By blaming his wife and his work, he externalized his feelings. Like most of my angry clients, deep down, he believed that his anger originated outside himself.
Strategies for Arousal Management
I met with Sarah and Adam individually for three sessions to identify their individual patterns of anger arousal—the physical sensations each experienced when anger was triggered. From there, the focus shifted to specific strategies to derail their arousal pattern before they became so angry that calming thoughts and self-control were difficult or impossible.
In my first individual session with each of them, I asked each one to keep an anger log, recording the situations when anger was experienced, the thoughts or “self-talk” that arose in their minds, their body sensations (tight shoulders, heat in neck and face, jaw tension), and the actions or words they used to express their animosity. The logs and my clarifying questions helped me identify their triggers: the actions or statements that seemed to instigate arousal. As partners become aware of specific triggers, they can “preview” an upcoming encounter to think ahead about how to manage their temper, if it arises.
To assess how each got triggered, I reviewed what I call the “Five S’s”—life factors that contribute to instigating and intensifying anger arousal. These include: inadequate Sleep; ongoing life Stress; not eating properly, or inadequate Sustenance; use of Substances like alcohol, caffeine, or other drugs; and any health issue or Sickness that increases irritability (a bad cold, headache, lower back pain). Adam told me, for example, that he often stayed up until 1:00 a.m. to have some time alone, yet arose at 6:00 a.m., getting only five hours of sleep. He agreed to begin pushing his bedtime sequentially earlier by about 15 minutes a night, to work toward a 10:00 p.m. bedtime. We discussed making the bedroom extra dark to further aid sleep onset.
Adam’s stress level was heightened by his feeling that he had to work late to avoid a threatened layoff. We discussed a variety of coping strategies, including work breaks, a power nap, relaxation techniques, and ways to challenge scary self-talk—”How will I support my family?” “What if I can’t find another job?”—which fueled anxiety and sometimes contributed to insomnia. He told me he often skipped lunch or grabbed a snack from a machine, since he felt he was too busy for a meal. I encouraged him to take at least 30 minutes to eat a healthy lunch to sustain his blood-sugar level, since low blood sugar is related to irritability and general disinhibition.
As for substances, Adam told me he drank lots of caffeinated diet colas at work and had begun consuming two or three glasses of wine each evening as a way of “winding down.” I told him that while we all vary somewhat, even small amounts of alcohol and caffeine tend to be disinhibiting and could fuel anger arousal. We agreed it was best to avoid drinking alcohol during the work week and to limit other drinks to decaf versions and water. Sarah’s Five S’s included drinking wine with Adam in the evenings, as well as frequent headaches, which fueled irritability and negative self-talk. I encouraged her to limit her alcohol consumption and to seek medical guidance for her headaches.
From their anger logs, we identified the first physical sensations of anger arousal. Adam reported that his chest felt tight and his breathing would get heavy. In contrast, Sarah found that her first anger tell was when her jaw felt tight. Both reported that the next phase of anger arousal they noticed was heat in the neck and face. I encouraged them to learn to identify these feelings as signals to begin arousal management.
At this point, I taught both Adam and Sarah to employ an easily remembered protocol for dampening arousal, which I call the Stop method—Stop, Think, Objectify, Plan. The first step to controlling anger is to reduce initial arousal by internally stating the self-instruction to “Stop!” while mentally picturing an image and/or hearing a sound associated with cessation. For example, Adam would imagine a bright, red stop sign and his father’s voice saying “Stop immediately!”
Next, to derail anger escalation, it’s helpful to ask clients to sit down (assuming a physical position the brain associates with safety) and engage in deep, diaphragmatic breathing. Adam and Sarah learned to sit in a fully relaxed position while practicing a version of diaphragmatic breathing and exhaling to a slow, internal count from 10 to 1. The acts of sitting and consciously breathing interrupt angry thoughts, because they focus attention on these tasks. Each was instructed to continue taking relaxing breaths as needed until his or her anger signal diminished.
