The Science and Art of Psychotherapy: Insider's Guide

this program is a presentation of University of California television your support makes uv's programming possible contribute online at uv. tv/ support check out our YouTube original Channel uctv Prime at youtube.com/ uctv Prime [Music] Subs [Music] I am pleased tonight to be able to introduce my colleague Victoria lley Beckner an educator researcher clinician focused on the study and practice of psychotherapy uh Victoria is an assistant clinical professor at UCSF she's a partner in private practice at the San Francisco group for evidence-based Psychotherapy a group that's committed to the integration of Science and practice and Psychotherapy Victoria is a very accomplished researcher she has uh published uh innumerable papers on uh Psychotherapy for depression anxiety post-traumatic stress disorder uh and she also is very interested in the an understanding of how Psychotherapy might work uh in the integration of psychological factors and underlying changes in the brain that might be involved uh her research in that area includes a three-year fellowship at UCSF studying neuroendocrine effects of stress on brain lesions and symptoms in multiple sclerosis um Victoria has taught on Psychotherapy uh everywhere from uh ucss to the University of Rwanda uh she's been involved in training psychologists psychiatrists in those places has led innumerable workshops and seminars uh she is the lead author on a book on the psychotherapeutic treatment of trauma conquering post-traumatic stress disorder um and what makes it a real treat to introduce Victoria for this talk is not only her passion for the science of of Psychotherapy uh but also her passion for the personal way in which Psychotherapy changes lives so without further Ado Victoria Beckner so thank you Canon very much for that uh lovely introduction uh so it's delightful to be here tonight um I was really excited to be invited to give this talk um I will say that when I asked what the topic was and they told me the topic was Psychotherapy that I was somewhat intimidated by the breadth and scope of that topic and and what do you talk about uh for an hour and a half uh on the enormous enormous topic of psychotherapy so I pulled some of my colleag colleagues and friends I asked my mom what would you want to hear um some of Mom's suggestions got into the talk uh and actually was a fun process and putting to this talk together uh was was an enormous and educational experience for me so I've kind of pulled from the research in a lot of different areas to to really take on and ask and sometimes answer sometimes not some of the big questions about Psychotherapy uh so so some of those big questions are and this will be how I will organize my talk tonight Psychotherapy who needs it and um one of the things I just want to say from the outset is I'm a huge advocate of psychotherapy for everyone and and it's not just because I'm make my living at it I'm I'm a Believer and um you know hopefully by the end of the talk you'll see why um okay what exactly is psychotherapy um you got to admit like even those of you who've been in Psychotherapy it's kind of a mystery right like what's going on in that room and so even though there are a variety of different approaches to psychotherapy uh there are common things that we are trying to do and uh I want to just give a very brief overview of that just to sort of do what my mom said I needed to do which was to Define Psychotherapy so advocating for Psychotherapy saying what it is you know the big question is does it work and um I you know I can I can tell you right now unequivocally tremendous amount of research psycho theapy is hugely effective that's a good news the question about what makes it worse work is actually not nearly as clear we know that it works we know a lot about a lot of treatments um but the research into exactly how Psychotherapy works and what makes it work we've got some prelimin we we have some data I'm going to present that um tonight uh but it's a question that um is an ongoing passion of mine so let's start with Psychotherapy who needs it so I just want wanted to give a snapshot of the prevalence of um psychological disorders in the United States um the first bar um right here uh this is a lifetime prevalence rate so what that means is somewhere between 45 and 50% of the adult population at some time if they walked in and were and and saw somebody to assess them would be diagnosed with um some type of mental disorder the second bar here is just the 12-month prevalence rate so in any given year it's still a pretty large portion so sitting here today a third of the people would actually meet criteria for some disorder uh children uh is a little closer to about 133% this is also a a 12-month prevalence rate so this is probably not a surprise but the most common disorders that we see in private practice and um really are the mood disorder orders which include which most of the people come and have depression the other mood disorders include the bipolar disorders anxiety disorders as a group um actually you see more people with anxiety even than depression um substance use disorders is probably the largest group um and then uh I just wanted to list here um some of the other common disorders not not quite the you know what we see as often but this just gives you a feel for uh kind of what people are struggling with just want to give you a snapshot also of um disorders for kids you can see that again mood disorders and anxiety disorders are really quite common and then ADHD is also one of the most common disorders for kids so it's not just mental disorders that actually you know are an issue here um even if you are one of the lucky 50% who never actually comes down with a disorder um every person in this room has is going has and will experience significant life stressors so you know the big categories are um you know loss of a significant relationship through death or divorce or breakup lifechanging events uh role changing events retiring getting married relationship problems are a really um a big issue we get a lot of people to come into therapy with relationship problems a lot of people don't but um we have a lot to offer there and and health problems end up being a major stressor so so you know what I want to say is that you know between disorders and stress I think that there's a a big place for Psychotherapy um and and both of these really do take a major life toll so certainly there's uh a psychological toll um in the emotional pain um in the impairment that's caused the loss of work productivity um school grades dropping and then in sort of a bigger scheme you know when we're really struggling with something our our dreams are really put on hold you know we're in survival mode um so there's this huge psychological toll but there is also um a large physiological tool and so one of the themes of tonight's talk is that um mind and body are connected and when we're suff suffering psychologically there's also physiological correlates so you've probably all heard about the research on depression uh and heart heart disease and also um mortality after heart attack so this is just showing that um post discharge after a heart attack those people who have are very low on a measure of depression um actually have a pretty good survival rate but those who are scoring in the moderate to severe range of depression when they are discharged this is their survival rate so it just you know it's like it it has a physical cost as well and a big part of that has to do with um uh a lot of the disorders and just regular stressors activate the stress alarm system which is called the HPA system uh hypothalamic excuse me pituitary axis and basically what happens is is that when you're stressed the brain releases a series of hormones to release cortisol adrenaline is also released these are designed to actually activate the body to cope with the stress um but over time when you see chronic stress you get um all kinds of problems so just a couple of examples we have a researcher here researchers here that look at um stress cortisol and aging and um this is a study by Alyssa eel and what she showing basically is so a marker of Aging is the ends of your uh DNA have telr and over time as you age those telr get shorter well guess what stress accelerates that that's what this study shows this is a study uh done by my mentor David Moore uh and and he's just showing that um people who have multiple sclerosis those who have significant work uh work and relationship stress eight weeks