Cognitive-bias modification may put the psychiatrist’s couch out of business
THE treatment, in the early 1880s, of an Austrian hysteric called Anna O is generally regarded as the beginning of talking-it-through as a form of therapy. But psychoanalysis, as this version of talk therapy became known, is an expensive procedure. Anna's doctor, Josef Breuer, is estimated to have spent over 1,000 hours with her.
Since then, things have improved. A typical course of a modern talk therapy, such as cognitive behavioural therapy, consists of 12-16 hour-long sessions and is a reasonably efficient way of treating conditions like depression and anxiety (hysteria is no longer a recognised diagnosis). Medication, too, can bring rapid change. Nevertheless, treating disorders of the psyche is still a hit-and-miss affair, and not everyone wishes to bare his soul or take mind-altering drugs to deal with his problems. A new kind of treatment may, though, mean he does not have to. Cognitive-bias modification (CBM) appears to be effective after only a few 15-minute sessions, and involves neither drugs nor the discussion of feelings. It does not even need a therapist. All it requires is sitting in front of a computer and using a program that subtly alters harmful thought patterns.
This simple approach has already been shown to work for anxiety and addictions, and is now being tested for alcohol abuse, post-traumatic-stress disorder and several other disturbances of the mind. It is causing great excitement among researchers. As Yair Bar-Haim, a psychologist at Tel Aviv University who has been experimenting with it on patients as diverse as children and soldiers, puts it, “It's not often that a new evidence-based treatment for a major psychopathology comes around.”
CBM is based on the idea that many psychological problems are caused by automatic, unconscious biases in thinking. People suffering from anxiety, for instance, may have what is known as an attentional bias towards threats: they are drawn irresistibly to things they perceive to be dangerous. Similar biases may affect memory and the interpretation of events. For example, if an acquaintance walks past without saying hello, it might mean either that he has ignored you or that he has not seen you. The anxious, according to the theory behind CBM, have a bias towards assuming the former and reacting accordingly.
The goal of CBM is to alter such biases, and doing so has proved surprisingly easy. A common way of debiasing attention is to show someone two words or pictures—one neutral and the other threatening—on a computer screen. In the case of social anxiety these might be a neutral face and a disgusted face. Presented with this choice, an anxious person instinctively focuses on the disgusted visage. The program, however, prods him to complete tasks involving the neutral picture, such as identifying letters that appear in its place on the screen. Repeating the procedure around a thousand times, over a total of two hours, changes the user's tendency to focus on the anxious face. That change is then carried into the wider world.
Emily Holmes of Oxford University, who studies the use of CBM for depression, describes the process as like administering a cognitive vaccine. When challenged by reality in the form of, say, the unobservant friend, the recipient of the vaccine finds he is inoculated against inappropriate anxiety.
In a recent study of social anxiety by Norman Schmidt of Florida State University and his colleagues, which involved 36 volunteers who had been diagnosed with anxiety, half underwent eight short sessions of CBM and the rest were put in a control group and had no treatment. At the end of the study, a majority of the CBM volunteers no longer seemed anxious, whereas in the control group only 11% had shed their anxiety. Although it was only a small trial, these results compare favourably with those of existing treatments. An examination of standard talk therapy carried out in 2004, for instance, found that half of patients had a clinically significant reduction in symptoms. Trials of medications have similar success rates.
The latest research, which is on a larger scale and is due to be published this month in Psychological Science, tackles alcohol addiction. Past work has shown that many addicts have an approach bias for alcohol—in other words, they experience a physical pull towards it. (Arachnophobia, a form of this bias that is familiar to many people, works in the opposite way: if they encounter a spider, they recoil.)
This study, conducted by Reinout Wiers of the University of Amsterdam and his colleagues, attempted to correct the approach bias to alcohol with CBM. The 214 participants received either a standard addiction treatment—a form of talk therapy—or the standard treatment plus four 15-minute sessions of CBM. In the first group, 41% of participants were abstinent a year later; in the second, 54%. That is not a cure for alcoholism, but it is a significant improvement on talk therapy alone.
Many other researchers are now exploring CBM. A team at Harvard, led by Richard McNally, is seeking volunteers for a month-long programme that will use smart-phones to assess the technique's effect on anxiety. And Dr Bar-Haim and his team are examining possible connections between cognitive biases and post-traumatic-stress disorder in the American and Israeli armies.
Not all disorders are amenable to CBM. One study, by Hannah Reese (also at Harvard) and her colleagues, showed that it is ineffective in countering arachnophobia (perhaps not surprising, since this may be an evolved response, rather than an acquired one). Moreover, Dr Wiers found that the approach bias towards alcohol is present in only about half of the drinkers he studies. He hypothesises that for the others, drinking is less about automatic impulses and more about making a conscious decision. In such cases CBM is unlikely to work.
Colin MacLeod of the University of Western Australia, one of the pioneers of the technique, thinks CBM is not quite ready for general use. He would like to see it go through some large, long-term, randomised clinical trials of the sort that would be needed if it were a drug, rather than a behavioural therapy. Nevertheless, CBM does look extremely promising, if only because it offers a way out for those whose answer to the question, “Do you want to talk about it?” is a resounding “No”.
Cyber Therapy
Today many doctors today say the best high-tech treatments are ones you can download from an app store. A trend in digital bootstrapping, using simple technology to solve complicated problems, reveals that the best cure isn't always a brand-new drug or gadget. Sometimes a simple iPad app or game can transform a troubled treatment into a successful therapy.
This was the topic of discussion at a talk presented by Anitko's Kel Smith at the WorldFuture 2012 Conference held from July 28 to 30 in Toronto, Ontario. Smith has made a career of exploring and developing "barrier-free" digital experiences — particularly for those who need it the most.
Simple tools to change behavior
Smith noted how any therapeutic tool, regardless of its cost and technological sophistication, has to be measured in terms of its effectiveness. Ultimately, if the desired end is achieved, the device or intervention should be considered a success.
As an example, Smith described the Grace app for iPhone and iPad. It's a simple device that helps autistic children and adults communicate more effectively and comfortably — and it does so by allowing them to build semantic sequences from a series of images that help them construct complete sentences. The app itself was developed to alleviate the frustrations often experienced by autistics when trying to communicate with neurotypicals.