I then encourage each partner to focus on his or her most upsetting, angry thoughts, which usually sprang from common cognitive distortions. Some examples include: mindreading—”Sarah just loves to get me mad, so she can accuse me of being irrational”; personalizing—”Adam’s fury isn’t about his stress: it’s to put me down!”; overgeneralizing—”Adam can never cool it: he’s always just on the edge of losing it”; and thresholding—”If Sarah corrects me in front of the kids one more time, I know I’m going to lose it.” These distortions trigger fight-or-flight instincts and associated arousal, making it critical to develop the ability to step back and look at the situation through a more objective and calming lens.
After quickly identifying one or two distortions prominent in their thinking, each learned to rebut and replace anger-arousing thoughts with affirming facts. This is called objectifying. I typically teach clients a strategy I call “camera checking” to focus them on the observable facts of the anger-inducing situation. By emphasizing the facts, rather than perceptions colored by resentments, experiences, or faulty beliefs, partners learn to avoid demonizing and personalizing the other’s words and actions. This process diminishes the perceived threat and, typically, leads to an immediate decline in arousal. For example, instead of thinking “She loves to make me mad”—an irrational mindreading of Sarah, Adam was asked to focus on observable statements and actions devoid of interpretation: “The fact is that Sarah is telling me her opinion of how I handled our son Jake. She disagrees with me.” This thought—an objective statement, rather than an attack on the other’s character—sets the stage for a discussion of differences of opinion.
Each partner is encouraged to think of an immediate plan, focusing on the facts of the situation. Having a plan reduces perceived threat by increasing one’s sense of control. Adam’s plan was, “I’ll suggest we table this until I feel less exhausted,” or “I’ll look at her and listen until she expresses her ideas—seeing them as information and not criticisms or put-downs.”
Therapy often involves entirely too much talking about new skills the client should put into place, but not enough rehearsing. Clients often understand well enough what to do when life challenges arise, but often can’t recall and enact new skills in the heat of the moment. Accordingly, new coping behaviors need to be rehearsed enough to be automatic. I spend a full session with each partner, role-playing how to implement the Stop in mock situations of provocation. I model how to use the Stop, and then we reverse roles and have the client use it in the heat of role-plays that enact the most difficult and volatile situations each client can imagine.
Making a Commitment to Change
After Adam and Sarah had experienced applying Stop techniques, I met with them together to put these skills into practice. Adam echoed the doubts of most clients at this juncture: “I still feel that I’m going to lose it when Sarah and I really get into it. How can I remember to do all this stuff when the heat gets turned up?”
To segue into the next phase of our work, I asked them to discuss together the words and actions that had most quickly provoked anger escalation in the past. For Sarah, it was when Adam raised his voice, approached within two feet of her, and told her she was incompetent as a wife and mother (using words like lousy, lazy, and weak) and criticized her in front of the children. Adam responded strongly when Sarah raised her voice, questioned his sanity (“You’re nuts!” “You need help!” “I’m going to have you put away”), refused to speak to him for hours, and threatened divorce. They were encouraged to discuss how they felt when these threatening behaviors were directed at them, while their partner listened without interruption.
I asked each to make a commitment to change, based on what they’d learned in the individual sessions and from each other. Which behaviors were they willing to alter? Which behaviors would they agree to substitute when angry? I helped them be as specific as possible, to ensure well-defined, practical, and measurable goals. Adam agreed that when conflict arose, he’d sit down and use a softer voice, tell Sarah what behaviors he wanted her to alter without resorting to name-calling, and do all this in private. As in other cases, I said that if they wanted to, they could write down and sign their commitments to each other as a contract.
We then spent two full sessions practicing “circuit breaking” to derail anger escalation. Each partner has two potential circuit breakers, warning signals that the system is getting dangerously hot. One, an inner physical feeling signaling anger arousal, originates in the self; the second, the partner’s anger actions, originates in the other. The activation of these circuit breakers signifies the need to shut down the discussion and begin using the Stop method.
