The embarrassing spectacle of a national therapy organization publicly unable to resolve a bitter internal conflict cast a shadow over the annual convention of the American Association for Marriage and Family Therapy (AAMFT) during its October meeting in Sacramento, California. Since last spring, three groups of protesters—MFTers for Change, Call for Change (CFC), and the New Jersey division of the organization—have been raising questions about the direction of AAMFT, claiming that the national leadership has become isolated from its members, has lost the original vision of the organization, and has failed to promote public awareness of the distinctive clinical perspective and relational skills of MFTs, while stifling dissent within the organization. They're calling for an independent audit to look closely at governance and finances and the operating culture that's been put in place by long-time Executive Director Michael Bowers, with many calling for Bowers's resignation.
Prior to the convention, the national office of AAMFT had threatened legal action against several CFC members for using the national listserv to e-mail members a letter of grievances. At the annual conference, the protesters were denied meeting space at the convention center. Further, AAMFT cancelled the town hall meeting, a natural venue for bringing up concerns about the organization. While AAMFT had promised all members a chance to speak at the business meeting, scheduled from 7:00 to 9:00 P.M., the first hour and forty-five minutes was devoted to hearing formal reports from organizational committees. During the meeting, however, because of the number of people who showed up to speak, the executive board extended the comment time until 10:30 P.M.
Protesters organized a meeting at a nearby church, where about 250 people gathered to hear a series of speakers voice their criticism of the current leadership and watch a videotape from family therapist William Doherty noting the dramatic decline in attendance at the annual conference (from 4,500 during AAMFT's heyday in the early 1990s to an estimated 1,300 this year). Doherty cited the organization's failure to encourage clinical innovation as evidence of the ineffectiveness of Bowers and the current board. But perhaps the most dramatic moment casting a spotlight on the organization's widening split came at the end of a plenary session, when the keynote speaker, psychologist Richard Schwartz, suggested that AAMFT needed to bring in an impartial mediator to handle the conflict it's been unable to address.
Despite AAMFT's portrayal of its critics as a tiny group of dissidents, many well-respected members of the organization echoed sentiments about the unwillingness of the national organization to tolerate criticism or listen to divergent views. For many years, according to Jim Thomas, former president of the Colorado division and a member of MFTers for Change, the organization's communication mode has been to "command, control, and contain" with "disagreement being seen as disloyalty." The AAMFT leadership, say its critics, has become a closed echo chamber that reflects and amplifies Bowers's management style. In addition, over the years, says Thomas, the number of AAMFT committees has shrunk dramatically, cutting off member input and further consolidating decision-making and information hoarding at the top. "When any association becomes top-down in centralized leadership and power, it's troubling," says Brier Miller, former president of the Minnesota division. "But it's particularly troubling in a profession that believes that truth is always contextual. We've become an organization that values structure over people."
Refusing to comment for this article, as did other AAMFT officials, Board President Linda Schwallie said only that, "As it does in all matters, the AAMFT board will continue to operate and direct the association toward the future in a manner that is consistent with our bylaws, our policies, our values, and the law."
In early November, Bowers and executive board members traveled to meet with members of the New Jersey division, which had recently learned that AAMFT had cut off their funds without informing them. Hanging in the air was a threat to revoke New Jersey's charter. The two sides had become so polarized that the New Jersey board insisted upon having a legal transcriber present. New Jersey members attempted to discuss their grievances, but the executive board insisted that those discussions take place only within the usual channels. The meeting's purpose, the executive board said, was to learn whether New Jersey would agree to work within those channels.
That meeting may have been the last chance for the protesters and the executive board to draw upon their therapeutic and conflict-resolution skills to begin a more productive dialogue. Instead, New Jersey insisted that the executive board is more interested in maintaining control of the dialogue than promoting the MFT profession, and AAMFT insisted that their rules of governance do allow for dialogue and change to occur, and that such rules are necessary for the organization to best serve its more than 20,000 members. The dechartering of the New Jersey division and escalation of the battle now appears increasingly likely.
According to the World Health Organization, the economic and societal consequences of depression make it the fourth costliest disease in the world. In the United States alone, depression costs more than $2 billion annually in direct treatment expenses and more than $23 billion in lost productivity. By 2030, depression is projected to be the number-one disease burden in high-income countries, surpassing HIV and heart disease. The leap to number one will occur because, despite the trumpeted effectiveness of antidepressants (whose therapeutic impact has been increasingly shown to be overstated) and the billions of dollars invested in developing and studying pharmacological, psychotherapeutic, and surgical treatments, depression's incidence is projected to remain at the same or slightly increased levels, while HIV and heart disease's incidences are projected to decline.
