Clinician's Digest

As the influence of the old ideal of the inscrutable psychoanalytic practitioner has waned and informality increasingly has come to dominate our culture, more and more clinicians seem to believe that self-disclosure has a role in therapy. But a survey of 695 psychology grad students and psychologists in the April Professional Psychology: Research and Practice suggests that many clinicians haven't yet considered how the Internet, particularly the social media side of things, can give clients access to their personal information, often without their even knowing that it's happening.

While more than 70 percent of the therapists surveyed reported maintaining a personal web page or a social networking site, such as Facebook or Twitter, many erroneously believed they had adequate privacy settings, not realizing that clients can still view some of the correspondence, screeds, photographs, and videos they've posted, there and elsewhere on the Internet. In fact, a cautionary article in the March 10 Washington Post told of a male client who found a photo of his female therapist in a bathing suit online and reported it to her board. Some therapists have even been matched with clients on Internet dating services.

In the survey, younger therapists expressed less concern about safeguarding their privacy than experienced therapists did, but this may reflect a different attitude toward therapeutic boundaries among the electronic generation more than obliviousness to standards of good therapy. Can we really know whether it adversely affects therapy when clients secretly know facts about their therapists? California psychologist Ofer Zur, whose book Boundaries in Psychotherapy challenged the concept of boundary violations by pointing out the clinical usefulness of boundary crossings, has argued that, for the new generation of clients, using the Internet to find out about their therapists has become a normal part of the therapeutic process.

Whether or not clients' knowledge of a therapist's personal information is harmful to therapy, both the ethical guidelines and the research that would illuminate the issue continue to lag behind the everyday realities of life in the Internet Age.

A Team Approach

One of the great ironies of our profession is that therapists, those maestros and apostles of connection, so often toil away in isolation. According to University of Ottawa psychologist David Pare, the usual attempts to break out of that isolation—supervision and consultation groups, agency staff meetings, workshops, and conferences—often are inadequate because they don't provide the immediate engagement that comes from vigorous, empathic, ongoing discussion that blends the personal with the intellectual. Now Pare and a few colleagues believe they've found a way to enhance therapists' sense of connection and rekindle their excitement in new discoveries: Collaborative Practice Groups (CPGs), biweekly or monthly meetings of up to 12 practitioners that use various approaches of the reflecting teams developed by therapists Tom Andersen and Michael White.

Pare believes that reflecting teams, originally used in supervision, encourage the kind of nonjudgmental, open-ended inquiry that avoids the competitive quest for a single answer or a collectively uniform point of view. At each meeting, a member presents a topic—a case, a new therapy approach, clinically relevant research, sometimes even a live session. The reflecting team then shares their reactions and thoughts with one another, scrupulously avoiding any judgments. The notion is that such freewheeling discussions without the immediate need to respond to or "solve" a problem encourage new ways of thinking and a more generative dialogue that can lead to new meanings and possibilities.

In one recent CPG, a counselor working with teenage mothers in assisted living expressed the lack of support she felt treating such a tough, vulnerable population. As the reflecting team shared their thoughts and reactions, one agency supervisor realized that she herself had been so busy and focused on problem-solving that she'd become disconnected from her supervisees. She returned to her agency with the understanding that, even though she'd answered her staff's questions, she ­hadn't been supportive because, she was simultaneously communicating that she ­didn't really have time for them.

"We were worried when we set up the groups that people would feel the process of reflection took up too much time," says Christine Novy, a CPG facilitator. "Instead we've found the reflecting team approach actually saves time." After the discussion described above, not only did the supervisor come to an important insight, but the counselor who'd been feeling so much at sea realized that if she stopped trying to provide all the answers, her clients might be better able to come up with some of their own.

When Self-Help Isn't Helpful

The influence of the self-help book market, which generates more than $1 billion a year, reaches deep into our profession. A survey in 2000 by psychologist John Norcross found that 85 percent of therapists recommended self-help books to their clients. By far, the most popular self-help books are based on cognitive-behavioral therapy (CBT), and there's preliminary evidence that such books can be effective at relieving and preventing anxiety and depression.

CBT self-help programs for depression typically include a module that directs people to focus on their negative or unrealistic thoughts, which led clinical psychologist Gerald Haeffel of the University of Notre Dame to question whether such programs, when used by individuals who ruminate, might actually make matters worse. He suspected that such modules could "provide further fodder for ruminative tendencies," which research shows can create deficits in executive capacity, cognitive flexibility, task-switching, and problem-solving. Ruminators also seem to have more difficulty removing negative thoughts from their memory.

