Curtailing Between-Session Phone Calls

This article first appeared in the September/October 2004 issue.

Last year, some psychology graduate students were brainstorming with Thomas Joiner, director of the psychology clinic at Florida State University, about possible research projects. Joiner happened to mention a counterintuitive opinion that he’d heard informally from several colleagues: therapists who reassure clients that they can call between sessions for emergencies seem to receive fewer phone calls of all kinds. That just didn’t make sense to Joiner’s students, so they decided to look for research on the issue. There wasn’t any.

Now there is. The students did their own research project, and the results, reported in June’s Professional Psychology: Research and Practice, validate the anecdotal reports. The students combed the charts of 139 clients of 20 therapists-in-training for between-session, client-initiated phone calls, and asked the therapists about their willingness to receive calls for both crisis intervention and non-emergencies, and how often they discussed their preferences with their clients.

Results regarding the receipt of crisis calls showed that therapists who indicated greater willingness to receive non-emergency calls between sessions received fewer crisis calls, whereas therapists who frequently reminded clients that they could call between sessions for non-emergencies received more crisis calls. The authors speculated that therapist willingness to be generally accessible to clients between sessions for non-emergencies conveyed a supportive therapeutic relationship that might have helped normalize periodic crises and thus reduce crisis calls, but that frequently reminding clients they could call for non-emergencies might have set up an expectation that the client would experience problems and should be calling for guidance.

Results regarding the receipt of non-emergency calls indicated that therapists who reported more willingness to receive calls in emergency situations received fewer non-emergency calls. This latter finding holds true even for clients who are low-functioning or have borderline personality disorders–notorious between-session callers. In fact, the study finds, if you want to increase non-emergency calls, tell clients that you’d prefer not to receive any crisis calls.

The study’s lead author, Lorraine Reitzel, speculates that willingness to receive crisis calls from clients between sessions reassures clients and provides a safety net that gives them the courage and determination to work through difficulties independently. Such policies, she thinks, orient clients toward practicing emotional self-regulation.

The findings make sense to Joiner, who coauthored Self-Determination Theory in the Clinic last year. He’s found that reinforcing clients’ belief that they can make their own decisions, and increasing their ability to do so, is a key component of successful therapy.

Of Spanking and Race

Over the years, studies have consistently demonstrated that spanking results in a host of long-term, negative consequences. The spanking research is so compelling that the American Academy of Pediatrics cautions against spanking. But some researchers have maintained that the effects of spanking depend upon its familial, community, and cultural context.

In the May Journal of Child Psychology and Psychiatry, a study headed by Jennifer Lansford of Duke University finds that, while white children who were spanked exhibit more aggressive behavior as young teens, African American children who were spanked actually exhibit less aggressive behavior.

Lansford cites a 2002 metanalysis of spanking studies by Elizabeth Gershoff in the July 2002 Psychological Bulletin. It associates spanking with 10 undesirable outcomes, including increased aggression, less internalization of moral precepts, a greater chance of becoming a victim of physical abuse later in life, and decreased mental health. In fact, the Gershoff study cites only one positive outcome for spanking: it gets immediate compliance.

In her study, Lansford speculates that European Americans may associate spanking with parental loss of control, anger, and aggression, while African Americans may associate it with a legitimate parental expression of authority and training. A white child who’s spanked regularly and lives in a community where spanking is frowned upon, Lansford says, may grow up feeling angry, ashamed, or flawed, while a black child whose peers are also spanked may suffer none of those negative effects.

Critics point out, however, that Lansford looks at only 74 black families, 16 percent of her overall sample, and that her small sample and her measurement instruments don’t adequately support her conclusions and speculations. Working with a limited sample is a of criticism that can be leveled at many studies, but several researchers feel so strongly about spanking that Lansford’s study set off alarm bells for them.

Joan Durrant, head of the Department of Family Social Services at the University of Manitoba in Winnipeg, Canada, points out that 11 countries, from Sweden to Cyprus, have proscribed schools and parents from using corporal punishment for children. “When you’re dealing with a risk-laden issue like hitting kids,” she insists, “you have an obligation not to contribute to their further abuse.”

Psychiatrist Alvin Poussaint, professor of psychiatry at Harvard’s School of Medicine and Boston’s Judge Baker Children’s Center, worries that studies like Lansford’s might inadvertently send the message that it’s beneficial or risk-free to physically discipline black children. Poussaint also questions the primary positive finding that black children who are disciplined in this manner end up less aggressive. Spanking, he says, can lead to depression, withdrawal, and shame–negative outcomes that can be mistaken for decreased aggressiveness.

Although Lansford stresses that her study looks only at spanking, not physical abuse, Poussaint and Durrant think that’s a difficult line for some people to draw. “When you tell parents and other authority figures that spanking’s okay,” says Poussaint, “you never know what they’re really doing.”