"People who are on the spectrum have a tantrum not because of the condition," said Smith, "but because they are being misunderstood." By using this affordable mobile app, autistics are finding new ways to communicate — and in a manner that leads to considerably less stress and angst.
Smith also pointed to the example of Mason Ellsworth, a musical prodigy who became paraplegic after being hit by a drunk driver. Ellsworth became depressed and despondent after the accident, unwilling to re-engage in life. Then, after working with California based Smule Apps, he started to rediscover his musical roots by using the Ocarina musical software program. Because of its social nature, he was able to perform with other musicians over the net — and it completely transformed Ellsworth's world.
"This simple app offered some tremendously positive emotional associations for Mason," said Smith, adding that "Competence is a continuum by which people adapt to their environment — how we measure that competence is by how you adapt to your environment." In this sense, Ocarina did the trick.
Indeed, it was clear from Smith's presentation that it's often the simplest things that can make the biggest impact. Take the story of Lee Ridley, for example, a British man who is using a speech synthesizer to overcome his cerebral palsy and make a career doing stand-up comedy as The Lost Voice Guy.
Playing games
Therapists are often frustrated with their patients who, for whatever reason, fail to take their medications. According to Smith, medical nonadherence results in over 125,000 fatalities each year — the fourth leading cause of preventable deaths. In addition, 28% of people returning home from the hospital end up having to go back on account of insufficient touch-points.
"We now live in a hi-tech, low-touch society," said Smith.
Home visits are a way of addressing the problem, but this strategy has resulted in physical therapists having to drive a total of nearly five billion miles per year — more than UPS's annual run of two billion miles.
"Drugs only work for those people who take them," said Smith. The trick, therefore, is to get compliance — and low-tech offers yet another elegant solution. By creating encouraging and fun video games, therapists have been able to motivate their patients into both remembering and administering their medications. The promise of reward, it would seem, can be a very powerful motivator.
Games have proven to be particularly effective when working with children. Smith highlighted Medical Acoustics' Lung Flute for the treatment of bronchial conditions. Children don't like blowing into the medical device — but they're required to do so two to three times per day. It was by turning it into a game where the children could inflate and blow up a virtual balloon that the therapists got the compliance they were looking for.
But games can be used for more than just compliance. Smith pointed out how Toronto's St. Michael's hospital is using the Nintendo Wii console to improve motor skills in patients by as much as 30%. He also noted how Microsoft's Kinect is helping autistic kids with their motor skills and coordination.
Other games can simply create engagement where previously there was none. Waterloo Labs out of Texas has developed a DIY version of Super Mario that can be controlled by just using eye movements — what will be an entirely new gaming opportunity for quadriplegics.
Changing realities
Though a little bit more sophisticated in the technology department, virtual reality devices are proving to be helpful as well — tools that virtually any hospital can afford.
Smith noted how therapists are increasingly taking advantage of a phenomenon called ‘cognitive bonding' in which a person feels physically associated with their avatar. For people working through a physical injury or developmental disorder, the act of working with an avatar in a VR environment is allowing them to get more comfortable with moving their bodies through time and space. As they "virtually" move their bodies around, they get better.
These tools are also helping with pain management. Pioneering work by Hunter Hoffman at the University of Washington's burn unit has shown that receptors in the brain that respond to heat also respond to pain. Hoffman has been able to take advantage of this phenomenon by transplanting a person to a snowy, blue, and snowman-infested virtual environment. The psychological impact of this "pain distraction" is so pronounced that therapists are no longer having to treat their patients with opiates. And as Smith encouragingly noted, "This cyber therapy, where we're separating body from the mind, is finally starting to gain credibility.
Which Type of Psychotherapy Is Best?
As a prospective client searches for a psychotherapist, numerous questions may spring to mind. How experienced is the therapist? Has he helped people with problems like mine? Is she someone I can relate to? Yet it may not occur to clients to ask another one: What type of therapy does the clinician deliver? People often assume that the brand of therapy offered is irrelevant to the effectiveness of treatment. Is this assumption correct?
Psychologists do not agree on whether the “school” of therapy predicts its effectiveness. In a survey in 2006 by psychologists Charles Boisvert of Rhode Island College and David Faust of the University of Rhode Island, psychotherapy researchers responded to the statement that “in general, therapies achieve similar outcomes” with an average score of 6 on a 7-point scale, indicating strong agreement. In contrast, psychologists in practice averaged a rating of 4.5, signifying that they agreed only moderately with that position.
As we will discover, both camps can justify their point of view. Although a number of commonly used psychotherapies are broadly comparable in their effects, some options are less well suited to certain conditions, and a few may even be harmful. In addition, the differences among therapies in their effectiveness may depend partly on the kinds of psychological problems that clients are experiencing.
Tale of the Dodo Bird
At least 500 different types of psychotherapy exist, according to one estimate by University of Scranton psychologist John Norcross. Given that researchers cannot investigate all of them, they have generally concentrated on the most frequently used approaches. These include behavior therapy (altering unhealthy behaviors), cognitive-behavior therapy (altering maladaptive ways of thinking), psychodynamic therapy (resolving unconscious conflicts and adverse childhood experiences), interpersonal therapy (remedying unhealthy ways of interacting with others), and person-centered therapy (helping clients to find their own solutions to life problems).
As early as 1936, Washington University psychologist Saul Rosenzweig concluded after perusing the literature that one therapy works about as well as any other. At the time, many of the principal treatments fell roughly into the psychodynamic and behavioral categories, which are still widely used today. Rosenzweig introduced the metaphor of the Dodo Bird, after the feathered creature in Lewis Carroll's Alice in Wonderland, who declared following a race that “everyone has won, and all must have prizes.” The “Dodo Bird verdict” has since come to refer to the claim that all therapies are equivalent in their effects.
This verdict gained traction in 1975, when University of Pennsylvania psychologist Lester Luborsky and his colleagues published a review of relevant research suggesting that all therapies work equally well. It gathered more momentum in 1997, when University of Wisconsin–Madison psychologist Bruce E. Wampold and his co-authors published a meta-analysis (quantitative review) of more than 200 scientific studies in which “bona fide” therapies were compared with no treatment. By bona fide, they meant treatments delivered by trained therapists, based on sound psychological principles and described in publications. Wampold's team found the differences in the treatments' effectiveness to be minimal (and they were all better than no treatment).
