He's back in Iraq, on foot patrol, nervously walking down a street that suggests Basra, when it happens again—an explosion right across the street. The sidewalk shakes, he smells the acrid smoke, and as the panic starts to take over, his therapist says, "Turn right and walk up those stairs over there." He goes up a stone stairway to the roof of a building and then watches the blast again, safely removed. Only the client isn't back in Iraq—he's watching the scene unfold on a computer screen.
Therapists are making increasing use of virtual reality (VR) therapy, which, several studies suggest, increases the effectiveness of exposure therapy, the most empirically supported treatment for anxiety disorders such as PTSD and phobias. A metanalysis in the April 2008 Journal of Anxiety Disorders found that VR is more effective than recalling memories exclusively through narrative, and just as effective as in vivo exposure for a wide range of anxiety disorders.
Its use may soon be growing. A study in the August 2008 Death Studies journal reports preliminary success using EMMA'S World, a VR application developed by Spanish researchers to treat complicated grief. Currently there are 50 VR sites in military hospitals and university clinics treating primarily PTSD and addictions. Albert Rizzo, associate director of the University of Southern California's Institute for Creative Technologies, points out that many of today's veterans, raised on video games and computers, are more comfortable using VR than talking in therapy. VR also enables therapists to bring a simulation of the outside world into therapy, rather than relying primarily on homework, narration, or imagination.
Until recently, VR therapy has been the exclusive province of high-tech labs and clinics, but that may be changing. A company called Virtually Better, launched by Emory University psychologist Barbara Rothbaum, a noted VR and trauma researcher, and computer scientist Larry Hodges, now markets VR software and equipment to qualified clinicians, along with technical support and training. Costs start at about $6,000 for a minimalist setup and go considerably higher if one includes the extras, such as vibrating platforms and scent machines.
But all the extra bells and whistles may not be necessary. In February, PBS's Frontline program "Digital Nation: Life on the Virtual Frontier" introduced viewers to VR therapy. Those who were expecting a completely realistic recreation of battlefields, airplanes (for flying phobias) and barrooms (for addictions) may have been disappointed because the stylized scenes are deliberately a step removed from vivid reality. Early VR studies on vets with PTSD were too intense and had a high dropout rate, and researchers realized that they could evoke enough anxiety for exposure therapy to work with less realistic scenes. The goal now is to evoke memories and emotion, not recreate the experience. Clients' traumatic, phobic, or addictive conditioning is already so strong that their own brains provide the emotional charge. "People with PTSD report seeing things like water buffalos in our Vietnam scenarios that aren't there," Rizzo says. "You can fool the brain pretty easily."
Meanwhile, therapists don't have to worry about being replaced anytime soon. Rizzo points out that VR is an aid for exposure therapy, not a magic cure-all. "Technology doesn't fix anybody," Rizzo says. "It's a tool in the hands of a well-trained clinician."
The Tracks of Our Tears
The idea that crying indicates that therapy is working and that it's good for clients is older than psychotherapy itself. Aristotle wrote that crying "cleanses the mind," and Ovid said that "grief is satisfied and carried off by tears." But for many people, crying doesn't heal and may even be counterproductive.
A study of 4,249 people who were asked about their reactions to crying, led by Jonathan Rottenberg and Lauren Bylsma of the University of South Florida and reported in the December 2008 Journal of Social and Clinical Psychology,finds that more than 50 percent said they felt better after crying, while 38 percent felt the same afterward, and just over 9 percent felt worse. The question, therefore, say Rottenberg and Bylsma, isn't whether crying is cathartic, but when it's cathartic. Understanding the function of crying is central to answering that question.
The physiological reactions that follow crying, such as respiratory arrhythmia, indicate that the body is attempting to regulate stress. But that doesn't mean that crying decreases stress—the decrease may be attributable to some other reason. Most social psychologists believe that, since crying typically attracts social support, it's the hugs, concern, and tender responses from others, not the crying per se, that make a tearful person feel better. Crying also can defuse others' aggressiveness.
Most of us learn as babies that crying gets us hugs, food, and attention. But it's important to recognize that some people haven't experienced that reaction; crying can fail to attract positive responses or even provoke negative ones. Parents who are narcissistic, depressed, or severely stressed may react to crying babies with inattention, hostility, or physical violence. In addition, some people who received nurturing when they cried as babies may experience negative responses to their crying at other developmental stages. As a result, crying can elicit shame or anxiety in some people just as it does feelings of connectedness, comfort, and support in others.
Rottenberg and Bylsma's study suggests that instead of assuming tears mean that therapy has hit a sweet spot, clinicians should explore their clients' past associations with crying and how they feel about their tears now. What's most likely to provide a healing experience when clients cry in therapy isn't the crying, but the therapist's response. When clients cry, therapists may feel sympathy or the urge to comfort, but if they don't communicate that to clients, even subtly, and explore the feelings associated with crying, shedding tears may be a disconfirming or miserable experience for clients.