Haeffel's study, reported in the February issue of Behaviour Research and Therapy, divided 72 students at risk for depression and anxiety into three prevention groups. The first group used a workbook to record everyday events, along with their mood and accompanying thoughts, and note down evidence that both supported and refuted those thoughts. They then identified their thoughts as realistic or subjective and rerated their moods. This is a common module in CBT programs. The second group recorded only their realistic thoughts and the evidence that supported it. The third group used the workbook to practice their academic skills.

Haeffel found that at-risk college students who were prone to rumination in the first group significantly deteriorated after using the workbook to record both their realistic and unrealistic thoughts, and that the negative effects lasted for at least four months after completing the study. In a surprising finding, the students in group three, who used the workbook to develop their academic skills, did as well as those in group two, who used the workbook to record only realistic thoughts. Haeffel speculates that because the students were attending an academically competitive university, the academic skills workbook helped alleviate a significant stressor in their lives.

Haeffel advises therapists to avoid recommending self-help books for at-risk clients who heavily ruminate, or to modify them to eliminate any focus on negative, unrealistic thoughts. His study can be viewed not so much as a warning about CBT self-help programs, but as a useful refinement. Up until now, CBT for depression has been shown to help only about half the people who use it. By finding different ways of working with ruminators, the overall effectiveness of the CBT model might be considerably enhanced.

The DSM Revisits Personality Disorders

In the March issue of the Networker, Senior Editor Mary Wylie pointed out that the DSM exerts a powerful impact on how both therapists and the public think about specific disorders and the people who have them. Accordingly, with so much at stake, the different work groups deliberating over DSM-5 due out in 2013, have tried to stay ahead of critics by giving the professional community advance notice of changes currently under discussion, along with a chance to respond to them. One of the diagnoses due for a major overhaul in DSM-5 is personality disorders (PDs).

Laymen often consider PDs as falling somewhere between neuroses—the less "serious" conditions—and psychoses. Having their own DSM axis, separate from other disorders and clinical conditions, reinforces the popular notion that PDs aren't conditions a person has, like depression or anxiety, but something a person is—a part of their personality structure far less amenable to treatment. Reinforcing that viewpoint, DSM-IV characterizes PDs as "enduring," "inflexible," and "pervasive across a broad range of personal and social situations."

Although it's still being debated whether PDs will remain on their own axis in DSM-5, the latest proposal characterizes them less extremely as "relatively stable across time." This brings the description more in line with recent research, which finds that some PDs abate when life stressors or coexisting conditions are alleviated. In addition, watch for fewer distinct diagnoses within the PD category. The 11 current types may become only 5: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal.

But the most significant proposed diagnostic changes are ones already incorporated by the Psychodynamic Diagnostic Manual, the alternative manual to the DSM. Discussions are under way to include resilient traits of PDs as well as symptoms. And DSM-5 will likely replace the current characterization of PDs as something a person either does or doesn't have with a continuum perspective. For example, DSM-5 proposes for borderline personality disorder that therapists use a 5-point scale to assess how well a person fits the overall criteria, and then additional 3-point scales to assess each of 10 traits, such as emotional lability, self-harm, and separation insecurity. DSM-5 advocates believe the result will be a more nuanced diagnosis that provides clearer guidelines regarding the symptoms on which treatment should focus.

Diet and Depression

By now the relationship between diet and physical health has been thoroughly established, particularly the connection between fried and highly processed foods, refined grains, high fat, and sugar and higher incidences of obesity, cancer, and cardiovascular and neurodegenerative diseases. But despite thousands of books and articles in health and fitness magazines, the links between diet and mental health have been more difficult to prove. Gold standard research in this area requires large budgets for extensive and costly longitudinal studies, but searching for dietary solutions to mental health isn't a promising revenue stream for pharmaceutical companies, currently the major research financiers. Nevertheless, well-controlled, long-term studies are the only way to clarify the essential questions of causality: does better diet improve mental health, or do people who are mentally healthy tend to make better food choices? Despair, depression, and anxiety tend to drive all kinds of unhealthy lifestyle choices, including dietary ones.

Psychiatric research has been slow to investigate the connection, but that's changing, and it's beginning to look as if the health magazines and mind-body thinkers and practitioners like Andrew Weil have been right. A study in the March 2010 issue of the American Journal of Psychiatry finds an association between diet and depression, and the journal underlines the study's importance by publishing an editorial in the same issue by psychiatrist Marlene Freeman saying it's time to direct more research money toward the impact of diet on mental health. "It's both compelling and daunting to consider that dietary intervention at an individual or population level could reduce rates of psychiatric disorders," she writes.

The study, led by Research Fellow Felice Jacka of Australia's University of Melbourne, claims to be the first to look at diets broadly. She investigated three habitual dietary patterns: traditional, comprised mainly of vegetables, fruit, beef, lamb, fish, and whole-grain foods; Western, consisting mostly of processed meats, pizza, chips, hamburgers, white bread, flavored milk, sugar, and beer; and modern, which includes mainly fruit, salad, fish, tofu, beans, nuts, yogurt, and red wine. The study showed that, of the three, the Western dietary pattern was most likely to be accompanied by dysthymia or major depression and increased psychological issues. The traditional dietary pattern was associated with a significantly reduced likelihood of both depressive and anxiety disorders, and in general, a higher healthy diet score was associated with fewer psychological symptoms.