One explanation for the Dodo Bird effect is that virtually all types of psychotherapy share certain core features. In a classic 1961 book the late psychiatrist Jerome Frank of the Johns Hopkins University argued that all effective therapies consist of clearly prescribed roles for healer and client. They present clients with a plausible theoretical rationale and provide them with specific therapeutic rituals, he wrote. They also take place in a setting, usually a comfortable office, associated with the alleviation of distress. Later writers elaborated on Frank's thinking, contending that effective therapies require empathy on the part of the clinician, close rapport between practitioner and client, and shared therapeutic goals.
Today many authors argue that these and other common elements are even more powerful than the features that distinguish one therapy from another. To take just one example, Wampold concluded in a 2001 analysis that the therapeutic alliance—the strength of the bond between a therapist and his or her client—accounts for about 7 percent of therapeutic effectiveness but that the school of the therapy accounts for only about 1 percent. Most of the remaining 92 percent is presumably caused by other factors, such as the personalities of the therapist and client.
Is the Dodo Bird Extinct?
Although most researchers agree that common factors play key roles in psychotherapy, some doubt that all methods are equally effective. Even Wampold has been careful to note that his conclusion holds for only bona fide treatments; it does not extend to all 500 or so therapies. For example, few experts would contend that rebirthing therapy, premised on the dubious idea that we must “relive” the trauma of our birth to cure neurosis, works as well as cognitive-behavior therapy for most psychological conditions.
Moreover, research suggests that even among accepted therapies, the type of treatment does matter under certain circumstances. A 2001 review by University of Pennsylvania psychologist Dianne Chambless and Virginia Polytechnic Institute psychologist Thomas Ollendick revealed that behavior therapy and cognitive-behavior therapy are more effective than many, and probably most, other treatments for anxiety disorders and for childhood and adolescent depression and behavioral problems. In addition, in a 2010 meta-analysis psychologist David Tolin of the Institute of Living in Hartford, Conn., found that these same two therapy types produce better results than psychodynamic therapy for anxiety and mood disorders.
The Dodo Bird verdict must also be qualified by evidence indicating that several widely used therapies do not work and may actually harm. For example, in a 2003 review psychologist Richard McNally of Harvard University and his colleagues evaluated crisis debriefing. In this treatment for warding off post-traumatic stress symptoms, therapists urge those exposed to emotionally fraught events such as shootings or earthquakes to try to reexperience the feelings they had during the event soon after it. McNally's team concluded that this treatment is inert at best and possibly damaging, perhaps because it interferes with natural coping mechanisms.
In light of such findings, a search for a therapist should at least sometimes involve a consideration of the type of treatment he or she practices. It is true that ingredients, such as empathy, that cut across effective therapies are potent and that various established techniques are roughly equivalent for a broad range of difficulties. Yet under certain circumstances, the therapeutic method can matter. For example, if a clinician espouses an approach outside the scientific mainstream—one that does not fall under the broad categories we have listed here—you should not assume that this treatment will be as helpful as others. If you suffer from an anxiety disorder or one of the other conditions for which behavior and cognitive-behavior interventions work well, then someone who practices one of those two types is probably a good bet.
Of course, scientists have systematically assessed only a minority of the psychotherapies invented so far for their efficacy in treating the numerous psychological difficulties that afflict humankind. In the coming decade, we hope that further research clarifies whether the brand of therapy makes a difference in an individual's recovery from psychological distress.
Smartphone Monitoring
WHAT really winds you up every day? Traffic on your commute? A frustrating boss? Or maybe something more subtle that you can't quite put your finger on...
Your smartphone may soon be able to tell you where you encounter the most stress, thanks to the development of software that can recognise stress from the patterns in your voice.
Called StressSense, the system is first trained to recognise someone's unstressed voice. To do so, the person must relax and read a 3-minute passage from a book, say, into their phone. StressSense then compares this recording to its preprogrammed knowledge of the physiological changes that stress induces, such as a faster speaking rate and a clipped frequency spectrum, and logs any instances of stress it detects. "Our stress model also adapts to different background noise environments," says Hong Lu of Intel in Santa Clara, California, who developed the system.
In tests that included putting volunteers through mock job interviews, Lu's team found their prototype's stress-recognition accuracy is 81 per cent indoors and 76 per cent outdoors, where sound quality isn't as good.
The team plan to make the system a plug-in to an Android app called BeWell, which uses a phone's accelerometers and GPS sensors to record people's activity and sleep levels. People will be able to set StressSense to either listen to their voice throughout the day, or to only activate when they are having a phone conversation.
Eye Movement Therapy
Imagine you are trying to put a traumatic event behind you. Your therapist asks you to recall the memory in detail while rapidly moving your eyes back and forth, as if you are watching a high-speed Ping-Pong match. The sensation is strange, but many therapists and patients swear by the technique, called eye movement desensitization and reprocessing (EMDR). Although skeptics continue to question EMDR's usefulness, recent research supports the idea that the eye movements indeed help to reduce symptoms of post-traumatic stress disorder (PTSD).
Much of the EMDR debate hinges on the issue of whether the eye movements have any benefit or whether other aspects of the therapeutic process account for patients' improvement. The first phase of EMDR resembles the start of most psychotherapeutic relationships: a therapist inquires about the patient's issues, early life events, and desired goals to achieve rapport and a level of comfort. The second phase is preparing the client to mentally revisit the traumatic event, which might involve helping the person learn ways to self-soothe, for example. Finally, the memory processing itself is similar to other exposure-based therapies, minus the eye movements. Some experts argue that these other components of EMDR have been shown to be beneficial as part of other therapy regimens, so the eye movements may not deserve any of the credit. New studies suggest, however, that they do.
In a January 2011 study in the Journal of Anxiety Disorders, for example, some patients with PTSD went through a session of EMDR while others completed all the components of a typical EMDR session but kept their eyes closed rather than moving them. The patients whose session included eye movements reported a more significant reduction in distress than did patients in the control group. Their level of physiological arousal, another common symptom of PTSD, also decreased during the eye movements, as measured by the amount of sweat on their skin.
One of the ways EMDR's eye movements are thought to reduce PTSD symptoms is by stripping troubling memories of their vividness and the distress they cause. A study in the May 2012 Behaviour Research and Therapy examined the effectiveness of using beep tones instead of eye movements during EMDR. The researchers found that eye movements outperformed tones in reducing the vividness and emotional intensity of memories.