The self-originating circuit breaker for Adam included a tightening of his shoulders and chest or warming of his face; his other-originating circuit breaker was when Sarah’s voice became significantly louder or she began criticizing him in front of the children. Sarah’s self-originating circuit breakers included a tightening jaw and a flushed, warm face; her other-originating circuit breaker was when Adam got loud, stood within two arm’s lengths of her, or called her a name.
These four levels of awareness (his and her self-signals and other-signals) warned that arousal was escalating and the action should be ended for as long as needed to employ the Stop techniques, calm down, and reassert control of arousal. As I encouraged them to discuss the hardest, most triggering topics that they could think of while practicing circuit breaking, they began readily to halt and derail their anger, and then redirect themselves back to calmer talking and listening about issues. I demonstrated these strategies for them, so they could practice during two sessions devoted exclusively to rehearsing together how to use circuit breaking.
As Adam and Sarah practiced using Stop with me, they not only became more proficient in derailing their anger arousal, but also less reactive to each other. Just as exposure training reduces anxiety to feared situations, these rehearsals helped them feel less threatened as they learned new ways of responding to old anger triggers. They felt more prepared for the next provocative encounter and more relaxed about how to handle each other’s actions.
A Vision of Relationship
Now that their anger arousal was under control, we could begin to discuss underlying relationship issues during our couples sessions. Through conversations emphasizing I-statements and active listening, I asked each to discuss their vision of how they’d like their lives to be in a year and beyond in major life areas: love and intimacy, friendships, activities/interests, spirituality, intellectual stimulation, family/parenting, financial. Once they each better understood the other’s vision and underlying needs, both could craft more-realistic expectations of their partner and a mutual vision for their relationship, reducing sources of future conflict.
During 10 additional sessions, they practiced using Stop to derail anger arousal that would emerge as they decided how to collaborate on implementing their individual visions and their common goals. For example, Adam wanted more time with his male friends, and Sarah wanted to visit her parents more frequently—something Adam had resisted in the past, which had been a source of arguments. They agreed that on the same weekend at least once a month, they’d fulfill these individual goals, removing a source of conflict. They reported using Stop and circuit breaking with much success at home. By mutually managing their arousal, they reported success in discussing and resolving differences as they worked on satisfying their needs.
This CBT based systemic approach to anger treatment acknowledges that couples inhabit an interdependent relationship, and that treating both of them, regardless of who’s the “angrier,” helps each identify and alter his or her contribution to the problem. Nevertheless, the approach I’m describing is no miracle cure. One partner frequently refuses to participate. When I’m forced to work with one partner alone, I employ the same methods for arousal management described above and use role-plays with me standing in for the partner to allow the client to practice circuit breaking. Safety is always the priority, and I routinely and ongoingly assess the degree of risk if violence is an issue. When the risk is too high, I refer the partners to separate therapists until they become comfortable with joint sessions.
The path to behavior change is often circuitous, and setbacks frequently occur, especially when one or both partners minimize the need to use Stop, rationalizing that “We’ve got this down and don’t need to do all those steps,” or returns to old thinking and actions when one or more of the Five S’s suddenly fuels arousal. Adam began working late and missing evening meals, driving home exhausted and out of sorts—which fueled irritability and rekindled old habits. At those times, it’s especially helpful to assess what exactly has taken place and recommit to new behavior. Thus, “booster” sessions are usually necessary.
Rather than becoming overfocused on the drama of anger or its roots in an individual’s life, it’s crucial to understand anger as part of an ongoing, interdependent system of expressed and unexpressed needs, which ultimately must be addressed in any relationship. Rather than something that must be managed by just one partner, it’s important to see it as being central to the dance of need fulfillment in a couple, and to help both partners learn new steps to convert this often destructive force into fuel for lasting relationship change.
