Tag: Clinician’s Digest

How to Help Learning Stick for Clients

By Tori Rodriguez

It’s usually easy to see when clients are tuned out or turned off, simply not absorbing what you’re trying to get across. What’s puzzling is when things seem to be really clicking in session—when you’re sure clients will return to report their success at having applied the new awareness and skills they’ve just acquired to their lives—and then you find that they haven’t followed through.

A study by David Atkins and colleagues, published in the June 2012 issue of Behaviour Research & Therapy, found that clients in couples therapy are less likely to recall communication skills learned during high levels of emotional arousal. As the authors report, “Greater emotional arousal predicts remembering fewer skills,” and “sustained emotional arousal may impact memory through encoding, retrieval, or both.” Other studies have also established how strongly stress hormones can affect learning and memory. However, in the June 2013 issue of Couple and Family Psychology: Research and Practice, couples therapist Brent Atkinson offers some practical suggestions for addressing this obstacle to therapeutic change. He proposes that combining our emerging understanding of brain science with the power of deliberate practice gives us effective tools for mitigating the power of emotionally charged situations. Keeping emotions in check would then prevent clients from losing access to the insights and skills they’ve presumably acquired in the consulting room.

“Many clients don’t have a basic level of mental fitness required to make changes,” says Atkinson. For these clients, despite their best intentions, being in conflicts with their partner or in other triggering circumstances results in flooding, or becoming overwhelmed by negative emotions. This often triggers diffuse physiological arousal (DPA)—activation of the autonomic nervous system’s alarm response, which initiates changes like increased heart rate, blood pressure, and levels of stress hormones like cortisol, all of which help prepare the body to deal with threats. In spite of the new insights and skills explored in therapy, the chance of new responses being tried out when a client’s nervous system has been hijacked by DPA are radically diminished. So before clients can make changes in their relationship with a partner, before therapy can really begin to have any real impact, the first order of business is to change clients’ relationship with their nervous system.

In Atkinson’s treatment model, the therapist first works with clients to get them motivated to tune up their nervous system, helping them understand why it’s important and introducing them to the concept of mindfulness. The couples then participate in an eight-week mindfulness course, and during concurrent couples therapy sessions, they practice extending the skills they’re learning to their relationships. If clients need help mindfully responding during stressful partner interactions, they listen to their partner’s criticisms via prerecorded voice messages, during which they practice using mindfulness skills to turn down their physiological and emotional arousal. As clients become more skilled at self-soothing, the therapist helps them to identify their typical sequence of conflict and to mentally rehearse how to respond more effectively when conflict arises—much like how athletes or musicians might engage in mental practice to enhance their skills.

Treatment models like Atkinson’s move the field of therapy away from a faith in the magical power of insight, or even the generalized benefits of the therapeutic alliance, toward a closer look at how to concretely make the process of emotional learning more efficient and sustainable. Since therapy outcome studies consistently show a discouraging overall finding—the average results of psychotherapy haven’t improved over the last 50 years—this new research certainly seems to be a step in the right direction.

The Doctor Is In. . . Your Phone

By Lee Coleman

Currently, there are between 100 and 150 smartphone apps designed to supplement—and occasionally even replace—face-to-face psychotherapy. In fact, the United Kingdom’s National Health Service maintains a library of approved smartphone apps for a variety of physical and mental health concerns. In this country, the United States Department of Defense has assisted in creating several apps designed specifically to help service members track anxiety and depressive symptoms related to military deployment. Given this trend in technology and the high-level support it’s receiving, it’s increasingly important for therapists to understand what mental health-related apps are available in the world and how they might enhance, or in some cases undermine, therapy.

The Optimism app, for example, can help clients become more active participants in their treatment, particularly if some form of self-monitoring is involved. Created by an Australian company, Optimism allows clients to track information related to emotional well-being, such as mood, symptom severity, medication compliance, and hours of sleep. The app generates charts and reports to monitor progress over time, and there’s even a desktop interface that allows clinicians to collect and view their clients’ data. The app started out as a desktop software package six years ago and now averages about 10,000 downloads a month as a smartphone app, according to its developer, James Bishop. Over 80 percent of surveyed Optimism users report using it in conjunction with visits to a mental health professional for a specific mental health issue, usually a mood disorder. For clinicians doing therapy that involves mood charting, supplementary apps like this one can boost compliance by providing a convenient alternative to paper charts.