Those studies relied on self-reports of symptom severity, however, so researchers at Utrecht University in the Netherlands sought more objective confirmation of a change in vividness by also measuring participants' reaction times to fragments of a previously viewed picture. The work, published online in July 2012 in Cognition and Emotion, compared two groups of participants who had committed one detailed picture to memory. When asked to recall the picture and focus on it mentally, one group was instructed to perform eye movements. That group had slower reaction times to the familiar picture fragments in a subsequent memory test, and subjects reported that the vividness of the recalled pictures had decreased.
These studies and others from the past several years have helped validate EMDR—so much so that the American Psychiatric Association, the International Society for Traumatic Stress Studies, and the Departments of Defense and of Veterans Affairs have deemed it an effective therapy.
Yet how it works remains unclear. Chris Lee, a psychologist at Murdoch University in Australia and co-author of the January 2011 study, says a common theory is that EMDR takes advantage of memory reconsolidation: every time we recall a memory, it is changed subtly when we file it away again. For instance, parts of the memory may be left out, or new ideas and feelings are stored alongside of it. Making eye movements during recall, Lee explains, may compete with the recollection for space in our working memory, which causes the trauma memory to be less intense when recalled again.
“Our experiments clearly show that negative autobiographical memories are very rich in sensory detail, and by pairing them with eye movements, they lose this sensory richness,” Lee says. “People describe that the memories become less vivid and more distant, that they seem further in the past and harder to focus on. What follows after this distancing is a reduction in the associated emotional levels.” In other words, the traumatic memory stays, but its power has been diminished.
Why Do Antidepressants Take So Long To Kick In?
Kate wanted to die. She remembers the moment the psychiatrist said “the antidepressant isn’t going to work right away. Can you promise to be here next week and not kill yourself?”
“I told her no,” Kate says. “I couldn’t promise my doctor I’d make it a week. That’s how bad my life had to be before I got help. When you’re struggling to stay alive every single day, and then your doctor tells you it’s going to take two to six weeks before the medications they give you are going to work, it’s devastating.” To make matters worse, after those weeks, the drug didn’t work. Kate went through five different anti-depressants over the course of six months before confirming that none of them worked. The debilitating disorder kept her out of school for extended periods of time.
The National Center for Health Statistics estimates more than one in 10 Americans over the age of 12 took antidepressants between 2005 and 2008, the last time period for which the data are available. The rate of antidepressant use increased 400 percent from 1998 to 2008.
Traditional antidepressants go after serotonin transporter proteins. These regulatory proteins take serotonin back into the nerve cell after it has been released in the process of signaling other neurons. Antidepressants keep the transporters from performing this function.
Although nowadays, most scientists feel that serotonin release and reuptake are fairly normal in depressed patients, many scientists nonetheless believe the changes in serotonin signaling caused by antidepressants, induces the alleviation of symptoms, says Gary Rudnick, professor of pharmacology at Yale School of Medicine.
Still, antidepressants stop the process of serotonin transporters sucking up released serotonin fairly quickly, so researchers don’t understand why it takes weeks for the medications to take effect, Rudnick says. Scientists believe the behavioral effects of antidepressants may be due to other changes that occur as a reaction to the changed serotonin levels. However, researchers don’t know what reactions include, and therefore cannot create medications that target them directly.
Targeting proteins
A large portion of depression research is associated with trying to ascertain the role of neurogenesis, the process by which the brain generates new neurons. Researchers have noticed that the hippocampus of a depressed person’s brain tends to be smaller than average. Some researchers hypothesize that a problem with neurogenesis causes both the small hippocampus as well as depression; others caution that the causal arrow may be reversed, with a small hippocampus leading to problems with neurogenesis and depression.
“Chronic [or long term] antidepressant treatment will actually increase levels of neurogenesis,” says Julie Blendy, a neuroscientist and pharmacologist at the Perelman School of Medicine at the University of Pennsylvania. Chronic treatment will also increase levels of the protein CREB, known to play a role in the long-term effects of anti-depressants.
To test the effectiveness of CREB, Blendy got rid of the protein in mice. Of course, CREB doesn’t work in a vacuum, and another protein CREM upregulated (increased) in order to compensate for the missing CREB. Interested in the effects of CREM, Blendy upregulated CREM without touching CREB, and found the antidepressants acted much quicker. This new development, published in The Journal of Neuroscience in August 2013, suggests that identifying CREM targets would be better than attempting to identify CREB targets.
Ketamine
An increasingly popular antidepressant solution involves Ketamine, more popularly known as the illicit drug ‘Special K.’ Ketamine has been shown to be effective in bipolar and depressed patients who have not responded to other antidepressants. The drug works in just two hours.
The use of ketamine as an antidepressant has been called the first true development in the field of antidepressant research in 50 years, for it targets an entirely different part of the brain than traditional antidepressants. Instead of focusing on serotonin, norepinephrine or dopamine neurotransmitters, ketamine focuses on a glutamate neurotransmitter. Glutamate accounts for more than 90 percent of all synapses in the human brain, which makes it the most prevalent of all neurotransmitters.
Further studies need to be done in order to figure out how patients can use the drug without experiencing dangerous side effects, such as severe inflammation of the bladder and addiction. Abundant research also needs to be done to further Blendy’s work. Although she and her team of researchers have shown that CREM is a promising target for antidepressants, targeting that protein with a new drug will be a whole new challenge.
Mrs Mills Advice Col
I am in love with two men. I had a long relationship with Man One, which ended up overlapping with the start of a new relationship with Man Two. I was disgusted at my “overlapping”, and this led me to end with One. Now I find myself in love with Two, but unable to fall out of love with One, which causes great issues with Two. Both have their pros and cons, and they’re complete opposites. One knows nothing of Two; Two is painfully aware of One. Any suggestions as to how to make a decision would be gratefully appreciated. I am approaching my late twenties and would like to be looking forward to marriage at some point soon.
Draw up two lists of the merits of each one and put them side by side. This will focus your mind. Then ask which one makes more money and balance that against how shallow you think you are.
Problem Boys
Morning assembly is starting at one of Britain’s most unusual boarding schools for boys. Pupils and staff crowd into the panelled entrance hall, where the principal, Richard Boyle, gives a few brief notices and then hands a box of matches to Junayd, a slight, solemn, 10-year-old. Junayd lights a candle at the front of the hall. “Education is light,” he mutters and steps back into the throng clutching the burnt-out match.