Making Peace with Auditory Hallucinations
Recent trends in therapy, especially those emphasizing mindfulness, encourage clients to turn their attention toward, and accept, emotions or "parts" of themselves that may initially seem frightening. Although that approach isn't new—Gestalt therapy advocated this years ago—the prevailing view has been that encouraging psychotic people to acknowledge different aspects of themselves as real encourages splitting and further psychosis. Now a study by a team of British psychologists led by Jasmine Chin of the University of Surrey, reported in the March 2009 Psychology and Psychotherapy: Theory, Research and Practice, suggests that instead of targeting schizophrenics' auditory hallucinations as symptoms to be eliminated, therapists should consider helping them develop a relationship with their voices.
It's a counterintuitive and controversial idea. Not only might this approach potentially support the psychotic symptom, but even Chin's study finds that most people who hear voices don't want to develop a further relationship with them. But want it or not, the study points out, people with auditory hallucinations already have a relationship with their voices, usually a difficult one, and they expend much time and energy trying to control them.
The study asked 10 psychotic people suffering considerable distress with their voices how they understood the relationship. Most personified their voices, assigning gender or names. (This urge was so strong that the few who didn't personify them fought the urge to do so). They usually experienced themselves as engaged in a struggle for power and control. "The voices magnify whatever it is I'm concerned about, or they'll comment on something I'm concerned about, which . . . often makes me more stressed than I was," one patient reported. But some voices served a potentially healthy function, reminding people they'd made good decisions in the past, or encouraging them to practice their social skills with the voices so they could go out into the world.
Along with these tangential supports for the notion of helping people with schizophrenia come into better relationships with their voices, Chin points out another reason. A study in the November 2004 Psychological Medicine, led by British psychologist Max Birchwood, found that people's relationships with their inner voices mirrored their social relationships with the external world, often reflecting their sense of being powerless and controlled by others. Chin speculates that when therapists, along with everyone else in schizophrenics' world, try to drive a wedge between them and their inner voices, it may actually reinforce this internalization of social stigma.
Richard Schwartz, the originator of Internal Family Systems Therapy, who's worked with nonpsychotic clients who hear voices, thinks there may be something to Chin's idea. "Once they realize that I'm neither afraid of nor pathologizing their voices," he says, "most clients are better able to relate to them from a less fearful and more curious, confident, and even compassionate place."
Teaching Old Therapists New Tricks
If you spend time hanging around cognitive-behavioral therapists, especially the research-oriented ones, says Yale psychologist Joan Cook, you'll hear so much enthusiasm these days about Acceptance and Commitment Therapy (ACT), the "third wave" of behavioral therapy, that you'll think it's swept across the entire field of psychotherapy. Yet you'll hear virtually nothing about newer therapies such as Internal Family Systems that have garnered more enthusiasm among psychodynamic or humanistic-oriented therapists. The converse is probably also true: how often do psychodynamic therapists show much interest in learning about ACT?
Most people would agree that therapists with a wider repertoire of skills and perspectives have a better chance of helping more clients. But learning a new treatment takes considerable time, money, and effort. So Cook began to wonder what makes therapists expand their clinical repertoire.
The scant research on the question has so far focused on samples too narrow to adequately answer her question. Then she realized that Psychotherapy Networker readers represented the broad spectrum she needed: the psychologists, counselors, and social workers who subscribe to the magazine have a wide range of experience and work in a variety of practice settings stretching across the United States and Canada. Over 2,000 Networker clinicians took part in Cook's survey, which is reported in the May 2009 Psychiatric Services.
It turns out that most therapists aren't influenced to learn a new treatment by reports of its effectiveness published in journals or the fact that a professional organization has designated it as having empirical support. One of the three top reasons clinicians learn a new therapy is a belief that it can be integrated with the approach they already practice. The other top two reasons are that it's endorsed by a respected therapist or mentor and that there are local training opportunities.
The strongest combination of motivations to learn a new treatment, as Networker readers might suspect, results from networking: therapists' colleagues introduce them to something new and demonstrate to them how the new technique can resonate with their existing skills and predilections.
Internet Self-Help for Porn Addiction
More than 41 million smart phones were sold worldwide in just the third quarter of last year, and the boom has helped increase the effectiveness of online support groups. Although such groups have been around since the early days of the Internet, the advent of smart phones, which allow people to communicate with text, video, and other graphics and to interface with social-networking sites like Facebook, have transformed online support groups.
Before smart phones and social networking, such groups were little more than electronic bulletin boards; people would post a message and check back later for a response. Despite exchanging messages with someone who shared the same problem, such groups did little to break the grip of isolation and shame. But now support group members share photos, videos, and their Facebook pages, and communication takes place 24/7.