later are more likely to show these are called galini enhanced MRI lesions it's basically brain inflammation it's what causes the exacerbations and the symptoms in Ms so it's again another example that when we're when we have disorders when we have stress it doesn't just have a psychological tool but it also has a physical tool so um you know I think that there are some of us in our generation who are pretty gung-ho for therapy but of course I I would say that there's a large part of the population who you know there's kind of there's still stigma Associated and and the attitude is I'm coping fine I don't need professional help and you know honestly I think that's true you know I think most of us can get through most you know most of life's hardships but what I would say is that you know we do cope but we cope In This Very automatic and conscious way and we learn to cope from our experience and what some of our natural coping strategies are but you know they're not always the most helpful or effective way to cope uh and in fact sometimes another term for them are defenses um and so there can be a cost in how we're coping and there isn't really a conscious Choice around how we're coping with these things well how do you learn to cope better how do you develop some kind of conscious Choice around what would be the best way to cope what I would say is we kind of need some courses on this I'm surprised it's not required at school and um at work and everywhere else you know like how do you cope with stress uh how do you have a healthy relation reltionship emotions oneone thriving through life I mean these are things that are not taught so we're just winging it when it comes to coping with our problems and so what I'd like to say is psychotherapy has something to offer to really step in and fill that Gap okay psychotherapy what the heck is it so in the broadest sense psycho Psychotherapy is designed you know usually brings people into Psychotherapy is some distress they're struggling with symptoms they're struggling with something in their life um but Psychotherapy also has a lot to offer on the positive side um for healthy behaviors well-being for defining our values and really creating a meaningful life um so actually it can it can do a lot um there are different modalities there's individual uh couples and uh family group Psychotherapy there's therapy with um kids and Adolescence and adults there are um many professionals who do Psychotherapy um these are sort of the main categories that you see um psychologists get a doctorate that's when I am um and our training is not just in how to do Psychotherapy or clinical practice we do a lot of training in the causes of disorders we get a lot of training in research and uh we get a lot of training and we do a lot of work on assessment assessment of um disorders and symptoms psychiatrists have an MD they're the ones who can prescribe medication and during their residency they also get training in Psychotherapy and then um the Master's levels the the big categories at least here in California social uh msws and mfts they get intensive um uh two-year training and then additional um hours a year or two of additional hours in in um Psychotherapy different approaches social work also gets they look at broader system level stuff as well so you know in the realm of mental disorders you know the psychiatrists are going to be able to prescribe medications Psychotherapy is the cure that's not the medication it's commonly called The Talking cure um but really it's a lot more than talking and uh the way that I think about it is it's a form of learning and some of it can be learning through knowledge and education and insight but a lot of it is experiential learning um and in many approaches it's not just what happens in the session there's also a lot of learning outside of the session so I think every here's probably pretty familiar with the fact that there are many many many schools uh or approaches to psychotherapy you may if you've been in Psychotherapy you know you you may have known what that was the therapist may have told you you may not but there there are some pretty different approaches just to give you an idea of some of the big um schools here um these are sort of some of the the big Cate ories but as I said there are many others and one of the ways to think about the different approaches or schools is that each are based on a different theoretical model about what causes the problems what causes the disorders what gets people stuck and then um what are the Curative factors in Psychotherapy how do we change things to address those problems and so each of these schools have their own model and their own techniques um that are designed to try to address that and I'll say a little bit more here and there about them but but this is an this is an entire semester class on this topic it's um I just wanted to kind of make you aware and and to say you know in the field the sort of psycho dnamic this is probably the most common approach in the Bay Area if you go to see a therapist they're probably psych dnamic or humanistic that's that's probably who you're going to see and in in the psychodynamic tradition there's a big emphasis on Insight understanding the origin of your problems uh and that that is a big part of the Curative factor in psychotherapy but also working with the therapy relationship um behavior therapy as you might imagine focuses a lot on how do behaviors get shaped and developed and do we actively change Behavior cognitive therapy came in and said hey beliefs and thoughts are an important part of this process and have a big effect on how we feel and what we actually do uh so cont to behavioral therapy sort of combined these Traditions we've got a whole third wave of Behavioral therapies that are actually um uh newer and um they tend to emphasize both the behavioral tradition active Behavior change but also rather than cognitive therapy which is about identifying and changing your thoughts they they emphasize mindfulness which is becoming aware and disengaging from your thoughts and then there are many others um emotion Focus uh interpersonal emotion Focus would be really really working zeroing in on the um Motion in the room and really working with that and so these are some of the just very quick um ways to think about some of these different um models but what I want to say and in the next few slides here you know continuing with this what is psychotherapy is I want to say that there's a tremendous amount of overlap in the different approaches and um and in fact research suggests that that many of the common factors of cross approaches um are what's really helpful um so I just want to give a a feeling for that so these are the these are some of the ways in which um we work with clients in the room these are our tools um different approaches emphasize different tools more or less but this is what's happening in the room so um I think if you have been in therapy one of the things that you recognize is that the relationship between you and your therapist is a pretty unique relationship and in some ways you can often come in and talk about things in a way that you might not be able to talk to your family or friends and um a big part of what makes uh Psychotherapy you know unique and different and a big part of what we're actively working to do is to help people really feel understood to create uh a safety and a bond that allows them to really open up about their um I say up here their Shadows but it's like our fears our weaknesses the things we feel ashamed about the things we don't want to talk about we sort of bring that out into the light and in the reflection of the therapist who is um holding a space and really trying to empathize and understand and give you unconditional positive regard and value is pretty transformative um and it enables people to take emotional risks with their therapists that they may not make with their with other people in their life and actually this is a new behavior and this is a new experience and this is part of the way people learn and so sometimes we talk about the corrective experience in Psychotherapy through the therapeutic relationship so so therapeutic relationship or Therapeutic Alliance doesn't just include that Bond and this is important because there's actually a lot of research on on Therapeutic Alliance so I do want to Define it it's also a sense of shared goals uh conceptualization of the problem and the plan so the client comes in with you come in with your goals and your values and then we do an assessment