Wednesday, July 26, 2017

Your Therapist: It May Be More Who S/he is than What Kind of Treatment S/he Provides

There is now plenty of evidence that, on the whole, therapy/counseling is helpful to people with a range of problems, such as depression, anxiety, and addictive behaviors.  (The evidence was not always clear; way back when I was in grad school, there was a bunch of research questioning the value of talk therapy – but it turned out that lumping all therapists and patients together kind of averaged good and bad results.)  

Most of the research on the effectiveness of psychotherapy tends to focus on comparing this treatment with that treatment, or with no treatment.  Thus, you have a myriad of schools of therapy with their own particular techniques, each making a case that their approach is the most helpful one.  (They can’t all be right, of course, and findings that are not replicated across researchers and settings are of questionable value.) 

My own doctoral dissertation study compared a cognitive-behavioral alcoholism treatment with a “traditional” treatment.  I was not at all surprised to find, when I followed 50 people for a year after treatment, that there was no meaningful difference in their outcomes.  One recurrent finding is that the type of treatment makes less difference than many of the characteristics of the individual, such as whether s/he is employed (i.e., has structure), married (i.e., not alone), and hangs out with heavy drinkers. 

But probably the most important factor about therapy (though it is the subject of many fewer studies) is not the treatment model but rather the specific therapist and the therapeutic relationship.  A former classmate of mine, now a celebrated psychology professor, reminded me about this at a recent reunion – it’s not a new discovery, but resurfaces in different forms every several years.  The importance of the provider’s personality and the treatment relationship, in fact, also applies to strictly medical providers  – there is an increasing body of literature on how doctors’ and nurses’ attitudes and interpersonal behavior affect patients’ confidence and outcomes.

Generally, people beginning therapy, which sometimes means sharing some private information for the first time, need to feel that they are heard and understood, and to develop a sense of trusting the therapist.  Decades ago, the then-prominent Rogerian school of therapy emphasized that, crucially, a helpful therapist  shows a combination of empathy, genuineness, and warmth (or unconditional positive regard).  These conclusions have held up over time.  It appears that patient characteristics matter as well – those who make harsher judgments of themselves may also find it harder to trust or respond positively to a therapist.

It’s still worth learning about the treatment orientation, and particularly the experience, of your new therapist.  But if, after a few sessions, you don’t feel understood or trusting, it may be worth trying another therapist.  (If it happens repeatedly with one therapist after another, however, that’s can be a signal to examine what barriers you may be bringing into the sessions.)

Monday, January 30, 2017

The Role of "Self-Help" Meetings in Alcoholism/Addiction Recovery

Many, many outcome studies (including my own, decades ago) have shown a significant correlation between attendance at “self-help” groups and better alcohol outcomes (and, by extension, addictions to other substances, but this post focuses on alcoholism, which is currently being subsumed under the label of "alcohol use disorder" by those in charge of naming diagnoses). 

These groups would be more accurately labeled “mutual” or “peer support” groups – they are distinct from professionally run therapy groups and derive their impact from the power of community among people who are “in the same boat.”  And yes, correlational findings don’t prove causation, but I like to make an analogy to cardiac, orthopedic, or obesity patients advised to exercise – it seems obvious that those who join a gym and keep going are more likely to achieve sustained fitness. 

Note, too, that the fact that attending self-help groups improves your odds of improvement does not mean that no one is ever successful without such groups.  And some people probably also sustain fitness just by having a treadmill in the house. 

12-Step Groups.  Among self-help groups, of course, the most available and utilized program, by far, is Alcoholics Anonymous, the original 12-step program that, in the 1930s, grew out of the Oxford Group (what was then a recently formed American Christian organization).  AA emphasizes the importance of a “higher power,” which may be defined as a Judeo-Christian God but also in a variety of nonreligious ways.  The 12 Steps comprise a program of personal growth through processes including honest self-examination, acceptance that there are things beyond one’s control, and helping oneself by helping others.  But these steps are phrased as “what we did,” rather than “what you must do,” and there are no rigid rules or requirements other than a goal of abstinence from alcohol.  The myriad of healing factors in AA (many of them shared with other self-help groups) are too numerous to summarize here.