“Education is light,” echoes Boyle in a booming Wearside accent. He reminds the boys that this is the “year of personal responsibility” at the school and sends them off to their classes.
The candle ritual is repeated twice a day at Muntham House, a school for 56 boys in West Sussex. The honour of lighting the candle is given to a boy who has behaved particularly well during the preceding few hours. The boys keep the matches and when they have ten are rewarded with a book token or a trip. Junayd was picked this morning “because he settled better than everyone else last night”, Boyle says. “We are trying to keep him positive.”
Junayd, like all his peers, proved unteachable in mainstream schools. Muntham House, based in an 1860s country house set in 23 acres, is a special school for boys aged 8 to 18 who are classified as having severe behavioural problems. The school is one of about 20 non-maintained special schools in England and Wales for pupils with BESD (behavioural, emotional and social difficulties). Fees are paid by 21 local authorities in the South East that refer pupils to the school when they run out of other options.
The boys disperse to their lessons. Some to English and maths, others to design and technology workshops, some into the woods to do conservation work. Boyle says that during my day at the school I may find it so tranquil that it won’t seem like a special school. “Or there’ll be a full-scale riot. It could be anything in between.”
Many of the boys are on the autistic spectrum or have had ADHD diagnosed. Boyle is “not a fan of the alphabet soup. I’m of the old school”. He uses words like “maladjustment”. He took the tests to see whether he was on the autistic spectrum and found that he was. He regards himself as hyperactive.
The background of the boys “runs the gamut from fantastic parents who have tried everything to drug addict parents”. Some are the victims of horrendous abuse. “They have a lot of background crap and they get marginalised. People say ‘this is a bad guy’. They become isolated, violent, disruptive. The boy automatically thinks: ‘Why bother? What’s the point?’ It becomes a habit. We are the end of the road for a lot of kids.”
I sit in on a maths class of five boys, including Junayd. As well as the teacher, there is a teaching assistant and two university students. Every boy has lots of attention and work is being done. When they have finished they are allowed to play a boardgame. I play chess with Harvey, a quiet, thoughtful boy who has only been at the school a few weeks. He smiles shyly as he beats me.
The school’s central strategy is to find something that each boy is passionate about. Junayd came to Muntham House after short-term exclusions for “difficult behaviour” from previous schools. He is regarded as very bright but has Asperger syndrome. The staff encourage his love of superhero comic books. He is especially fond of Spider-Man. Junayd lives with his grandparents and took some time to make friends at the school. He is often withdrawn and expresses the unjustified view that other people won’t like him.
“Spider-Man is a lonely high school student who lives with his aunt and uncle. He comes to realise that he needs to be part of the community and control his anger if he is to be good, a lesson Junayd is starting to learn,” says Marc Williamson, who followed Junayd for months for a documentary he has made about Muntham House.
In the afternoon, the class goes to the library in Horsham. Junayd pores over the comic books. I try to interest him in a Manga book. He looks unimpressed and turns his laser-like focus to the Marvel volumes. I ask why he likes Spider-Man more than the others. “He’s the best,” he says, and turns to evaluate me as if he has just realised that he has met a prize idiot. Who would win a fight between Spider-Man and Batman? “Spider-Man,” he replies, without missing a beat. “He’s got super-strength.” In the park on the way back he scales the web-like conical climbing frame and hangs upside down.
“Every child has self-esteem issues, even if they are the most flamboyant child,” says Karen Allen, practice leader in the behavioural management team. “They have trouble regulating emotions, low self-esteem and self-confidence.”
Allen inhabits an inner sanctum in the school where boys can be brought to cool down or share private troubles. One room contains bean bags and a small library of picture books. Many of the boys have not previously enjoyed the opportunity to bond with an adult over a book. “They love picture books. There are blocks of development they haven’t had. If we can put them back in, we can help them to move forward,” Allen says.
She has built a particularly strong relationship with Ryan, a hyperactive boy who struggles to focus and looks and behaves younger than his 15 years. He was ejected from seven schools before he came to Muntham House. One day a therapist brought a horse to the school and everything changed for him. “Ryan couldn’t see any point in sitting in class but he was just drawn to the horse and was convinced that was what he wanted to do,” Allen says. Working with horses became part of Ryan’s therapy. “It’s amazing the conversations you can have with a child when you are on the other side of a horse grooming it. You can’t believe what they talk about.”
He has an offer of a placement at the stables of the racehorse trainer Gary Moore if he behaves himself and works hard on his work-experience placement at another stables. He is not in school today, but in the documentary we see him come alive with Moore, uninhibited and peppering him with questions. We also see him beset with doubt about his chances of landing the job: “I don’t think I will get it. There are loads of people better than me.”
The vast majority of pupils at Muntham House go on to further education. One recent pupil has a first-class honours degree in English and media studies from the University of Kent. Dave Payne, who smashed up four windows in a maths classroom in a moment of fury — “It was wonderful to watch,” says Boyle — went to college and came back to work as a part of the estate’s team. “Now, if anyone does any damage he is the one who fixes it.”
Boyle, 55, was a barman in Sunderland (“where I got my training”) before he became a teacher 30 years ago. He has been principal at Muntham House since 1999 and has the big charismatic personality to match the challenges posed by the boys in his care.
Many of the boys have suffered from a lack of male role models: “Often there are no male messages about how to react personally.” Some arrive with misogynistic attitudes. Boyle and several other teachers are imposing and blokeish. His messages are simple. To a boy with ADHD, for example: “We say: ‘You have a problem, you need to fix it and we will help you to fix it.’ They have got to accept they have a problem.”
The first task is to convince unsettled children that the school is a safe place run by people who care about them. The staff use the word “family” a lot when they talk about the school.
Teachers need enormous reserves of patience as they seek to build relationships with often disturbed and hostile boys. “If you can build a relationship with a kid who has spat at you and told you to f*** off and called your mother every name under the sun, that is fantastic,” Boyle says.
A key Boyle rule, endlessly repeated, is: “Talk to an adult. Don’t pull out if you’ve got a problem.”
Praise is key. We live in an age of periodic spasms of middle-class angst over whether we praise children too much. Perhaps the most heartbreaking thing I hear all day is an observation from Boyle: “Some of the boys have never heard an adult say ‘that’s really good’.”