Last Sounds

The hospital room is filled with equipment and shuffling relatives. In a coma, the dying patient’s breathing is labored, phlegmy. His body twitches. The agitated family members stand by his bedside or pace the room, until Margaret Pasquesi and Tony Pederson arrive, carrying their harps.

They set up on either side of the patient’s bed and reassure the unconscious patient and his relatives that they don’t have to do anything. Margaret feels the dying man’s pulse and temperature, watches and listens to his breathing, and then begins playing music that is synchronized with the man’s breathing. Tony joins in, adding emphasis, harmony, texture. The harpists subtly adjust their music to the slightest changes in the patient’s condition. Gradually, the relatives calm down, focusing on the harps and the dying man. His twitching abates, his breathing slows. Margaret and Tony soften their music. For a half hour, they alternate between playing and sitting in contemplative silence.

Pasquesi and Pederson are music-thanatologists who work for the Evanston, Illinois, Palliative CareCenter and Hospice. They’re among some 70 music-thanatologists worldwide. They and their colleagues have completed a two-year curriculum covering transcultural views of death and dying, physiology, music, and meditative and focusing techniques, which helps them stay present and connected with themselves and with the dying person and family. The diverse members of this group include musicians, nurses, monks, and even a chiropractor. They all trained at the Chalice of Repose Project at St. Patrick Hospital in Missoula, Montana, directed by harpist and composer Therese Schroeder-Sheker.

Music thanatologists bypass cognitive processes and focus on the physiological obstacles that stand in the way of dying. Even when a person wants to give up, the body often fights and gasps for breath. Lungs fill with fluid, making breathing tortured. Sometimes pain breaks through the gathering haze.

Hearing is often the last remaining sense before death. Music therapist Don Campbell, author of The Mozart Effect, points out that some medications, including pain opiates, intensify hearing, and that the sounds of talking, hospital machines, and even lawnmowers halfway down the block can disturb and distract people from their dying. Music-thanatologists, whom Schroeder-Sheker has described as midwives to the dying, weave a blanket of sound that mirrors respiration and pulse rates. Drawing on a healing and soothing music tradition that goes back to monastic chanting, music-thanatologists avoid recognizable songs, which may stimulate conscious thoughts and memories, creating instead what might be called physiologically expressive music.

Is music-thanatology anything more than a New Age gimmick? Along with anecdotal and observational reports, quantifiable data is slowly accumulating, as more hospices use music-thanatologists and have to justify the expense to third-party payers. Preliminary data shows that even people on life support and in deep comas breathe more easily and slowly, their pulse rates slow, and their body temperatures drop as the music soothes them and accompanies them toward death.

Schroeder-Sheker, a visiting professor of pastoral theology at Duke University, plans to offer her next certification course at the Catholic University of America in Washington, D.C., later this year.

Strong, Silent, and Healthy

There’s a widespread belief these days that the strong, silent male who bottles up his emotions is a psychological problem waiting to happen. But a new study in July’s Psychology of Men & Masculinity warns us not to fall for that myth.

It finds that such men aren’t prime candidates for anxiety, depression, or intimacy problems. In fact, if you want a much stronger predictor for psychological distress, look at how men perceive their ability to solve problems. The more men perceive themselves as being effective problems solvers, the study says, the better they feel. Conversely, when they perceive themselves as avoiding problems or not being able to make good decisions, they’re likely to be distressed.

The study of 260 male undergraduate students, by psychologist Glenn Good of the University of Missouri, Columbia, has important clinical applications for one of the most common presenting problems in couples therapy–a woman complaining that her partner doesn’t share his feelings or communicate. Rather than focusing on trying to open up the man, says Good, a better strategy may be to invite the man to help solve the relationship problem. You can’t, and shouldn’t try, to turn Clint Eastwood into Alan Alda, but if Clint decides to take on a relationship problem by turning off the television for one hour and sitting with his partner, things may have a better chance of working out.

The Myth of the Blind Study

If a carefully designed blind study compares a specific treatment to a placebo, we trust the results more than a study that isn’t blind, right? Shouldn’t it mean more, for example, when an antidepressant proves to be significantly more effective than a placebo, if the subjects, physicians, and raters don’t know who took what? Now a review of blind studies in the February 21 British Medical Journal calls into question the effectiveness of blinding, and will likely lead to fundamental changes in the way such studies are conducted in the future.

The review finds that only 15 of 191 “gold-standard studies”–randomized, placebo-controlled, and double-blind–published between 1998 and 2001 provided any evidence that the researchers assessed whether the blinding had been effective. It gets worse: 9 of the 15 that studied the effectiveness of the blinding reported that it hadn’t worked perfectly.

“If a patient realizes he’s on a placebo, he may seek other treatment without even telling the investigators,” says the lead author of the review, epidemiologist Dean Fergusson of the Ottawa Health Research Institute in Canada. Likewise, someone who knows he’s taking a bona fide medication may expect to improve, confounding whether the improvement comes from the actual treatment or the subject’s expectations. Imperfect blinding also affects the person who administers the treatment, who may unconsciously communicate information and expectations to the patient.