Numerous apps also offer a form of life coaching and other services traditionally provided through face-to-face psychotherapy. Unstuck, for instance, designed by SYPartners, has had more than half a million downloads since its launch in December 2011. Geared toward people struggling to make difficult life decisions, the app helps users navigate factors that may be interfering with the decision-making process and gives specific advice for developing new perspectives. For example, someone who’s taking on too many tasks alone can indicate that they’re feeling like a “lone leader” and get advice on how to start working more collaboratively.

A related app, MoodKit, was developed by two clinical psychologists to help people use traditional cognitive-behavioral therapy techniques in their daily lives. Among other features, it encourages mood-elevating activities, helps users change self-defeating thought patterns, charts daily moods, and records journal entries to increase a sense of well-being. It can certainly be used to augment professional treatment, but users don’t need to be in therapy to take advantage of what it offers.

These apps and others like them are easy to use and may be promising pathways to increased treatment compliance for that reason alone. However, they’re a long way from being a silver bullet for curing people’s mental woes. As psychiatrist Andrew Gerber of Columbia University notes, “We are built as human beings to figure out our place in the world, to construct a narrative in the context of a relationship that gives meaning to our lives. . . . I would be wary of treatments that don’t allow for that.”

But even as psychiatrists like Gerber contemplate the creation of apps that could undercut the therapeutic relationship, researchers around the world are testing their effectiveness in treating clinical problems. Cognitive bias modification (CBM), for example, involves the use of a game-like app that trains users to respond to distressing stimuli in new ways, which may have applications for people struggling with anxieties and phobias. For example, socially anxious individuals might play a game in which they’re trained to pay more attention to an image of a neutral face than a hostile one. Although the idea is promising, psychology professor Richard McNally of Harvard, whose research team conducted a 2012 study of CBM, notes that people who used the CBM smartphone app became less anxious, but so did the control group whose members played a nontherapeutic game. In other words, the placebo effect might be responsible for at least some of the positive outcome.


So while many jobs these days are being made obsolete by advancing technology, that doesn’t appear to be the case in the therapy field as of now. Rather than fearing these apps as competitors, savvy therapists will want to explore their potential as clinical assistants. After all, as intelligent and intuitive as Apple claims its iPhone personal assistant Siri to be, she’s certainly not ready for licensure.

–Lee Coleman

Resources

Therapy Apps: Benedict Carey. “The Therapist May See You Anytime, Anywhere.” New York Times, 24 December 2012. http://www.nytimes.com/2012/02/14/health/feeling-anxious-soon-there-will-be-an-app-for-that.html?pagewanted=all&_r=1&;

Peter Reuell. “A Therapist at Your Fingertips.” Harvard Gazette, 13 March 2012. http://news.harvard.edu/gazette/story/2012/03/a-therapist-at-your-fingertips/.

Reading Emotions

By Jared DeFife

When it comes to the craft of conversation, most of us believe that some face-to-face interaction is the key component of emotional communication. For social engagement, we connect with our social network over Facebook or use our various iDevices for a little FaceTime with relatives. But new research is questioning how we actually process and interpret the emotional reactions of others. The findings might make us take an about-face turn on conventional wisdom regarding facial expressions and emotions.

For decades, researchers have relied on the “Ekman faces” for studying how we process emotional expressions. In the 1970s, psychologist Paul Ekman created a set of black and white photographic images of actors portraying six “universal emotions”: happiness, sadness, anger, disgust, fear, and surprise. Although the stimuli have varied over time (to incorporate actors of varying ethnicity, for example) and the universal emotions have expanded (to include emotions such as pride, guilt, and shame), the fundamental reliance on facial expressions as a primary indicator of emotional state has remained. Now it appears that, when it comes to intense real-world emotional experiences—such as the joy and relief of seeing your first child born or the agony and disappointment of a crushing defeat—our faces may not be as revealing as once believed.