Consistency is paramount. “We tell them what we will do and we do it,” Boyle says. “The best way to manage kids is to tell them to stop [if they are misbehaving]. There is a consequence if they misbehave.” This might be withdrawal of a trip or a detention.
As we tour the school a boy is on his hands and knees cleaning a wall. Boyle explains that he had scuffed it kicking a football. He gave the boy a bucket and a sponge. If that doesn’t work he’ll be given a paint brush. Someone tells me the story of a white boy who used a racist word. Boyle called him into his office with a group of older, larger boys, including black boys and asked if he would care to repeat the word.
All staff are trained in restraint techniques and on average there is one incident a day in which a boy has to be subdued in this way. “If they are going to lamp somebody you’ve got to do something about it,” says Boyle matter-of-factly. “We are not wandering about with angels’ wings. If some kid says ‘f*** you’ and spits at you, you are not going to say ‘peace out man, that’s wonderful’.”
Some of the boys look pretty tough. “Two women can take a bloke easily. In 30 years I’ve come across only three kids that were handy. Kids these days can’t fight properly,” Boyle says. He has other techniques for de-escalating situations. He likes to whistle or sing to pupils, or bemuse them by starting a chat about politics or history.
About one boy a year leaves the school because even Muntham House can’t help them. “If they don’t buy in there is nothing you can do,” Boyle says. “If all they want to do is take your head off, you have to look for a more severe environment.” Typically this would be somewhere with a ratio of two staff to every pupil.
The school day ends with another assembly. Harvey, my vanquisher at chess, is one of those who has scored the maximum of 42 points for his work and behaviour today, and lights the candle. There’s a scuffle between two other boys and two male teachers swiftly extract the chief culprit with arm tweaking and lifting. A few minutes later, after a ticking off, he is allowed back in to pick up a gymnastics certificate.
Boys who have been “a pain in the backside” are told to stay behind for detentions or discussions.
Another boy, Ben, is applauded for gaining a National Vocational Qualification in land-based studies. Afterwards Boyle says he is particularly pleased because Ben “used to spend a lot of time under here”. He points to his desk. Sitting under Boyle’s desk is a popular pastime. “It’s a safe place. They’ll sit and read, or I’ll read to them. When I get bored of them I switch Maria Callas on. That’s brilliant for getting rid of them.”
Sixth formers, who go to local colleges and come back in the evenings to their own flats on campus, begin to roll in. I sit with Sandra West, a higher-tier learning assistant specialising in literacy, and Cole, a 16-year-old who came to the school at 14 having somehow managed to get through mainstream school without anyone successfully addressing his inability to read or write. He says he lacked confidence in his ability so got himself thrown out of classes, and then schools. “I knew I wouldn’t be able to do it so I messed around. I don’t think they wanted me.”
West helped him with his literacy and he found his interest in life: fixing cars and motorbikes. He is studying for a diploma in vehicle systems at a local college and doing work experience at a garage. In a recent exam he scored 95 per cent but still needs a scribe to write down his answers. “There are a lot of Coles out there, all different,” West says. “You have got to pull that individual apart and see how he works.”
She knows what she’s talking about. Her own son, James, who has ADHD and Asperger syndrome, was at Muntham House. He prospered at the school, went on to college and trained as a sports coach. One of his jobs is at a local school. James knows it well: he went there as a pupil before being excluded.
Don't Sleep On It
If you have just experienced a traumatic event, contrary to common advice you might not feel better after a good night’s sleep. In fact, scientists have said, going to bed could be the worst thing you could do.
There is a growing body of neuroscience research that suggests that sleep is crucial in laying down memories, which is one reason why people revising for exams are advised to turn in early. It is also the reason why scientists at the University of Oxford believe that sleep deprivation could in some cases be desirable.
A study, published today in the journal Sleep, suggests that keeping people awake could a tool for reducing the long-term psychological effects of traumatic events by actively impairing their memories.
For the research, 42 people were shown a traumatic film that included footage of a suicide. “The film was disturbing, but not horrifying,” Russell Foster said. “It was things that the normal person would not find soothing.”
The group was split in two, with half going to bed as normal and the rest being kept awake by “staff trained to prevent napping”. They were asked in the days that followed to record how often images from the film popped into their heads. Those who had slept were found to be more likely to experience flashbacks.
Professor Foster said he was not surprised by the result, even though it is still common for some patients to receive sedatives after a traumatic event to help them to sleep. “That always seemed strange to us. What sleep has been shown to do is to promote memory consolidation,” he said. “What we wanted to see is if you did the complete opposite to sleep, would that improve the situation?”
The hypothesis seemed to be proved correct and Professor Foster said: “Maybe the routine treatment after such events should be gently to keep people awake — to sit with them and chat to them.”
While it may seem counterintuitive to keep people awake as a means of preventing post-traumatic stress, he added that there was more of a precedent for it than people might think.
“What used to happen after battles in early cultures? It is likely the tradition was to stay up and carouse after a battle and drink lots of alcohol,” Professor Foster said. “To me that would seem to be a particularly effective way of stopping memory formation.”
Metric Based Therapy
GRACE WAS A HEROIN ADDICT WHO HAD BEEN CLEAN FOR ABOUT SIX MONTHS; I WAS A 34-YEAR-OLD THERAPIST IN TRAINING. WHEN WE STARTED PSYCHOTHERAPY, IN 2006, GRACE HAD A LOT GOING AGAINST HER.
She was an unemployed single mother who had been in a string of relationships with violent men and was addicted to drugs. Yet despite these challenges, she was struggling bravely to put her life back together and retain custody of her young son. (I’ve changed my patients’ names and some details about them to protect their privacy.)
Our therapy focused on supporting Grace’s attendance at Narcotics Anonymous meetings and reducing the anxiety she said had driven her to drugs. The first few months seemed to go well. Every week, she told me about her successes: She attended the NA meetings, got a job, and found a boyfriend who respected her.
We both knew the stakes—custody of her son, and perhaps her life—and we refused to consider failure. Frequently, I asked Grace for feedback about our work together. She always assured me that the therapy was proving productive. However, her enthusiasm had a desperate, hard edge; she often spoke quickly, with a tight, forced smile.