do you have a disorder what are the problems um uh what are the origin of the problems what what's what's maintaining it uh what are your strengths and weaknesses what's your coping style we're putting together what we know say about if you have depression you know I have a lot of hypotheses about why you know what's going on there but I'm putting it together with the individual and um and what you want in therapy and part of what my job is is and this is part of what builds Alliance is that you and I have to be on the same page um for do do are we on the same page for understanding what's causing the problem and what's the way through so um part of the therapy Alliance is agreement on this Inc CBT is Contin into behavioral therapy um so con behavi behavioral therapy is one of the approaches I use I actually also integrate acceptance and commitment therapy and humanistic approaches um and what I wanted to say though in in cont behavioral therapy this process of really conceptualizing and coming up with a plan is made very explicit in therapy and so for example I have a whiteboard and we map out what we think is going on you know so the client and I are actually breaking down and we're doing this over time what's really happening so this would be a client who's having relationship problems and we're really trying to understand what are the beliefs that are running how is she interpreting things what emotions are coming up how is what are her automatic coping strategies that aren't that helpful what do we want to start teaching her to do how do these feed back and so this is part of an explicit conceptualization process so education is also a big part this happen s in um all Traditions um again in some traditions it's much more explicit um but you're learning about what's going on um you're learning about emotions you're learning about your disorder um I do a lot a lot of work and anxiety that's really my specialty and so for example uh I'll draw on the board something like this if in one of the early sessions with someone with an anxiety client and I'm going to talk to them about really what's the nature of anxiety um how do you know it's an evolutionary system that it's adaptive it's a response to threat what's happening in the brain what's happening physiologically um and so on so I I'll I'll actually give them a lot of information and part of that is to take the fear out of the anxiety but it's also to really help the person learn how to effectively cope and and really understand what's going on because again all of this is a mystery because our parents didn't teach it to us our the school didn't teach us so um again we get a lot of information here so education is an important part I think of psychotherapy as uh also a course on emotions 101 so um emotions have an evolutionary role um that's why we have them uh they are a signal when we're feeling emotion that a core need is either being met or not being met uh it and the function of emotion is to strongly motivate certain kinds of behaviors so anxiety strongly motivates Escape or withdraw or freeze anger strongly motivates um aggression attack assertiveness and so on um the problem is is that uh the emotions that we kind of categorize as negative like like anxiety fear sadness guilt shame um are really uncomfortable States again they're designed to get us into action and to try to control things and fix things um and so they Propel us forward in a certain way um and that's an important thing to learn because part one of the skills that people learn in therapy is actually to learn to tolerate the feeling to feel your feelings to not run or fix or try to do something with the feelings and to go deeper with them and to really try to understand what's going on so we do this in session and there's a lot of uh attention put to emotion in session um and uh we in some tradition like what I do is we explicitly teach skills to tolerate um an uh different kinds of emotional states especially distress and anxiety which is key to being able to choose how to respond to something rather than to just react to something so okay so we talked about the therapy Alliance and insight and education as being components of psychotherapy obviously Insight is probably one of the first things you thought about what what is what the heck is psychotherapy um so you know one of the things that you learn when you come into therapy is kind of what makes you tick um you learn about kind of your relational style your attachment style um patterns of behavior um what I would call your automatic coping strategies um sometimes called the fenses um and how your history and experience have shaped these um and part of the reason that this is healing is that by just really understanding what's going on with you it really reduces shame it's incredibly validating um but I think the other reason that insight's important is it can motivate you to actually change things in your life so what I like to say about Insight is that it's necessary but it's not sufficient for Change and sometimes Insight itself can be very relieving and as I said validating but often we need to put that insight into action um yeah and in Psychotherapy we work a lot with thoughts and beliefs now this is a little different from Insight Insight is kind of how do I work but we we as we grow up um we develop our stories our story about who I am our stories about what other people are like our stories about what's right and wrong our stories about the world and this is another term for this is schema we have schemas about how everything is and how it should work and this is what makes the world predictable it's what makes makes it understandable um so this is how we understand things in in um our life the problem is is that often we have many schemas or beliefs that are um distorted or exaggerated or a little bit black and white or we we may have evolved pretty negative views of ourselves um so the thing is is that our core beliefs D um Drive how we interpret everything happening so right now objectively what's happening is I'm speaking I'm saying words but out there the funny thing is if we could see a little popup like this in each one of your brains you'd be saying radically different things you'd be interpretting you know one person be like oh this is totally boring and it's all science I thought we were going to get all juicy with transference and somebody else is is like wow this is really fabulous and blah BL you know and and but this is driven by our beliefs and and so we work with these in Psychotherapy um I was just going to say that um two approaches that do this pretty explicitly one is cognitive behavioral therapy where we map stuff out like this and we really identify the relationship between thoughts emot itions and behaviors in this cycle in mindfulness-based approaches there's a slightly different relationship to thoughts instead of trying to identify and in cont to behavioral therapy we we're actively trying to challenge distorted thinking um mindfulness is about actually just noticing observing and in a way stepping back and just disengaging it not taking the story quite so seriously so that then you can still make choices in your life and not be ruled by how you're interpreting things and finally and in my opinion most importantly maybe not most importantly but this is this is a huge part of my work is um we're very focused on Behavior change um so especially in in some of the Traditions that I I work in there's a very explicit process for um figuring out what current behavior what your current patterns are how they're getting in the way and what we need to do to change them so um so the therapy involves testing out new behaviors trying out new behaviors with the therapist like even the act of opening up and and accessing sadness for somebody who has trouble doing that that is a new Behavior they're doing in therapy um we also do behavioral experiments testing out things so somebody who thinks that they're a loser and they're never going to get a date well they get some homework assignments to go out and test that out and um uh there's also um techniques um such as exposure I'm going to say a little bit more that are behavioral techniques that really have a profound impact on anxiety and avoidance and so when we encourage people to try out new behaviors that changes things in two ways one is it enables experiential learning right you're not just sitting in the session and I'm saying oh really you're you're you're wonderful everybody would want to date you no you go out and you actually get the