Why do so few studies report on the effectiveness of their blinding? Fergusson suspects two factors account for this: many journals have tight requirements on the length of articles, and researchers often have a tendency to hide bad news about their studies. But his review may change that. It suggests that the Consolidated Standards for the Reporting of Trials (CONSORT), an international group of researchers and journal editors, amend its standards to require that every randomized blind study conduct and report an assessment of its effectiveness.

Psychologist-Ghostbuster

Underneath Edinburgh’s great South Bridge, gloomy stone vaults–dark, dank enclosures–date back to the 18th century. Rumor has it that they’re haunted. It makes sense: for two centuries, the most miserable of Scotland’s people have slept, loved and murdered in the vaults’ dark shadows. Hundreds of miles to the south, in the more genteel surroundings of Surry’s Hampton Court Palace, visitors to the Haunted Gallery have also reported ghosts for centuries.

British psychologist Richard Wiseman, a former magician and paranormal debunker, set out to discover the secrets of the Edinburgh Vaults and the Haunted Gallery. He had more than 400 people wander inside all of Hampton Court Palace and then asked them to indicate on a floor plan precisely where, if at all, they’d felt a ghostly presence. When he compared their reports with a floor plan that plotted the precise locations of centuries of sightings, he found a high degree of correlation. Wiseman queried people ahead of time about their prior knowledge of sightings. Those without prior knowledge had felt the ghosts in the Haunted Gallery as often as those who’d heard the stories.

He did a similar study in the haunted vaults underneath the South Bridge. Ranking the 10 vaults that’d had the highest number of reported sightings, he asked 218 visitors about any eerie feelings. Again, the 21st-century visitors’ haunted feelings pretty much matched historical rankings, regardless of prior knowledge. Ninety-five people reported 172 occurrences of unusual events that made them uneasy.

Using an array of equipment worthy of Bill Murray’s ghostbusters, Wiseman sent teams of investigators, who were not aware of previous reports of paranormal events, into the vaults and the Haunted Gallery, where they measured fluctuations in magnetic fields, air movement, light, and temperature. Wherever the ghostly reports were most frequent, investigators found the most fluctuations from the norm in one or several of these environmental conditions.

Wiseman’s conclusion: certain environmental factors give people a vague sense of disorientation, and this spooky feeling fuels a sense that ghosts are lurking around.

CBT vs. Light Therapy

When therapists hear “Seasonal Affective Disorder” (SAD), they think “bright-light therapy.” That’s not surprising. In addition to the logical connection between SAD and light therapy–if lack of sunlight depresses you, get more light–mountains of biological research link SAD with decreased serotonin, underactive thyroids, and overactive biological clocks.

Until researcher Kelly Rohan’s study appeared in the June Journal of Affective Disorders, there’d been no published studies of cognitive-behavioral therapy (CBT) and SAD. No wonder that before treatment in Rohan’s study began, 26 percent of the participants thought that light therapy would work, while only 4 percent expected CBT to work. However, Rohan’s pilot study of 23 people finds that a CBT modified to treat SAD works as well as light therapy, and better in one important dimension.

This is potentially good news for people with SAD. Despite its reputation, studies have shown that light therapy works on just over half the people who try it, and that the beneficial effects don’t last more than a few days after therapy ends. Many people also have difficulty following the treatment regimen of sitting in front of a light box for about 30 to 90 minutes daily.

Rohan’s form of CBT encourages SAD sufferers to find pleasurable activities in the winter. It helps them identify the specific negative thoughts that accompany the changing seasons and to think of them not as facts, but as a learned pattern. It alerts people to the outside cues that trigger depressed thinking, like the calendar, the turning leaves, the smells of autumn, and the resetting of the clocks.

Rohan’s three groups of subjects–one treated with light therapy, one with CBT, and one with a combined treatment–all improved at similar, and significant, rates. But the following winter, the combined-treatment group experienced far less SAD, and no one treated with CBT–with or without light therapy–relapsed into full-blown SAD. By contrast, 60 percent of those treated with light therapy alone relapsed.

The news for people with SAD seems clear: “You might be biologically prone to experience SAD,” Rohan says, “but you can change the way you feel in the winter.”

Resources

Phone Calls: Professional Psychology: Research and Practice35, no. 3 (2004). Spanking: Journal of Clinical Child Psychology and Psychiatry 45, no. 4 (2004): 801-12. Last Sounds: For more information on music thanatology, see www.chaliceofrepose.org.Strong, Silent: Journal of Man & Masculinity 5, no. 2 (2004): 168-77. The Myth of the Blind Study: British Medical Journal 328 (2004): 432-33. Ghostbuster: British Journal of Psychology 94 (2003): 195-211. CBT vs. Light Therapy: Journal of Affective Disorders 80 (2004): 273-80.