I received weekly supervision from a psychologist at my community-counseling training site. She was smart and perceptive, with decades of experience helping addicts; I was lucky to have her guidance. Three months into treatment, I told my supervisor Grace was doing so well that we had agreed to cut our sessions from weekly to biweekly. “It’s remarkable how quickly she’s improving,” I said. But my supervisor was cautious. “Getting clean is hard,” she told me, “but staying clean is harder.”
She was right. Soon thereafter, Grace no-showed for three straight therapy appointments. When she finally reappeared, she had relapsed on heroin. Over the next several months, everything she had built fell apart. She lost her job and her boyfriend, and kept going back to drugs. Yet she came faithfully to therapy, so I had a front-row seat to her painful unraveling. I tried every therapeutic technique I could find, but nothing stuck. Through it all, she insisted she could do it. “I’ve just got to stay positive,” she said.
A few months after relapsing, Grace died of a drug overdose, and her son was sent to foster care. I was devastated. The episode sparked a crisis in me: What could I have done differently? How could I become a more effective therapist?
Casting about for solutions, I recalled an idea that one of my professors had discussed in class a year earlier. He had read the book Moneyball, which described the Oakland Athletics’ revolutionary use of performance metrics, and he was curious whether psychotherapy could also benefit from more data and analytics. He showed us promising preliminary research, but also noted that many therapists were skeptical.
I’d had little interest in this topic when my professor first mentioned it. The very idea seemed too hypothetical, too academic, and almost insulting to the profession. Psychotherapy is unlike any other field, I’d thought, with the arrogance that comes from being untested. We work in a human relationship. What we do can’t be measured. However, after Grace died, I found myself more open to different approaches—to anything that might help me fix my blind spots and weaknesses.
A SMALL MOUNTAIN of clinical research shows that therapists— that is, anyone who provides talk therapy, from psychologists to social workers—vary widely in effectiveness. One study, led by John Okiishi of Brigham Young University, compared clinical outcomes from 91 therapists and found that the highest-performing among them helped clients improve 10 times faster than the overall average. On the other end of the spectrum, a study led by the psychologist David R. Kraus found that clients of the lowest-performing therapists were significantly worse off in the areas of violence and substance abuse at the end of treatment.
My introduction to the field came from my own therapist, who’d helped me greatly during my troubled teens. “Psychotherapy,” he once told me, “is a relational art. You can’t quantify personal growth.” I hadn’t really understood what he’d meant at the time, but meeting with him over a period of years had helped me considerably when I was depressed, angry, and anxious; whatever he did, it worked.
A decade and a half later—after many adventures and odd jobs in my 20s and early 30s—I entered graduate school with this same perspective on psychotherapy: that it was an art too nuanced and complex to be measured. Still, I couldn’t help but notice that, at my first training site, many of my clients remained stuck in neutral despite our best efforts together. A quarter or more of my clients dropped out without explanation a few weeks or months into treatment. And at least 10 percent were deteriorating. Because many of them had started treatment feeling suicidal or on the edge of needing hospitalization, they couldn’t afford to get worse. Unnervingly, I couldn’t predict which clients would stall, drop out, or deteriorate.
Psychotherapy, on the whole, can be very effective. This bears emphasis, because many people are still skeptical that it is a bona fide treatment. There is no shortage of empirical evidence demonstrating that psychotherapy helps patients with a wide range of problems, from the relatively simple (fear of flying, for example) to knotty and treatment-resistant conditions such as borderline personality disorder. It may not help everyone, but neither does a whole host of medicines for physical ailments. The point is, it does help a lot of people.
That said, as in any profession, there is still considerable room for improvement. My training experience was typical of broader trends: Across the field, dropout rates are estimated to be about 25 percent or more, and, most disheartening of all, 5 to 10 percent of clients deteriorate during treatment. These problems have been acknowledged since the birth of psychotherapy, when Freud himself wrote about “analysis terminable and interminable.”
In recognition of this challenge, psychotherapists have been working hard to boost outcomes. During the past three decades, much of this effort has focused on studying and debating which models of therapy are most effective. However, the results of these initiatives have been largely disappointing. Plenty of models—such as inter personal therapy, emotion-focused therapy, and cognitive behavioral therapy— have performed well in studies. But larger meta-analyses suggest that most models are not consistently more successful than any other. This research was summarized in a 2012 statement by the American Psychological Association, which declared that “most valid and structured psycho therapies are roughly equivalent in effectiveness.”
Certainly, some models may be better or worse for individual clients. But encouraging therapists to generally favor one model over others hasn’t improved client outcomes. For example, a recent study in Britain examined the results of a major effort to train psycho therapists in cognitive behavioral therapy. Despite a massive investment of time and money, client outcomes did not improve.
If promoting one model over others doesn’t improve client outcomes, what does? As the APA put it, “Patient and therapist characteristics, which are not usually captured by a patient’s diagnosis or by the therapist’s use of a specific psychotherapy, affect the results.” In other words, more important than the model being used is the skill of the therapist: Can therapists engender trust and openness? Can they encourage patients to face their deepest fears? Can they treat clients with warmth and compassion while, when necessary, challenging them?
Doctors rely on a wide range of instruments— stethoscopes, lab tests, scalpels. Therapists, by contrast, are the main instruments of psychotherapy. But this merely brings us back to the central question I faced after Grace died: How can those instruments— the therapists themselves— be improved?
IMAGINE A SURGEON OR A DANCER LEARNING WITHOUT SOMEONE OBSERVING THEIR WORK. THAT’S THE PREDICAMENT THERAPISTS ARE IN.
MOST FIELDS HAVE EXPERIENCED dramatic advances over the past century. The story of how they moved forward often involved two closely related phenomena, both of which were brought about by technology.
The first of these is performance feedback, which gives individuals a heightened awareness of how well or poorly they’re doing their job. Consider the recent impact of slow-motion video technology on professional dance. In 2015, Wired argued that “for dancers, it’s become an incredibly useful tool for honing their craft. The newfound affordability of slow motion has enabled them to improve their technique, spruce up their audition reel, and isolate aspects of their performance that were once intangible.”
Unfortunately, perhaps no field faces higher barriers to incorporating performance feedback than psychotherapy. Because of the personal, sensitive nature of our work—which is protected by laws, regulations, and the general norms of the profession— therapists function largely in private, sheltered from objective feedback. Try to imagine a surgeon, a dancer, or any type of athlete learning without someone observing their work, but instead by simply sharing with their boss reflections on their recent performance. That’s the predicament many therapists are in.