data so um the other thing is is that when people engage in new behaviors that data that evidence feeds back and starts to challenge and and change uh some of their core beliefs hopefully in a positive way um the other thing that we're doing behaviorally very often is actually teaching explicit skills some of these I've already mentioned but skills around managing emotion and tolerating emotion the cognitive and mindfulness skills of relationship skills communication assertiveness um how to how to accept differences uh problem solv thing there's also you know people have Sleep Disorders we teach sleep behaviors health behaviors and so on but the way that we get lasting Behavior change is really through deliberate practice and the creation of new habits right you can't do it once and you can't just do it with your therapist whatever it is you know you open up with your therapist but you never open up with anybody else you're actually not going to grow and change your relationships are not going to get better um and so there's an importance to practice in session where you have a relationship that is safe and controlled and you can test things out but then you actually need to go out in the world and do it and therapy can do that through homework or more informal ways in which you go out and do things and come back and process that with the therapist but there needs to be practice we need to create new habits of thinking and behavior and finally I always if I'm going to talk about Behavior I just want to say that this is all in the service really of trying to help you move towards your deepest values and where you want to go in your life that that's what this is in the service of so that was a very brief overview of the ways that we work some of the tools in psychotherapy so sounds good right you saw the problem why we should do why we should pursue Psychotherapy you've gotten a taste of what Psychotherapy is but it's a fair question to say does it work because as all of you know generally Psychotherapy is once a week it's time consuming it's expensive it asks you to do hard things um so you better be worth it right um so I'd like to address that so one of the ways that we can answer the question uh does Psychotherapy work is um through the research that's done through randomized control trials and you're all probably familiar that when a drug is developed how do you know if it's effective you can't just give it to people and people say oh it's great I feel much better because you don't know really whether it's the pill or it's thy or it's some other effect right so one of the things we do um in medicine is we set up a randomized control trial where people are randomly assigned either to a you know uh if it's medicine it's going to be the active pill versus a placebo pill and then your tracking outcome well uh a few decades ago it people started to realize gee maybe we should do that for Psychotherapy as well so this is just kind of a graphic of um a typical what's called an efficacy trial in Psychotherapy um so somebody comes in if this is a depression scale or an eating disorder scale or it doesn't matter what it is a alcohol use scale they come in high on the symptom scale and then what you're doing is you're seeing how does Psychotherapy do versus some control group and and in in the beginning it will be basically a weight list or tra treatment as usual um and so you're trying to see really is psychotherapy better than nothing it's better than better than right and you have you have to do that with a control group and so when you get this kind of an effect a difference you can have some confidence that actually Psychotherapy is making a difference so when you have there's there's kind of a tradition in Psychotherapy that if you have two very well-designed randomized control trials between a a particular Psychotherapy treatment and a control group and they both show the superiority of the Psychotherapy then we can say that we have an empirically supported treatment or an EST okay usually there are a lot more studies than two but that's kind of the gold standard that's the base the base that you have to jump over um but it's but then often once a a a treatment gets established it can be tested against um other treatments it can be tested against medication it can be tested against another form of psychotherapy uh they dismantling studies that look at are there are particular aspects of psychotherapy that work and um so an example relative efficacy then would be a comparison between two Bonafide treatments to see does one win you all wanted a stats lesson today right you come to a Psychotherapy Les talk and you get a stats lesson um I just want to just a couple of terms just to clarify since I'm going on so when you get a a a group difference we talk about that is it statistically significance basically means is there and the tradition is a uh 95 or greater chance greater probability that it did not occur by chance so what you say is we can be confident that there's a difference but that doesn't tell us how big a difference it makes and so that's where we get effect sizes which is a standardized way of understanding the difference between the two groups and this is kind of a convention for um coin D which is a is one of the ways to measure effect size so this would Point 2 would be a small that's a small difference between group means this is a medium or moderate and this would be a large um so this is need to remember this because we're going to be talking about it later um and then just to define a met analysis A met analysis is a way of comparing lots of treatment trials and aggregating them to be able to come up with basically a um an aggregate effect size that can that starts to make us feel a little bit more confidence not just one trial here one trial here but in looking at all of them how effective so here's the effect size for Psychotherapy in general this is based on studies that look at multiple Med analyses this is actually summarized by Bruce Wold who's done a lot of this work and the bottom line is that Psychotherapy which basically has an effect size of about about 8 that's a large effect size you're sort of like okay it's kind of hard to measure that but if you just compare it to a couple of medical interventions you start to get a little bit of a feeling right so aspirin definitely absolutely a significant has a significant impact on heart attack but the actual size how how much how protective it is very very very small so it's a real difference but it's a small difference um SSR Ando pressant such as prac or SOA for depression um moderate Effect size. 3 to.5 in general uh medication for lower back pain also on the moderate level and so on just to kind of give you a a sense here and in terms of improvement rates 50% improve Within sessions half get better at 14 and many people just go on to be um nonsymptomatic uh within 2021 and even if someone's not coming in with symptoms per se symptom measures are a good marker for other problems and and so this is really saying you know people are getting better this is a graph of kind of the typical symptom Improvement that you um see in psychotherapy so Psychotherapy works it's a big effect it impacts symptoms but I also along the theme of the Mind Body Connection want to say that Psychotherapy doesn't just affect the mind it also affects the brain and this is this makes sense right this is probably one of the reasons why it works so this is a study that I love this is a really brilliant St was a series of studies actually by Baxter and Schwarz um and what this shows here is this is a brain of somebody with obsessive compulsive disorder and what you see here are is increase activation in an area of the brain the the right cadate nucleus part of the basil ganglia and also in the thalamus area sorry I've got yeah and what you see this is before treatment now if you treat the person with a medication um what you see is you see this decrease and overactivity of those areas of the brain that are associated with OCD um the interesting thing is if you treat them with conary behavioral therapy which is a Psychotherapy you also see this sustained change in Baseline activity of the thalamus and the cadate nucleus I think that's pretty cool and certainly there have been a lot more studies to show this but um you know just like stress T can have an effect on the brain and body Psychotherapy which is a psychological intervention can feed back and have an effect on the the brain and the body this is just another example this is a mindfulness intervention