By Ronald Potter-Efron
Robert Nay presents a patient, thoughtful, and practical approach to the difficult task of working with angry couples. He’s quite thorough in his three-phase technique, and recognizes that a major concern in working with such couples is getting them to stick with the therapeutic program long enough to develop new habits of respectful communication. Brain research on neuroplasticity suggests that it takes at least six months of practicing new behavior to create permanent change.
My major critique of Nay’s approach is that it isn’t truly systemic in the classic sense of that term. Rather, he begins by separating the parties and working with them individually for several sessions. In my own work, I try to avoid individual sessions, because all too often, clients use them to share potentially explosive secrets—”I just want you to know that I’m having an affair with my secretary, but don’t tell my wife.” Individual sessions increase clients’ tendency to try to make the therapist their ally against their partner. At a deeper level, I believe that holding separate individual sessions implies that the real issues are individual, rather than systemic.
I prefer to keep the couple together in sessions so that they can focus on how they’re mutually creating their miseries. One approach I use helps couples chart the details of their here-we-go-again arguments—the fights that have occurred so frequently that both parties know all the lines, but still become so emotionally flooded that they seemingly can’t stop these conversations from happening. It’s critical, I believe, for the couple to realize that they’re mutually responsible for these minidramas. Although either partner can derail the scene by refusing to say the lines, these fights in reality usually don’t end until both parties decide to quit. Until that happens, most partners tell me that even when they try not to get sucked in, they quickly return to their habitual roles when their partner plays out the old drama.
It appears to me that, instead of a truly systemic approach, Nay does what I call side-by-side individual work. In essence, his goal is to help each partner inoculate himself or herself from their partner’s provocative words and deeds. His Stop method certainly will help them do exactly that, but I don’t see how it’ll lead to a significant change in the system.
This is most apparent in the individual approach Nay uses to elicit the couple’s sharing of personal visions of a presumably brighter and more constructive future. This attempt to get them out of their current quagmires and help them look ahead to a more positive future is certainly valuable, but, from a pure systemic perspective, I believe that much more emphasis should be placed on having partners craft a mutual vision together—a shared dream that offers a more cooperative direction.
In summary, I’d say that, despite his useful insights into the struggles of angry couples, Nay’s case description offers a side-by-side therapy approach, rather than truly systemic counseling.
I appreciated Ronald Potter-Efron’s perspective that, for lasting change to occur, the couple must continue to rehearse new anger actions and reactions to each other over time, so that they become more automatic, particularly when anger arousal is triggered and old habits rear their heads. However, I was perplexed by his focus on the lack of purity in following a classic approach to working with a couples system of learned interactions.
This case clearly melds cognitive-behavioral methods with couples therapy and communication strategies. The thrust of the case is to move away from the individual-therapy approach to working with both partners, each of whom participates in the dance of anger. I thus agree that we must move beyond a side-by-side approach to anger treatment. After a few individual visits to instruct each partner in the rudiments of managing arousal—a CBT approach that can best be carried out individually—I work with both partners, if possible, to help them collaboratively craft an approach to attaining their individual needs.
As their needs are better fulfilled, anger arousal is likely to be reduced or eliminated. I’ve experienced few problems in making it clear that the goal of treatment is to alter how they manage anger arousal as a couple, not to do parallel, individual therapy. In particular, the circuit-breaking strategy, through which both partners learn to recognize and communicate early on that arousal is escalating, permits them to remain focused on clear communication and resolution of needs, without being derailed by recurrent anger patterns that defeat their best efforts at making necessary relationship changes.
W. Robert Nay, Ph.D., is clinical associate professor at Georgetown University School of Medicine and the author of Taking Charge of Anger: Resolving Conflict, Sustaining Relationships and Communicating Effectively Without Losing Control and Overcoming Anger in Your Relationship: How to Break the Cycle of Arguments, Put-Downs and Stony Silences. Contact: email@example.com; www.wrobertnay.com.