To examine the role of facial expressions and body language in how we interpret the intense emotional displays of others, researchers at Princeton, New York, and Radboud universities captured photographic images of peak emotional expressions from a variety of powerful real-life situations, including high-stakes tennis matches, sexual orgasms, home-makeover reveals, and navel or nipple piercing. After manipulating the images to isolate facial expressions, bodily expressions, or bodily and facial expressions combined, the researchers asked study participants to rate the type and intensity of emotional experience they thought they saw in each image.

As published in the journal Science, the results demonstrated that when viewing facial expressions alone, viewers were no better than chance at identifying whether the expression indicated a positive or negative experience. Viewers were much better able to identify positive or negative experiences when viewing the images of bodily expressions of emotions (with or without the corresponding facial display).

In case you’re tempted to read these results and think you knew it would turn out that way all along, the researchers actually described their methods to a separate group of participants beforehand. Of those asked, 80 percent thought viewing the face alone would be most accurate, whereas only 20 percent thought the body/face images would be most effective, and zero people predicted that the body image alone would be the most useful indicator. Furthermore, by manipulating the body image, the experimenters successfully manipulated viewer perceptions of the emotions shown. For example, when putting the face of someone undergoing piercing on the body of a tennis victor, viewers were more likely to rate the photograph as someone experiencing intense joy.

“These results show that when emotions become extremely intense, the difference between positive and negative facial expression blurs,” said the lead researcher Hillel Aviezer in a released statement. “From a practical-clinical perspective, the results may help researchers understand how body/face expressions interact during emotional situations. For example, individuals with autism may fail to recognize facial expressions, but perhaps if trained to process important body cues, their performance may significantly improve.”

Beyond that, the study’s results may have implications for therapist practice and training by overcoming our natural inclination to pay attention to facial expressions and highlighting more focused attention on body language and physical cues. Videotaped supervision sessions might need to zoom back to incorporate the body posture of therapists and their patients. Also, teletherapy through Skype, which focuses primarily on the face, might be improved with more attention to the whole-person image.

Resources

Reading Emotions: Science 338, no. 6111 (November 2012): 1225–29; http://www.eurekalert.org/pub_releases/2012-11/thuo-bln112912.php.

Can Video Games Power Up Your Practice?


By Jared DeFife

Wonder if Pac-Man and Ms. Pac-Man ever needed couples therapy? What might a family therapist say about the sibling rivalry of the Super Mario Bros? It’s time to get serious about gaming, because some suggest that video games and psychotherapy fit together like a well-placed Tetris block.

Surveys suggest that between 95 and 97 percent of American teenagers have played video games at some point in the recent past, and most of them play games on a regular basis. Adolescents aren’t the only ones gaming, however. More than 50 percent of adults play video games, too, whether they’re launching Angry Birds on their phones or questing in multiplayer online universes like World of Warcraft.

“They’re a part of our patients’ lives,” says Mike Langlois, a clinical social worker in Cambridge, Massachusetts, and author of the eBook Reset: Video Games & Psychotherapy. “Anything that much of the population is doing is something that psychotherapists need to know about.”

Unlike the arcade games of the past, modern video games offer an immersive social experience that therapists can use to build relationships with young clients. Forget about the dusty old board games like checkers and Parcheesi! “If I’m doing play therapy with adolescents in the 21st century,” Langlois says, “I should be playing the games of adolescents in the 21st century.”

More and more, gaming consoles are making their way out of parents’ basements and into our offices. “As I’ve learned in my child and adolescent psychiatry practice, the focus should be not only on what kids play, but also, perhaps more so, on how they play,” writes psychiatrist T. Atilla Ceranoglu in an editorial for the Boston Globe. Ceranoglu’s research on the use of video games in psychotherapy suggests that by playing video games with their patients, psychotherapists can build relationships with their gamer clients. In the process, they can learn valuable information about frustration tolerance, creative problem-solving, competition, and collaboration.