and um just uh by uh Philipe golden who's at Stanford and also a friend he um he showed that before Psychotherapy you see this pattern this is of activation of the amydala which is this um area of the brain involved with anxiety and anger and you can see there this is actually just symbolizing kind of avoidance and then intense reactivity after um mindfulness-based stress reduction therapy you actually see people much more willing to approach um these are actually threatening negative self- thoughts and are much less reactive to them afterwards another study by my mentor looking at how a treatment for depression also reduces pro-inflammatory cyto kindes which are really problematic in say multiple sclerosis and other autoimmune diseases so again effects on the immune system all right so that data that I just presented was really addressing the question overall is psychotherapy effective and and I hope by now you can walk around and tell people yes it is the effect size is about 8 it affects immune function it changes brain function symptom profile looks like this okay that's what you need to tell your friends when they ask you why you're in Psychotherapy okay 88 effect size um what that doesn't answer is the question why what is it about Psychotherapy that's effective right I gave you a description of kind of what what we're trying to do in psychotherapy but it's a it's a different question what what is actually you know what is predicting outcome and I I want to say before going into this section that the truth is is that we have a lot of data about how certain treatments are effective we actually have very very little data about what it how the person is changing what are some of the factors within Psychotherapy that really predict outcome so to me this is kind of the Wild West there's a lot of data and and I'll show you this now um that we can say that there are a lot of treatments that are effective but why is a little bit more of a mystery so here are some of the big categories of research as to what makes Psychotherapy effective so as I mentioned here and where I'll start one of the things that makes Psychotherapy effective is the particular treatment or approach or right so that's what all those randomized control trials were and I want to talk a little bit about that this is this is the main thing that our field has been researching it's like the question's been well is psychotherapy effective okay which treatments are effective and I can tell you now we know a lot about What treatments are effective and the bottom line is is that most treatments that are bonafied treatments are effective to some degree and so this is good and this is why you get that aggregate effect size of 08 right that's across all treatments and approaches um so I want to talk a little bit about that but there there are other factors that actually get a lot less attention and that is um there's certainly a lot of research talking about how the Therapeutic Alliance actually predicts outcome uh there's a there's a little bit of research on client effects and that's probably no surprise just the idea that of course what you bring to therapy probably makes a difference but there you know it's not as it's not as research and um there's also data to say that um deliberate practice and giving homework in Psychotherapy is effective and also monitoring progress and the therapist has an impact so I want to talk about each of these so we have now had decades uh and decades maybe three decades of research looking first establishing just whether a treatment is effective versus control but then you know over time trying to get effect sizes for different treatments comparing them to others and the truth is what all of that data says and there's been some really brilliant um summaries of metaanalyses um has shown is that you know for many disorders most treatments work and that's good news right you walk in and you know um in some ways well I'll say a little bit more about where uh treatment May matter but overall you're probably in good hands um let me just say however that the effect sizes do vary a little bit for different treatments for different disorders and so um that's an enormous literature which I cannot review here and in fact it's hard to find review paper even just all the treatments um for one disorder is it's an enormous amount of literature so I'm going to be giving you the big picture but let me just say the fact that we have we do have so many empirically supported treatments that are better than control um and tells you actually that whatever it is that all these different approaches have in common has powerful Curative effects right um it's not that every one of these is doing something totally different and then uh and miraculously they're all coming up with the same findings right um there may be different mechanisms of change but there's also some common mechanisms of change let me also just say that in this literature some um approaches have been studied more so cognitive behavioral therapy is a great example it came out of a research tradition uh it's you you get that training I got that training you know at sort of research oriented universities um all the early studies were CBT studies there's there's just an enormous amount of data and so CBT basically has enormous amount of support but that's partly because it's been studied more um if other approaches have have less data it may mean that they just have been studied less or it may mean they're less effective it's sometimes hard to tell um but what I want to do is give you a big picture on uh depression and anxiety disorder since these are two of the biggest categories um of problems that people struggle with so you can see that the um bottom line for depression is um it's a quote by the dodo bird in aliceon Wonderland it is all have won and all must have prizes and this was the dodo birds comment when Alice wanted to have a race and everybody just ran off in different directions but but the idea is that so this is kind of a a good example study this is a study I worked on with my mentor it is um comparing two Bonafide treatments for depression one was ctive behavioral therapy the other was um supportive emotion Focus therapy um it was actually uh delivered by telephone so it was a telephone treatment um and what you see here is um sort of this is the end of treatment right here and what you can see actually at the end of treatment CBT wins over EFT um and uh this is you so you get this but here's what's important in a treatment trial is that you also once this treatment stops you want to track over time what happens during followup and what happens in followup is basically people in both treatments continue you know in CBT they maintain their gains and they continue to get better in the EFT group so in the end they're actually comparable at followup and this in the early days when cognitive therapy and ctive behavioral therapy were the most studied you know the the the the research Community could say with some confidence you know cognitive therapy cognitive behavioral therapy is the most effective treatment for depression but as we have studied over and over again almost every approach to depression is effective and um so in enormous metanalyses you just find that you could you can really um seek treatment from for from any kind of a therapist any approach for depression and they tend to be equally effective um and that's important but when it comes with uh comes to the anxiety disorders there's actually a little bit of a winner and um so the data does suggest that um treatments that use exposure such as cont to behavioral therapy um and all the specific therapies underneath that um uh do tend to be more effective for anxiety and I just I want to say a little bit about this because this is a pretty important finding it's it's my area feels important to me um but uh so one of the things that we actually know not from the Psychotherapy literature but from fundamental research both animal research and human research isn't one of the ways one of the mechanisms by which we develop anxiety or fear of certain situations or things is through classical conditioning and we have an area of our brain the amydala that's designed to remember frightening situations and all of the cues associated with them so you know if you are on uh a bus and that bus gets into an accident your amydala is going to remember everything about that the person sitting next to you the time of day the bus um uh the area of town um cars being in accidents it it it's going to remember