Ronald Potter-Efron, Ph.D., is a clinical psychotherapist, co-owner of First Things First Counseling and Consulting, and director of its Anger Management Center. He’s the author of Rage: A Step-by-Step Guide to Overcoming Explosive Anger. Contact: firstname.lastname@example.org.
By Ryan Howes
Back in the 1970s, Donald Meichenbaum was part of a group of innovators that included Albert Ellis and Aaron Beck. Together they challenged the prevailing behaviorist paradigm, lobbying to have the psychology field recognize the pervasive influence of thoughts and beliefs on observable behavior. Four decades later, the sometimes acerbic Meichenbaum remains an outspoken critic of what he considers unproven therapeutic practices and fads, upholding standards of empirical proof for clinical methods within the field. Now 70 and retired from his professorship at the University of Waterloo in Canada, he’s presently research director of the Melissa Institute for Violence Prevention in Miami, and has a particular interest in ensuring that the combat vets returning from the wars in Afghanistan and Iraq receive the best treatment available. As active as ever and a popular figure on the workshop circuit, he recently talked about conclusions he’s drawn from decades of experience in the field.
RH: My students have an ongoing debate about the nature of therapy, and how much the therapist-client interaction should resemble a real relationship.
MEICHENBAUM: I get hung up with the word “real.” I mean, what’s an “unreal” relationship? Clearly, when we’re talking about therapeutic alliance, we’re talking about a relationship. The therapeutic alliance depends on the degree to which the therapist and the client agree on a set of goals and the means to get to those goals. That alliance necessarily has to do with the affective bond that develops, and the alignment between the client’s view of what’s wrong and how to get help and what the therapist has to offer. If those are in line, then you’re going to get a therapeutic bond, and everything follows from that.
RH: So the relationship needs to be real enough in clients’ lives that they’ll take the process seriously?
MEICHENBAUM: Yeah, and I’m essentially at my therapeutic best when the clients are themselves offering the advice I’d otherwise offer. In other words, I need clients to convince me that what they need is cognitive-behavioral therapy (CBT). So I use a lot of Socratic questioning to draw out people’s own wisdom. I’m a bit like Peter Falk playing Columbo: I try to get people to provide the answers they’re looking for themselves, rather than trying to become their surrogate frontal lobe.
RH: A former client just contacted me after coming home from Afghanistan. He’s had a tough time, and he’d been specifically advised to seek out EMDR treatment for post-traumatic stress disorder. What would you recommend?
MEICHENBAUM: I’ve done battle with the EMDR people so many times that I don’t want to get back into that debate. Rather than thinking that there’s one approach to PTSD that’s across-the-board better than any other, I think it’s more important to look at what’s common among all these procedures, and help people understand that there are a range of methods—besides exposure-based interventions—that can be helpful.
The choice of which method to recommend should be determined by the client’s symptomology. If your client’s main problem is hypervigilance, avoidance behavior, and mistaken beliefs, then some variation of in vivo exposure, where he can tell the narrative and then change the mistaken beliefs, would be acceptable. But if, in fact, his primary concern is guilt—his feelings about killing a buddy in friendly fire or killing others—then the treatment of choice would be a procedure focused on guilt or moral injuries. The field has advanced to a point where we can now tailor interventions to fit more closely the specific nature of the client’s distress, not just the broad category of PTSD.
Researchers Anke Ehlers and David Clark have identified that the major problem that leads to chronic PTSD has to do with biographical memories. Many people need help to incorporate the trauma memory into the larger narrative of their lives. They need help getting a larger perspective.