CBT-Based Groups.  In Massachusetts, where I practice, the main self-help alternative to AA for those who wish to stop drinking (or drugging) is called SMART Recovery (SMART stands for Self-Management and Recovery Training).  Like AA, meetings are free and the goal is abstinence, though people who are still drinking are not turned away (nor are they in AA).  SMART’s leaders have some training in running groups, and the program collaborates with affiliated volunteer treatment professionals and bases its techniques on the same kinds of strategies employed by practitioners of cognitive behavioral therapy (CBT).  Unlike AA, SMART has no steps or references to a higher power or spirituality.  There is also much less emphasis, in comparison to AA, on connecting with and relying on others in making one’s way on the path to recovery.  SMART grew out of Rational Recovery, a program that now eschews grew meetings in favor of website and publication dissemination of its methods; its primary method focuses on identifying and resisting the “addictive voice.”  Although AA certainly uses a number of techniques that could be considered types of CBT, it can be considered to place more emphasis on “heart,” “spirit,” and human connection, while the CBT-based programs emphasize techniques for changing one’s thinking.  As you may know, there are many, many more AA meetings available, no matter where you are, than any other kind of meetings addressing alcohol or drug problems. 

Secular-Emphasis Programs.  A nonprofit agency called S.O.S. (Secular Organizations for Sobriety) presents itself largely as a non-religious version of AA.  It was the brainchild of a man who had been raised in a oppressive Baptist family, and who could not find comfort in a religiously-toned program.  In addition, there is a sort of confederation of AA groups specifically geared for atheists and agnostics, known as WAAFT (We Agnostics, Atheists and Freethinkers in Alcoholics Anonymous).  Neither of these programs lists any meetings here in Massachusetts, but S.O.S. offers online meetings. 

Women for Sobriety.  This program has been around since 1976, also nonprofit.  Open only to women, it puts forth 13 affirmations that tend to place a greater emphasis, in comparison to AA, on loving relationships and self-esteem, but like AA promotes the idea of personal growth.  I know of no current WFS meetings in Massachusetts, and the WFS website does not seem to provide a meeting list (though it does offer and sell literature).   
Moderation Management.  MM is a program that, in a group format, allows people concerned about their drinking to monitor their attempts to drink in a non-problem way.  It seeks to prevent drinking from progressing to the point of alcoholism (which would imply that control of consumption is not consistently possible).  Many people who attend MM later conclude that the goal of moderation is not realistic for them and move onto an abstinence based program.  There appear to be no active MM meetings in Massachusetts. 

Professionally Led Therapy Groups.  Therapy groups, unlike self-help groups, involve a fee, to cover for the therapist’s time and overhead.  Health insurance may cover group therapy, but because the reimbursement rates tend to be very low, many group therapists only accept self-pay.  Groups can be led in many different kinds of formats, but in general there a less fixed format and more opportunity for so-called “crosstalk,” since a trained professional is in a better position to keep all such interactions constructive.  For reasons I cannot really explain, there are many fewer professionally run sobriety or early-recovery therapy groups (of the weekly, outpatient kind) than there were years ago.  Of course, time-limited inpatient and intensive outpatient or partial hospital programs are composed largely of therapist-led groups. 

“It Doesn’t Work.”  I’ve heard this phrase in relation to multiple kinds of self-help groups as well as other treatments.  To be sure, there will be aspects of any self-help group that will feel useless to a given individual at a given point in time.  But this phrase would usually be better phrased as “I didn’t find a way to make good use of it.”  Recovery isn’t something that happens to you; it’s not like getting a shot of penicillin.  It’s a process that requires sustained commitment, attention, and legwork.  You wouldn’t say (or perhaps you would), “exercise didn’t work for me.”  You might prefer biking to running, or you might feel more comfortable at Planet Fitness than at Gold’s Gym, but getting healthier depends primarily on daily continuity of effort.