Even if you don’t have an Xbox set up in your office, it’s important to be aware of and sensitive to gaming-related issues, says Langlois, who brands his clinical practice as “gamer-affirmative.” By talking to everyone from adolescents to active-duty military veterans in Iraq and Afghanistan about their gaming experiences, Langlois says he started to hear stories about how people used video game communities to get help when they were depressed or even suicidal. “It was very different than the media hype I was hearing about how video games are all addictive and cause isolation.”

Now researchers and practitioners are starting to catch on to the power-up potential of video games for clinical practice. Research studies have found that playing video games improves pain management during medical procedures, while some specially designed psychoeducational video games have been used to increase treatment adherence in managing chronic diseases, such as diabetes and sickle-cell anemia. Businesses such as San Diego–based SmartBrain Technologies and Atlanta-based Virtually Better are headed by psychologists to develop, test, and use special therapeutic video game programs for everything from brain injuries to AD/HD and panic disorder. Even major commercial entities like Nintendo’s Wii gaming system and Microsoft’s Xbox Kinect platform are marketing games to improve physical activity and mental coordination.

Meanwhile, if you want to improve your own gamer-practice competence, try video gaming yourself. “I don’t think you need to play every single game, but you do need to be willing to have the experience of playing a game and learning to play,” says Langlois. He’s started a class on social work and technology in which one session requires students to attend in the online environment of World of Warcraft. Some students new to the game environment (gamers might call them newbies or noobs) find themselves fumbling around and frustrated as they learn the intricacies of navigating a new world. “I tell them to pay attention to that, because that’s exactly how their patients feel. For them, life is as difficult to negotiate as learning how to navigate this video game is for you.”

Resources

Video Games: Review of General Psychology 14, no. 2 (June 2010): 141-46; http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2011/07/05/video_games_can_be_healthy/.

What Causes Borderline Personality Disorder?

By Jared DeFife

Do childhood trauma and a chaotic family environment cause adult borderline personality disorder (BPD)? Common clinical wisdom says yes, but new results are leading some researchers to insist that it’s more complicated than that.

Investigators from the Minnesota Twin Family Study, first begun in 1983, collected data about childhood abuse and adult personality from 1,382 pairs of same-sex twins, followed over time from ages 11 to 24. By examining differences in abuse exposure and genetic overlap (whether the twins were identical and thus had the same DNA, or fraternal, and thus had only about 50 percent genetic overlap), the authors, led by Marina Bornovalova of the University of South Florida, concluded that childhood abuse in itself isn’t a direct cause of adult BPD traits. But since childhood abuse is seen so frequently in individuals with BPD (some studies suggest in as much as 90 percent of cases) why the overlap? According to the study, common genetic factors contribute to both childhood abuse and BPD.

The researchers suggest two possible genetically influenced reasons for the connection between childhood abuse and adult BPD. In the first model, called “passive genetic mediation,” children not only inherit genes from their parents, but are raised in an environment that’s an expression of the parents’ own genetic influences. In this model, children inherit genetic tendencies toward aggression, impulsivity, and emotional dysregulation from their parents and are raised by parents who are themselves aggressive, impulsive, and dysregulated. Abuse and BPD are thus different manifestations of the same emotionally dysregulating factors.

In a second, more controversial scenario, known as “evocative genetic mediation,” children who inherit difficult genetic temperaments from their parents tend to behave as moody or impulsive children. Emotionally intense and difficult to raise, these children strain their parents’ own genetically limited coping resources, contributing to parenting failures characterized by childhood abuse and neglect.

If the second scenario sounds like blaming the victim, the authors are quick to point out that their results “don’t support the idea that [childhood abuse] is inevitable, justified, or without harm.” However, their work raises possibly provocative questions about the causes and effects of childhood abuse and adult borderline personality disorder, once again putting science at odds with facile, politically correct perspectives on complex psychological phenomena.

Resources

What Causes Borderline Personality Disorder? Journal of Abnormal Psychology, doi: 10.1037/a0028328.

“Manpocalypse” Now: Today’s Masculinity


By Jared DeFife

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.

Resources

Manpocalypse: http://www.demiseofguys.com; British Journal of Psychiatry 198, no. 3 (March 2011): 167-68.