The other thing that’s now emerging in the literature is that helping people with PTSD isn’t just about getting rid of bad thoughts, but retrieving positive thoughts of what they did to survive. There’s an increasing recognition of the need to incorporate into treatment resilience-engendering, strength-based interventions, such as fostering positive emotions, psychological flexibility, optimism, gratitude, and spirituality. I’ve been involved in developing iPod technology for returning service members (see www.warfighterdiaries.org). These videos can be downloaded onto an iPod and people can listen to these coping stories whenever they want. This project dovetails with the Constructive Narrative approach that I now advocate.
RH: So there’s no one true cure?
MEICHENBAUM: There’s no single model that fits all. I really see myself as an honest broker, so anyone who says I have the cure, like Steven Hayes’s idea that his Acceptance and Commitment Therapy is “The Third Wave”—ACT may work with many people, but it’s not a panacea.
RH: You’ve done research specifically on what constitutes therapeutic expertise or mastery. You’ve written that people need about seven years to become an expert at anything. Is that similar to the 10,000 hours to achieve expert status that Malcolm Gladwell writes about in The Outliers?
MEICHENBAUM: That’s exactly right, we’re using the same data—10,000 hours, or, if you’re a chess player, 50,000. I say it takes seven years for a therapist to become an expert, because that’s how long it takes to see enough patients really shape up. You learn by deliberative practice, learning from your mistakes.
RH: So what can less experienced therapists do to provide good client care while they’re gaining sufficient experience to move to the next level?
MEICHENBAUM: I think it’s a journey. Some people start off a bit ahead of others because they already have core skills, like knowing how to listen, how to reflect, those kinds of things. I think that the main thing is not to be sucked up by the hype that’s associated with certain therapy models—you need to be a critical consumer. It’s also important to find a good mentor and be part of a peer group in which you look closely at each other’s work.
I think that a crucial pathway to expertise in psychotherapy is to have the guts to audiotape or videotape your sessions, and watch them with someone else; we all need that kind of feedback. The other thing is that you should develop a habit of soliciting feedback from your patients. At the end of every session, you should ask them, “Is there anything I said or did, or anything I failed to say or do, that you found particularly helpful or unhelpful?” We all need to regularly do those kinds of dipstick assessments and solicit that kind of feedback. If you’re an athlete and you miss the shot, you get immediate feedback. If you hit the golf ball in the rough, you get immediate feedback. Psychotherapists don’t get that kind of feedback automatically; they have to ask for it.
RH: As one of the founders of CBT, how far do you think it’s come?
MEICHENBAUM: Years ago, the behavioral traditionalists attempted to get all cognitive types kicked out of the American Association of Behavioral Therapy. They tried to make sure that no articles with the word “cognition” appeared in journals like JABA [Journal of Applied Behavior Analysis]. A letter was even circulated specifically identifying people who were bastardizing behavior therapy. Today AABT has changed its name to the American Association of Cognitive Behavior Therapists. One has got to be impressed with that kind of growth.
In addition, there’s an increasing appreciation of the particular factors that make cognitive-behavior therapy effective, like the therapeutic alliance and the whole business of nurturing hope and attending to feelings. So I think CBT has continued to develop and embrace a broader perspective, recognizing that feelings impact thoughts, as well as thoughts impacting feelings.
Finally, I think that there’s a great deal more humility about the limitations of CBT. Recent studies in the area of depression highlight that behavioral activation and helping people get exercise is equally, or more, effective than cognitive therapy. In the area of substance abuse, CBT is no better than other kinds of interventions, like 12-step groups. In fact, in substance-abuse studies using CBT, there’s no evidence that the cognitions have changed, or that the mechanisms of change are in any way linked to the specific CBT procedures. So I think anyone who’s sensitive to the data has to be given pause by how little we still know about what particular mechanisms lead to change.
RH: It’s humbling!
MEICHENBAUM: Sure. I think if you’re honest in this profession, that’s usually the right stance.
Ryan Howes, Ph.D., is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs “In Therapy” for Psychology Today. Contact: rhowes@mind spring.com; www.ryanhowes.net.
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