Another study of overall dietary patterns and the incidence of depression, reported in last year's British Journal of Psychiatry, led by epidemiologist Tasnime Akbaraly of London's University College, found the same thing. Of 3,486 middle-aged participants, those with a diet similar to Jacka's Western diet were significantly likelier to develop depression over time than those with a diet similar to her traditional example. They also found evidence of a protective effect of a healthy dietary pattern.

The studies certainly don't nail down the connection between a high-fat, high-processed, low-nutrition diet and depression, but they're enough for Marlene Freeman to suggest that therapists focus more on their clients' eating habits. Even if improving their diets proves to have only a minimal impact on psychiatric disorders, she says, contributing to their physical health will still represent a valuable contribution to their overall well-being.

Brain-Scan Battles

Since the 1990s Decade of the Brain, there's been growing interest in how the emerging neuroscientific technology can improve psychotherapy's diagnostic and treatment effectiveness. No one has addressed the challenge of using the advances in brain imaging more directly than psychiatrist Daniel Amen, who's developed a method for using SPECT scans (a nuclear medicine tomographic imaging technique using gamma rays) to guide diagnosis and treatment, not just for difficult brain-injury cases, but for common clinical issues like depression, aggression, AD/HD, eating disorders, obesity, and addictions. An effective and popular presenter, Amen has brought his work to a broad audience through his workshops, books, public lectures, and PBS appearances.

In contrast to Amen, however, most neuroscientists have remained cautious about the direct applications of neuroimaging in psychotherapy, and during the last year, Amen's work has been widely attacked, most recently in two strongly worded critiques from neuroscientists in the normally staid American Journal of Psychiatry (AJP).

The dispute began in the May 2009 AJP when UCLA neuropsychiatrist Andrew Leuchter reviewed Amen's book Healing the Hardware of the Soul. Leuchter referred to the author as a "self-described clinical neuroscientist, psychiatrist, and brain-imaging specialist [italics added]," and stated that Amen's "science" was based not on solid research, but upon "anecdotal evidence, post-hoc rationalizations for his preferred approaches, and his own strongly held religious beliefs." (Amen, who earned his degree at Oral Roberts University, has been open about the importance of his Christian faith.) Claiming that Amen has failed to make the case that SPECT scans provide any better treatment information than ordinary clinical judgment—which spares patients the added expense and radiation—Leuchter added the caustic aside that, "Dr. Amen does practice what he preaches: he states that he benefited from his own self-help approach, most notably to manage the stress of an investigation by the Medical Board of California for his unorthodox diagnostic and treatment approaches (an investigation that he says vindicated him)."

Now a year later, the May 2010 AJP has printed a letter critical of Amen by psychiatrist Bryon Adinoff from the University of Texas Southwestern Medical Center and radiologist Michael Devous. Again challenging the scientific basis of Amen's work, they write that the Society of Nuclear Medicine offered him the opportunity to prove his claims that he could diagnose disorders through neuroimaging by submitting samples of his scans to a blind study. According to them, Amen ignored the offer. In a phone interview, however, Amen insisted that no such offer was ever made to him. Nor, he added, would he have accepted it because, he says, contrary to Adinoff and Devous's claim, he's never said that he can diagnose anyone solely on the basis of SPECT scans, which are only one component of a more comprehensive diagnostic procedure. He pointed out that Leuchter is financially involved with a rival brain-imaging company, and dismissed Devous as someone who's "not a physician." Accusing the three of "intellectual dishonesty," Amen pointed to more than 2,400 articles on his website, the majority in peer-reviewed journals, and his coauthoring of a chapter on functional imaging in the Comprehensive Textbook of Psychiatry. But while most of the articles discuss SPECT imaging, say his critics, almost none provide any empirical evidence of its efficacy in treatment.

The bitter debate reveals a common fault line between researchers and clinicians. From the research perspective, Amen's claims for the therapeutic use of SPECT scans are too far ahead of sufficient confirming empirical evidence, although he points to a 2001 study in the Journal of Nuclear Medicine that supports his contention. Adinoff and Devous insist that going public with their concerns isn't so much an attack on Amen as an attempt to protect the credibility of their field. If people have been "led astray by unsupported claims," they write, they'll be "less inclined to utilize scientifically proven approaches once these are shown in the peer-reviewed literature to be effective."

Garry Cooper

Garry Cooper, LCSW, is a therapist in Oak Park, Illinois.


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