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|Point of View|
Point of View
By Ryan Howes
Telling It Like It Is
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.