Depression breeds depression. The earlier in life depression occurs, the more likely it'll recur; the longer it goes untreated, the more difficult it is to treat; and children of depressed parents are significantly more likely to develop depression. So while the lion's share of research money and clinical attention goes to treating depression, it also makes sense to look at preventing it.
A recent metanalysis of 19 depression-prevention trials, reported in the October 2008 American Journal of Psychiatry, presented some encouraging news about the possibility of staving off depression. The educational and therapeutic prevention programs included in the metanalysis targeted both general populations and at-risk groups like pregnant and post-partum women, adults with sub-threshold depression, senior citizens with macular degeneration, and adolescents with a familial history of depression. The interventions included psychoeducation, problem-solving and support groups, cognitive-behavioral therapy (CBT), and Interpersonal Psychotherapy. (For an example of a CBT prevention program for adolescents, see http://www.kpchr.org/public/acwd/CWS_MANUAL.pdf.)
Considering the personal and social costs of severe depression, it's encouraging that all the prevention programs studied proved effective, particularly those that targeted at-risk populations. What's even more encouraging was that the results were as impressive as they were without the inclusion of two of the most promising interventions: CBT-based mindfulness meditation, developed by Zindel Segal, Mark Williams, John Teasdale, and Jon Kabat-Zinn, and Internet-based programs for adolescents, such as MoodGym (http://moodgym. anu.edu.au) and CATCH-IT (http://catchit-public.bsd.uchicago.edu).
With research money usually geared more toward treatment than prevention, the accumulating evidence supporting depression prevention may help readjust funding priorities, so that resources can go toward interventions with the most impact for the greatest number of people to reduce depression's enormous human and financial cost.
What are they putting into placebos, those supposedly inert pills with no medicinal effect that have long been the benchmark against which the effectiveness of new medications are measured? Something's going on, because placebos are getting stronger. An intriguing metanalysis in the November 2009 Journal of Affective Disorders, for example, found that the potency of placebos has nearly doubled between 1985 and 2005. How can that be?
The question has important ramifications. Because the Food and Drug Admin-istration (FDA) requires new medications to show significantly more effectiveness than placebos, fewer and fewer drugs have gained approval in recent years. Writing in the September 17 issue of Wired, journalist Steve Silberman points out that if they were to undergo clinical trials today, several widely used antidepressants wouldn't make it to market. In 2007, the FDA approved the fewest drugs since 1983, despite the record amount of money that pharmaceutical companies had spent on research and development. Half of late-stage trial failures of new drugs happened because they couldn't outperform placebos by a wide enough margin, says Silberman.
As brain-imaging technology has revealed that people's expectations produce actual brain reactions, the key to understanding placebos has shifted from the notion that their effect is purely imaginary to a new appreciation of their real physiological impact. Silberman speculates that the pharmaceutical companies may be victims of their own multimillion-dollar advertising successes. Press reports and mass advertising have led us to believe increasingly in the power of medications, so clinical trial subjects and raters (whose unconscious biases often influence results) may have developed higher expectations that pills will work.
Instead of arguing about how to reduce the incidence of placebo response, suggests Silberman, we ought to think about how to better use the placebo effect in treatment, something already done by many doctors who frequently prescribe pills and supplements they know are the equivalent of vitamins. Skeptics about the effectiveness of psychotherapy treatments suspect that many therapists, both consciously and unconsciously, are doing something similar. In the meantime, discussions are already going on about whether the FDA needs to rethink its guidelines on clinical efficacy, as well as how researchers can better differentiate between the effects of placebo and active treatments. As the links between mind and body become harder to disentangle, the previously held distinctions between medication, placebo, and a plethora of other therapies may soon seem less important than the notion that whatever works, works.
How Traumatizing Is Child Abuse?
In the 1980s, a recovery movement spearheaded by feminists as well as books such as Laura Davis and Ellen Bass's The Courage to Heal brought the once-taboo subject of child sexual abuse to wide public awareness. The therapeutic community began to recognize that childhood sexual abuse was far more widespread than previously believed, and the belief took hold that such abuse was invariably connected with severe psychological trauma, influencing many treatment approaches that continue in use to this day. But in her controversial new book The Trauma Myth, psychologist Susan Clancy argues that, in many cases, the trauma associated with the sexual abuse sometimes isn't caused by the perpetrator, but by well-meaning relatives, friends—and therapists.