everything and that's one of the ways that we learn what's dangerous in the world so there's this ongoing constant process of conditioning either big conditioning or little conditioning and a lot of anxiety is linked to conditioning it's it it interacts also with what we actually learn we may learn that something is dangerous um like riding a motorcycle having never been on a motorcycle you know you may know that and have some anxiety from the knowledge but it also comes from this experience so you you can create phobias very quickly in Animals by just doing um classical conditioning and uh they used to do that with humans way back uh before the ethics committees stepped in um but so the question is once that part of the brain this is not a conscious part of your brain this is part of your lyic system learn something it holds on to it you're not going to unlearn that anxiety unless you have a new experience unless you learn that that situation or that thing is not dangerous and so what happens is is that um through again fundamental research they realize that if you expose the subject to the faar object whatever it is it's a snake or it might be taking somebody back onto the bus um if you do that and you keep them in the situation their anxiety is really high but you keep them there long enough that their brain starts to see nothing bad is happening anymore their anxiety starts to come down they habituate in the situation and then you do that repeatedly that is how we unlearn conditioning that is one of the most powerful mechanisms of change for anxiety and so exposure therapy is based on that it is based on exposing people to the things that they fear it's technical term is extinction of the conditioned fear response and one of the most one of the most important impact that that has is that the things that we're anxious and we're afraid of we avoid and that may get in the way of our life and have a big impact on what we do and our choices and so to be able to overcome that anxiety and overcome that avoidance is a pretty profound change for people in their lives so um the approaches that have really developed this have been behavior therapy and cognitive behavioral therapy but let me just say that exposure is also happening in other forms of therapy so when you're really afraid to experience an emotional state and your therapist encourages you and creates a safe space for that that's a form of exposure and you're doing it and you'll be anxious but then as you do it you will start to see that it's okay oh I can feel my feelings I'm competent to feel my feelings oh this person is not going to think I'm weak oh she still cares about me there's a learning experience that happens in the amydala is literally learning oh okay I can do this so it happens informally in your life and in Psychotherapy as well but there just some approaches that really uh do it in a very structured way and that's why I think CBT and uh tends to win in the competition of what's the most effective treatment for particularly these anxiety disorders especially obsessive compulsive disorder panic disorder and phobias and to a certain extent PTSD as well so um there are many people here tonight who have some of these issues and it's just important to know there's a really really effective treatment for that and that's a that's a really hopeful thing I just wanted to give an example with panic disorder of like sort of you know the summary of the treatment some of the treatments so there have been you know so a lot of you know a lot of the treatments are kind to behavioral therapy versus control establishing efficacy but a lot of them have been comparative trials against other approaches and CBT even beats medication for panic disorders as well um so again this is a disorder that is 3% of the population it's where people have spontaneous panic attacks and they worry about anxiety and they avoid situations they develop agoraphobia it's a very impairing disorder um and there is a really effective treatment for it so that was talking a little bit about specific approach or treatment um but these are important too so let me say um when it comes to therap Therapeutic Alliance so this is the therapy Bond and shared goals and shared plan um there is very very robust evidence that the quality of the therapy Alliance predicts how well you will do in Psychotherapy this is actually really important this doesn't have to do with any specific approach this is across approaches um and let me just say here there's been a lot of criticism of This research um because people will say well maybe people start to get better and then they like their therapist more because of that right it's a you know in a lot of these studies it's basically it's a correlation you can't conclude causation from correlation um but there have been studies that have controlled for early change and found that the early therapy Alliance the nature of that relationship reliably predicts outcome so there's a bottom line with this right if you're in therapy you better be feeling it with your therapist you better feel like you're on the same page you better feel like it's a good match and and as a therapist I have to say I'm thinking about that too if if early in the therapy me and the client are not clicking there isn't that Bond we're on a you know their conceptualization of what's going on and how they need to change is really different from mine I know that that is that that predicts a poor outcome I'm probably going to refer that client if I can't get on the same page and that's what I should do because they might actually do well with another therapist so clients also bring their stuff to therapy and um there's been certainly research on um stages of change where how ready are you for change how motivated are you and to to do the work of psychotherapy so so that is one of the factors clients who are higher uh who are further along in their Readiness for Change and highly motivated do not surprisingly do better in p therapy um hope hope that the therapy is going to work and expecting that it would work is also a Curative Factor what does this sound like I hear in the placebo effect which Placebo doesn't mean that it's an imaginary effect it's a real effect right it's so real that every drug study has a placebo right like hope and positive expectancy has physical and psychological effects it's a big effect I think it has an effect size of something like three so um so that's actually important and that's that kind of goes back to the alliance right if you believe in your therapist and you feel like you're working well together you're going to have more hope and you're going to believe you're going to change and that affects outcome so engagement uh and you know the an ability to learn to have new experiences you know some people come in and they want to change but they don't really want to think differently they don't really want to do anything differently they kind of come in they fold their arms and they're like make me better and it's not going to work right because the client has a huge power you're the ones who actually do it right when in some sense you know we're we're your warm empathetic coach um I also just want to say this goes back to my point that we have to be encouraging work outside of the session and there is research to support that homework uh in Psychotherapy predicts outcome now why would that be um I've already just mentioned the need for deliberate practice and the creation of new habits there's also a whole literature called expertise literature on how people really develop expertise at different things like chess and swimming and Mathematics and you know how do people really get better at whatever it is they're trying to do they have to have clear goals and they have to be actively practicing new behaviors and um they have to be shooting for that and they have to be doing it over and over and over again right so that sort of suggests it's not enough to just do it in the therapy room you got to be doing it outside um I I I also like to say that there's a physiological dis you know explanation for this you know your old habits have very well-worn neural Pathways if you're going to change something in a lasting way you have to not only lay down some new neural Pathways you have to drive over them over and over and over again that's how we create a new habit so this is laying down in strengthening neural Pathways in the brain and it is associated with better outcome that by the way was a typical that's that would be like a typical homework list for one of my