Some people insist this form of communication just provides an excuse to avoid the "real" contact of face-to-face support groups or therapy. However, for the increasing numbers of people who have grown up using electronic communication, it may not be an intimacy dodge, but real communication, and research finds that checking in electronically with people who are also struggling with depression, anxiety, or substance abuse can reduce symptoms.
In an article on an Italian online support group for Internet pornography addicts, Israeli social worker Gabriel Cavaglion, from Israel's Ashkelon Academic College, reports that many of the group's more than 2,500 registered members have found that using the same Internet that enabled their difficulties has provided an avenue out of shame and isolation to deeper human connection. A group member who fears surrendering to the temptation of porn can choose instead to send out an e-mail for help and receive instant support. "Stand up, go drink a glass of water, go OUT, take the first train without even looking where it's headed," another member may reply instantly. "Start looking at things as if it's the first time, and you'll discover how we look at things only superficially."
"Porno-dependence gives us strong and uncomfortable emotions," posts the group's moderator Vincenzo Punzi, who's helped challenge the stigma of porno addiction by appearing widely in Italian media. "In order to get rid of those emotions, we need to find others." Today's online support groups, no longer chained to desktop computers and anonymous texting, can help create healthier emotions through stronger social bonds.
Should Therapists Self-Disclose?
In the psychoanalytic tradition, therapists were supposed to remain dispassionate, blank screens so that anything they "revealed" to clients resulted exclusively from the clients' projections and transference. But through the years, society's increasing informality and the expansion of the field to include social workers, counselors, somatic therapists, and clinicians practicing other approaches has resulted in a transformation of the classic therapeutic style. Now therapists and clients often use first names with each other and therapist self-disclosure—talking about their own past experiences or sharing their thoughts and feelings—once seen as "inappropriate," seems to be much commoner. Janine Roberts, creator of "Family Therapy Guidelines for Therapist Self-Disclosure" (Family Process, March 2005), who runs workshops for therapists internationally about the topic, says that, while there are no reliable statistics, almost every therapist she's spoken to on the subject admits to having done it. As often happens with changes in the profession, research and clinical guidelines on the topic have lagged behind. Now, in the February Clinical Psychology Review, University of Memphis psychotherapy process researchers Jennifer Henretty and Heidi Levitt have pulled together the research on the subject to propose some guidelines for when to self-disclose—and when not to.
The findings indicate that therapist self-disclosure can be effective but occasionally risky. Out of 30 studies, Henretty and Levitt found that 20 showed positive effects, 4 showed negative effects, and 6 had no clear effects or mixed results. The beneficial effects of self-disclosure include clients' experiencing greater warmth in their therapists and liking them more. According to their review of the theoretical literature on the subject, self-disclosure may repair ruptures to the therapist-client alliance, assist clients in identifying and labeling their own emotions, and provide clients with the experience and model of authentic communication. On the negative side, some studies have shown that clients who value separateness find self-disclosure to be intrusive or burdensome.
Henretty and Levitt conclude that self-disclosure should be used strategically and sparingly, and that it requires both forethought and afterthought. Before disclosing personal information, therapists should know the client well enough to have an accurate idea how the self-disclosure will be interpreted. After self-disclosing, therapists should check to see how the client responded, staying alert to the possibility that the intended effect of the self-disclosure may be different than the actual effect.
It's generally not advisable to self-disclose to clients with poor boundaries or who tend to focus more on the needs of others than on themselves. The former may interpret self-disclosure as a threat or a narcissistic injury, and the latter may feel obligated to reshape their own truths to match their therapist's view of life or to take care of the therapist. When therapists do share something of themselves, less is usually better than more, says Roberts. Telling clients, for example, that you were once in a similar situation can promote connection, but telling how you resolved it can rob them of their insights about the issue.
Are therapists better off avoiding these hassles and potential pitfalls and simply not self-disclosing? Given its effectiveness, Henretty and Levitt believe that therapists have an ethical obligation to consider incorporating self-disclosure in their therapeutic toolkit. "Although for decades therapists have sat quietly and comfortably behind a mask of anonymity," they write, "the theoretical and empirical research suggests that nondisclosure has risks and benefits that need to be weighed (as does disclosure)."
Virtual Reality: Virtually Better: www.virtuallybetter.com; Journal of Anxiety Disorders 22, no. 3 (April 2008): 561-569; Death Studies 32, no. 7 (August 2008): 674-92. Tears: Current Directions in Psychological Science 17, no. 6 (December 2008): 400-04. Hallucinations: Psychology and Psychotherapy: Theory, Research and Practice 82, no. 1 (March 2009): 1-17; Psychological Medicine 34. no. 8 (November 2004), 1571-1580. Teaching Therapists: Psychiatric Services 60, no. 5 (May 2009): 671-76. Porn: International Journal of Mental Health and Addiction 7, no. 2 (April 2009): 295-310; Cognitive Behaviour Therapy 38, no. 2 (June 2009): 66-82. Self-Disclosure: Clinical Psychology Review 30, no. 1 (February 2010): 63-77.
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