When Clancy was a graduate student at Harvard in the 1990s, she and her associates interviewed about 200 adults who'd been sexually abused as children, hoping to learn more about the nature of their trauma. To her surprise, she found that most people recalled the abuse not as clearly traumatizing, but as a much more puzzling and ambiguous experience. With a large number of the subjects, along with a sense that something was done that wasn't right, their memory of abuse was also influenced by positive feelings. Some recalled feeling wanted, accepted, loved, and special or being rewarded with gifts. Some felt stirrings of physical pleasure that were difficult to express or understand. Aside from the complicated negative and positive feelings and emotions that her subjects described, what stood out for Clancy was that many of the people interviewed had never been asked what their experience had really been like for them. In fact, their trauma, Clancy concluded, often came from the narrative others, including mental health professionals, subsequently insisted upon: that the abuse was so horrific that the children had repressed their memories or lied to themselves about how it had felt. Often for people abused as children, this disjunction between their own and others' narratives created guilt, shame, and distrust of their own perceptions and feelings.
Although Clancy is clear that any sexual advance to children, no matter how gentle or mixed with positive emotion, is still abuse, she believes that these experiences need not necessarily create deeply disturbing psychological effects. That viewpoint, a decidedly minority position in the abuse treatment community, discouraged her from writing her book for years. But she finally decided that the victims' accurate reports of their abuse, not the inaccurate reports of their well-meaning advocates, needed to be aired.
Some within the field have begun to moderate the view that sexual abuse is always traumatic. "It's not just the specific act of abuse that's so damaging in itself," says Chicago trauma specialist Mary Jo Barrett. "It's a series of interactions with others that can either reinforce the sense of vulnerability or counteract it. The community can heal, traumatize, or retraumatize."
Clancy is highly critical of trauma experts who refuse to understand the variety of individual responses to abuse and who, she says, insist on seeing every case through the same lens. But many trauma experts fear that the effect of Clancy's work will be to cause people to take abuse less seriously and to blur the protective boundaries for children. Christine Courtois, author of Healing the Incest Wound, insists that all sexual abuse is traumatic and that although other issues can exacerbate the trauma, the traumatizing action itself provides the foundation that the later issues build on.
Clancy's advice to therapists who treat clients who've been sexually abused comes from an early research subject's reply to her queries about the "traumatic" abuse: "If you're trying to figure out why the abuse screwed me up so badly," the young woman told Clancy, "why are you asking so many questions about what it was like when it happened? What you need to be focusing on is what it was like later on."
Dealing with Chemo Brain
Psychologist Barry J. Jacobs, who specializes in working with families dealing with serious medical issues, still remembers an intellectually adept, 60-year-old cancer patient who discovered that, after he underwent chemotherapy, much of his mental acuity had drastically eroded. Hoping it was just a short-term side effect, he waited for his concentration, verbal fluency, and short-term memory to come back. They never did. Angry and depressed until the day he died, he often told Jacobs he wished he'd never decided on the chemotherapy, even though it had gained him another five years of life.
The man, a high school principal, claimed that he hadn't been warned about the side effects, and that if he had, he wouldn't have agreed to the chemo. That's possible. The realization that chemotherapy can have permanent cognitive effects on about 15 percent of people who undergo prolonged, highly toxic treatments is relatively recent. It was once thought that most cognitive loss from chemotherapy was short term and caused as much by the emotional stress of being diagnosed with cancer. But it's also possible that the man was told, says Jacobs. Many cancer patients and their family members, wrestling with fear, stress, and anxiety, must make difficult treatment decisions, and with their survival at stake, they often underestimate what living with the side effects will be like. Later, experiencing impaired memory, difficulty with word retrieval, incorrect word substitution, and the loss of deep focus, they question their decision. Sometimes that regret can be caused by the brain damage itself, which can make their thinking more rigid and cause them to fixate on what they've lost.
Weighing survival against future quality of life is terribly difficult, and knowing who's more likely to regret some cognitive deterioration is part of the art of counseling these patients. Jacobs believes that people who base much of their ego strength on their intellect are particularly likely to regret their reduced intellectual capacity. Surprisingly, pessimistic people may actually have an edge in dealing with the tough trade-offs in these kinds of treatment decisions—a fact often ignored in today's Positive Psychology tsunami. "People who think life has always thrown them curveballs and who have always had to fight to cope and adapt," says Jacobs, "often do better accepting the loss."
Is Therapy a Science?
What does science have to do with what therapists actually do in their offices? According to a 36-page report from the Association for Psychological Science (APS), which was widely publicized by science editor Sharon Begley in the October 12 Newsweek, not a whole lot. Calling for a complete restructuring of how therapists are educated and licensed, the APS report said that therapists rely too much on unreliable clinical experience and intuition and not enough on the array of research-supported treatments with established clinical track records. In her column, Begley concluded that, as a result of the gap between practice and research, "millions of patients" currently receive useless therapy.