clients so feedback and Progressive progress monitoring so in all those randomized control trials those were examples of how differences between group means right this group of people who got this treatment did better than this control group what that doesn't tell you is the individual who's in my room who's in my session are they getting better right so randomized control trials are they're not individualized you know they they're they're clients that are picked for generally one disorder so they exclude everybody who has multiple disorders you know they're very clean and but the person who comes into our office is a messy human being with probably complicated things going on sub threshold depression a little anxiety here they got some relationship problems they're drinking a little too much they don't meet criteria like right they've got their strengths they've got their weaknesses and one of the things I want to know is is this client getting better and um so one way to do it is to use traditional outcome measures which is what they use in um psychother in randomized control trials you take a symptom measure so I might measure anxiety and depression and see how that's changing over time with my client but also you want to measure some of these other things that we know affect outcome like the therapy Alliance um how much how homework completion U but also um I often include measures about the thing that I'm trying to Target in therapy what I'm trying to change maybe it's a belief maybe it's a more specific behavior maybe it's the the size of the person's support group um maybe it's how easily they can access emotions in session I I'm going to be tracking what's happening with the client and what the research shows is that when therapists get feedback about how their clients are doing and this is Mo this researches on outcome feedback um it improves outcome so why would that be um so you you want to do it because the research says it's helpful let me just say that but I think you can kind of understand why I mean the truth is is that like I have this client right now who um he's fabulous he's like really psychologically minded and he's really motivated and he comes into session and the hour goes like this and we're like we're doing this fantastic work together and like if any of my colleagues would say you know um how you know how's your therapy going I might say oh I've got this client he's doing great but what's interesting with this client is I'm also measuring outcome and a couple of the mechanisms that I think is maintaining his anxiety and depression one of them being say is perfectionism perception of harm some other things and when I so we've been working for six months and when I look at his measures he is not getting better he loves me he's like we're having the best therapy time right he could be in therapy forever but he's not getting better like it's not working and and if I didn't have the measures I wouldn't know that right that's part of what I'm saying is that you know we therapists we do this because we care because we want to help we want to believe the person's getting better if they're coming in and they like us we think they're getting better you know it's like we have our biases we want to see that that's happening um and you know the other thing I'll say is that we also start with a conceptualization of what we think is happening and how we want to work and this is a cognitive bias in all human beings we get stuck in our initial way of looking at it and then we just keep trying to confirm that over and over it's called confirmation bias we we do it everybody does it so you need something outside of you to indicate you the you the therapist that in fact people are changing and as an outcome measures is basically a measure of distress you know if they're changing if they come in and they want their relationships to improve if their relationships are improving their distress will go down I mean it's a good marker or barometer of how your client's doing so this is just a example I I this is a form that um a few of us developed I I want to acknowledge Jackie person's here uh Janie Hong um we developed this this is it started off just as a homework form um but what I was interested in is I was sort of measuring aspects of Alliance and then we the form sort of evolved but basically this is a form that a client comes in and at the end of session we write down the homework uh we um and they fill this out and one of the things it says is what do you want to remember from the session like what's important to them what did they learn what do they want to hold on to I also explicitly ask what didn't you like what bothered you right cuz I also want negative feedback because that's important to the alliance too if things are not working I want to know and I we get some of these measures and um you know how did you feel understood in session how effective was the session was anything confusing I'm gathering all this data from my client right and then and um they have their homework assignment and then they indicate how helpful the assignment was right and part of this is is like we need to work together to find out what's working you know and and so on so um I use this form and I don't use it with every client there are definitely clients who are like not going to do it all right you don't have to do it or they'll like you can write down my homework but I'm not filling out the rest like all right um but it works with a lot of my clients and this is an example this is probably one of my most common outcome measure it's called the D it's the depression anxiety stress scale it's 20 Questions uh for many of my clients who come in and are elevated with anxiety and depression um I'll have them fill it out right before they come in every week and so what we're doing is we're tracking so here this is a client of mine came in um the are elev this is the stress scale the depression scale and the anxiety scale came in pretty depressed moderate anxiety High um they're actually on different relative scales but and and pretty stressed and this is kind of the pattern you want to see that over 24 sessions anxiety and depression in the normal range stress here has been normal range but you can see actually that this is somebody who gets goes through periods of stress but at least a couple of our Target things have moved down into the right area that's helpful and by the way sometimes clients will be um convinced that they're not getting better they're like oh I feel nothing ever changes and you know you pull this out and you're like really look at this wow and like I'll have them look at what they filled out at the beginning and what they filled wow they've like forgotten actually how distressed they were um so it can be helpful too in that way so finally the therapist has an effect on outcome and that may seem obvious too kind of like the client has an effect on outcome it's like I think everybody you know they they they're like who do you recommend you know who's the best out there who does you know Eating Disorders or who does you know personality disorders whatever um and uh I think you know we we sort of know of course there's going going to be differences between therapists I have to say that this is an area of research that's pretty um minimal I don't think we know a whole lot about what makes therapists better but here's what we do know this is a couple of studies at large counseling University counseling centers with hundreds maybe actually thousands Canon thousands of therapists this is a big big sample size and what you see is they they have the clients fill out outcome measures and they basically they if you look at the therapists with the lowest outcome scores across all their clients and those with the best you see these enormous differences there there really are some therapists who are reliably reliably bringing down symptoms and other therapists and not only are the person not getting not improving they're actually getting a little bit worse and you can imagine how this is if you're not getting better you're going to start to get demoralized right and you're like here you are in therapy and that's not even working so I mean so um let me just say that um it's a hard job being a therapist so I I sort of want to say that um again here's here's one of the things that we know years of experience is not related to therapist effect Effectiveness I have to say that's kind of discouraging for some of us who go out and get more and more train like your you and and I subjectively I keep I feel like I'm getting better and better but and maybe I am maybe some so maybe what's happening is some therapist they they learn how to do it and then they just kind of do the same thing forever maybe some of us are working hard to constantly improve and learn and we don't really know but basically um experience is not correlated with outcome for therapist Effects by the way it's not correlated for doctors and their outcomes either just an except actually in surgery I don't I think actually and you can see why right so so this is some of the stuff I think about this is kind of a summary of what we went over like so it is a complicated job um I think therapists have different models and things that they take into account you know I'm try from what someone comes in with a problem I'm thinking what are the empirically supported treatments I want to draw from I'm also thinking about fundamental research in other areas I'm thinking about how do I make an good alliance good goals make sure I do homework there's also some research that flexibility is important with therapists I'm monitoring progress and I'm integrating all of this with the individual with the client with their goals their values their preferences their history what makes them tick right it's complicated and that that's how I do it I every therapist you know is kind of putting together things but but even in the area of you know working within one tradition you know you could you know it's a lot of work to become really really good at anyone approach so it's a challenge um I want to sort of end here with uh the American Psychological associations sort of their statement about what evidence-based practice in Psychotherapy is um so evidence-based practice is the integration of the best available research with clinical expertise in the context of patient characteristics culture and preferences it's a tall order I'll say for some of my friends in the audience who are psychotherapists out there that um it is hard but we love what we do it's a total privilege what we do um and it's been really great to be able to share some of that with you today thank you so we um actually have time for 15 minutes of questions I know looks like some people need to go um and then afterwards if you have other questions I'm happy to stick around yes okay so the question was how do you choose an effective therapists and how do you know sort of their General outcomes um there stats their stats you know they're only now starting to collect the stats on in the medical field and they really there's no there is no way to know what's that Yelp so Yelp and the online stuff I have to say that's not a probably a reliable way right because probably the most likely thing is you get one disgruntled client who writes a terrible review of you or somebody who loves you and that doesn't you know that doesn't really say right um how do you pick it so I I think I would say a couple of things I mean if you've got depression you can go to somebody with any from any tradition right I would say that if you have an anxiety disorder you probably want to look for somebody who does kind to behavioral therapy or at least integrates that into their approach Maybe some of the other Behavior therapies as well um you want to look at someone who's good at establishing an alliance right you want somebody who's working with you like if it's not working they're going back to the drawing board with you right and so they're flexible they're willing to say wow I'm not doing a good job or this isn't working right um so those are some of the things that come to mind yeah yeah I mean so so Psychotherapy with Children First of all not I I work with adults so I'm going to say that um it's not really my area there are studies with children that look at different treatments um but it it is complicated right often they're not motivated or they didn't choose and that's one of the things that makes work with children much more challenging I think but there is data on that certain treatments for for different problems just for example one of the most common problems are like behavioral problems ADHD uh conduct disorder acting out and again there's a lot of research to support behavioral interventions for those problems right so that that might be um an example does that answer your question okay hi right here she says she has a a high ECT and yet her question is she's really asking have there been treatment studies comparing Psychotherapy to talking to your friend every week you know there haven't but there should be um you know I actually think that that is really helpful and I think people know that intuitively right it is helpful especially if that person is willing to really listen especially if they're willing to make space here's something though that people who are not trained professionals don't do well you you're my friend and you say oh my God I'm really struggling with this the instinct is to stay let me tell you how to fix it have you tried this have you done this have you done this what about this have you tried this um you know try this herb drink this go do that right the fix it impulse is in is there and that's because when someone comes to you with distress it makes me distress and then I want to fix it okay it actually a big part of training in Psychotherapy is overcoming that urge and learning to be like tell me more about how suicidal you are tell me how Bleak the world looks to you tell me how you are sure you know it's like let's make that space and people really need that so that's actually just one difference and then of course A friend is not going to have all the training and all of the other things that we do and it's complicated with a friend because when you're talking to a friend there's a there's a mutual relationship you're also going to be sort of taking care of their feelings and you're not going to want to reveal too much that then like maybe they're going to change their view of you and you there's all the stuff you don't have to worry about Str oh a stranger well the Stranger On The Bus well yes yeah that that piece is taken away with the stranger yeah okay question is you uh what about length of therapy or closure so um many of the treatments that have been studied have been short-term treatments um short-term being generally 3 to 6 months and um many of them are are very very effective it depends a little bit on the issue um a typical treatment for panic disorder you know very often if it's a sort of a pure panic disorder three months they're better right but they come in and it's complex relationship issues and chronic depression it's going to be longer term but all of these approaches have short-term treatments that really try to accelerate that work but one of the ways what what's helpful is actually to set goals and have a time frame that you're working on even with my long-term I have clients I have a I have clients I've I've seen for seven years um but part of what we're doing is we set goals and work within that and see where we are and then we'll set new goals and this is you know these few my longer term clients they've got multiple problems it's it's lifelong but we're making active progress towards specific things and that's part of what makes it work it's not just like they're just coming in every week right so I think if it's longer term you need to have that frame those goals that kind of thing but short-term therapy for many problem is very effective so the about closure um yeah you know it's interesting I think that you know sometimes the client comes in and thinks hey I'm feeling better I'm I'm kind of wanting to wrap up sometimes the client keeps coming and I'm like I think you're better I think we should be wrapping up um or we need to be setting goal like what are we working on here because you know um you know I I think it's really driven by the goals and you know definitely some people um find therapy valuable as you know who are in therapy off and on their whole life and get a lot out of it and want and want to stay and you know I've got I've got a couple of those as well and you know as long as there's a clear understanding what it is that we're we're doing um and then when you're wrapping up therapy I think there's a whole process for doing that and to try to really make sure that that's Mutual thank you very [Applause] [Music] much [Music]

Channel: University of California Television (UCTV)

Views: 92,018

Keywords: Psychiatry, psychotherapy, cognitive behavioral therapy, CBT

Id: 2J3DLFMsGaE

Length: 89min 9sec (5349 seconds)

Published: Fri May 18 2012