In one especially provocative section, the APS report accuses the American Psychological Association (APA) of helping to foster a "prescientific" approach to psychotherapy by not fostering more rigorous scientific education, training, and licensing, and thus turning out inadequately skilled therapists who are akin to physicians who once relied on bleeding to balance the body's humors. Katherine Nordal, the APA's Executive Director for Professional Practice fired back a response to Newsweek, insisting that, "The assertion by Begley that many psychologists are not trained in, nor do they use, evidence-based practices is untrue." But like Begley's article, Nordal's letter didn't address the more important points raised by the APS report.
Since its inception in 1988, APS has positioned itself as more science-based than the APA, its membership consisting primarily of professors and researchers, rather than clinicians. Their report issued a call for an accreditation system that focuses primarily on science and screens out graduate student applicants who lack a solid track record in science and mathematics. It also called for faculty who are "successful in producing high quality research products, securing extramural research support, and developing, testing, and implementing experimentally supported interventions." Nevertheless, the APS report, unlike Begley's column, acknowledged the large body of research showing that factors common to a variety of treatments, which rest more upon therapists' relational skills and client variables than upon therapists' knowledge of the research, have a great deal to do with successful outcomes. (For a fuller discussion of this, see Jay Lebow's article on page 32 of this current issue). In fact, no studies have yet shown that therapists' knowledge of the research has any impact, positive or negative, upon therapy outcomes. In her longer blog response to Newsweek and to the APS report, Nordal writes that "psychologists combine our understanding of the research with how to best understand the patients who come into our offices with their complicated problems. . . . We have to realize the limitations of science in regard to the generalization of research results to the individual patient."
New Treatments for Borderline Personality Disorder
For many years, Marsha Linehan's Dialectical Behavior Therapy (DBT) has been widely recognized as the model for developing an effective therapeutic treatment by marrying painstaking research and clinical practice. Dozens of research studies have made DBT the field's most recognized and empirically supported treatment for borderline personality disorder (BPD). But although DBT remains by far the most researched therapy for BPD, other therapies have done as well in comparison trials of treatment outcomes.
In the latest study, reported in the September 15 online edition of the American Journal of Psychiatry, a team of researchers, led by psychologist Shelley McMain from the University of Toronto, has used the American Psychiatric Association (APA) guidelines for treating BPD to develop a more psychodynamic psychotherapy called General Psychiatric Management (GPM). Like DBT, it's a manualized, structured therapy, and it did as well on every symptom of BPD, including the most serious—suicidal and self-harming attempts.
GPM and DBT both share some common principles. Both acknowledge the client's suffering, make it clear that treatment will be difficult and slow, teach clients to take responsibility for their actions, and set clear goals in a structured therapy setting. Both emphasize decreasing impulsivity and increasing reflection, moderating black and white thinking, identifying and moderating inappropriate behaviors and feelings, and promoting more effective interpersonal relationships. But GPM differs from DBT in some important ways.
DBT deemphasizes medications, whereas GPM guidelines recommend them for distressing comorbid conditions or symptoms, such as impulsivity, depression, or anxiety. DBT therapists organize the hierarchy of treatment targets (suicidal, treatment-interfering, and quality of life interfering behaviors); in GPM the patients choose the hierarchy. DBT uses behavioral assignments, such as keeping diary cards, to handle negative transference, whereas the psychodynamic therapy focuses on addressing the negative transference in session.
Two other psychodynamic therapies, Transference-Focused and Emotionally Supportive, have shown effectiveness in treating BPD (see Clinician's Digest, November/December 2007).
Interpersonal Therapy, which straddles the line between psychodynamic and behavioral, is acquiring a promising track record. Anthony Bateman and Peter Fonagy's mentalization therapeutic approach, which, like DBT, focuses on helping clients develop the capacity to think about themselves in relation to others and to understand others' states of mind, has also proven effective.
The emergence of several effective treatments for BPD offers considerable hope for treating what, in the days before Marsha Linehan's innovative work, was widely considered an untreatable condition. Often we think of research as narrowing the road ahead. But Linehan's careful research, while solidly validating DBT, has also helped illuminate some common treatment philosophies and approaches and paved the way for the development of new ones.
AAMFT: Doherty's video may be viewed at www.youtube.com/watch?v=tmNfyCkKAW8; MFTers for Change Facebook page: MFT's For a More Dynamic, Inclusive, and Effective AAMFT. Depression: American Journal of Psychiatry 165, no. 10 (October 2008): 1272-80. Therapists and Scientists: Psychological Science in the Public Interest 9, no. 2 (November 2008): 67-103. Borderline Personality Disorder: American Journal of Psychiatry Online (September 15, 2009) doi: 10.1176/ appi.ajp.2009.09010039.
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