Sure, we can ask our clients for feedback about what’s helping and what isn’t; most therapists do. However, asking only helps if clients are forthcoming with their answers. And many clients withhold critical feedback, especially when therapy is unhelpful. In a recent survey, Columbia University’s Matt Blanchard and Barry Farber asked 547 clients about their honesty in therapy. A whopping 93 percent reported white washing feedback to their therapists, commonly by “pretending to find therapy effective” and “not admitting to wanting to end therapy.” And if patients aren’t telling us the truth, how can we know whether they are likely to deteriorate, as Grace did before my eyes?
Which leads to the other 20th-century development that spurred many professions forward, while largely bypassing psychotherapy: the use of metrics to forecast likely outcomes. The most famous application of metrics is the “money ball” concept that inspired my professor in graduate school: In the 1970s, a baseball fan named Bill James collected reams of performance data that had previously been ignored (or at least under appreciated) by professional teams, such as slugging percentage and on-base percentage. From this, he developed statistical tools for predicting the performance of baseball players. Ultimately, those tools transformed how baseball teams are managed. Could a similar approach—looking for statistical patterns among a vast array of psychotherapy outcomes—help therapists better predict our patients’ trajectories?
OVER THE PAST FEW DECADES, Michael Lambert, a research er at Brigham Young University, has developed a system in which therapy clients take a 45-question survey before each appointment, and a computer tabulates their responses. The results are then displayed as a graph that quantifies the trajectory of each client’s symptoms, allowing his or her therapist to track the progress being made.
Lambert and his team have also been at the forefront of developing psychotherapy metrics. Drawing on historical data from thousands of cases, they created algorithms predicting when clients are at risk of deterioration. If, based on their answers to survey questions, clients appear to be at risk, their therapists are sent alerts that are color-coded for different concerns: red for risk of dropout or deterioration, yellow for lessthan- expected progress. In an initial test, the algorithms were able to predict—with 85 percent accuracy and after only three therapy sessions—which clients would deteriorate.
Today, these surveys and algorithms are known as feedback informed treatment, or FIT. The system aids therapy in two primary ways. First, it provides an element of blunt performance feedback that therapists too often lack. Many clients are more willing to report worsening symptoms to a computer—even if they know that their therapist will see the results—than disappoint their therapist face-to-face.
The second benefit comes from the metrics: Risk alerts allow therapists to adjust treatment, and can help them compensate for natural overconfidence and clinical blind spots. In one study, 48 therapists, seeing several hundred clients at a single clinic, were asked to predict which of their patients would “get worse.” Only one of the therapists accurately identified a client at risk. Notably, this therapist was a trainee. The licensed therapists in the study didn’t accurately predict a single deterioration. Only three clients were predicted to get worse, despite therapists being informed by the researchers that the clinicwide deterioration rate hovered around 8 percent— and despite the fact that 40 clients, or about 7 percent of those in the study, ultimately did deteriorate.
SOME YEARS AFTER GRACE’S DEATH, I began working with a client named June. At that point—inspired by talks given by Scott D. Miller, who co-founded the International Center for Clinical Excellence and helped develop a FIT system that uses algorithms built from 250,000 completed cases around the world—I was using FIT as part of my approach to therapy.
June, who had recently dropped out of a local community college, was seeking help with anxiety, depression, and social isolation. She told me that she had been experiencing these symptoms her whole life. Her parents, with whom June still lived, were religious fundamentalists and very controlling.
Our therapy sessions seemed to start well. June was shy and quiet, and never made eye contact with me. But she seemed genuinely interested in learning skills to reduce her anxiety and reported practicing the skills between sessions. When I asked June for feedback at the end of each session, she told me the therapy was helpful. “The skills you’re teaching me are good,” she replied in her soft, careful voice.
METRICS SIGNIFICANTLY IMPROVE THE EFFECTIVENESS OF PSYCHOTHERAPY, REDUCING DROPOUT RATES AND SHORTENING THE LENGTH OF TREATMENT.
Before each session, June took a few minutes to complete the FIT survey on an iPad in the waiting room, responding to statements like “I feel fearful” and “I enjoy my spare time” with preset answers ranging from “never” to “almost always.” Though I had access to her clinical graph every session, I didn’t bother checking it at first, because she seemed to be progressing so well.
After a few sessions I finally checked the graph—more because I felt like I should than because I thought it would be helpful. I was shocked to see that June’s chart showed a red alert. Her symptoms had not improved since our first session. The algorithms reported that she was actually at a high risk of deterioration and suicide.
My gut reaction to the alert was skepticism—as it almost always is, to this day, when the program’s algorithms contradict my instincts. There must be a mistake in the software, I thought. June had repeatedly told me that therapy was helpful. At the beginning of our next session, I asked her how she was doing. Looking into the corner of the room, she replied that the skills I was teaching her were useful; but this time, I persisted: “I’m glad to hear the skills are helpful, but how are you doing?” June was silent for a while and shifted in her chair, clearly uncomfortable. I felt my own anxiety rise, and resisted the urge to change the subject. “Take your time,” I said. “There’s no rush.” After a period of silence, June looked me in the eye for perhaps the first time ever and said, “I’m sorry, but I think I’m worse. I just don’t want you to think it’s your fault; it’s mine. You’ve been really helpful.” June was deteriorating, but I never would have seen it without the program.
My experience mirrors that of therapists around the world.
The success of Michael Lambert’s research sparked a surge in the creation of feedback systems: Close to 50 have been developed over the past two decades. As the systems have spread, they have accumulated ever larger banks of clinical data. Studies have shown that metrics significantly improve the effectiveness of psychotherapy, including reducing dropout rates and shortening the length of treatment. What’s not to like?
UNFORTUNATELY, IN PROFESSION after profession, metrics have not been received with open arms. The history of the thermometer provides a classic example. In the mid-19th century, 250 years after the thermometer’s invention, Carl Wunderlich analyzed patient temperature data from more than 25,000 cases. He found that the average normal temperature of a healthy person ranged from 98.6 to 100.4 degrees. Going further, Wunderlich proposed the radical idea of tracking an illness by reading the patient’s temperature at regular intervals.
Many medical professionals were skeptical. Thermometers of that era were cumbersome—almost a foot long—and took 20 to 25 minutes to register a patient’s temperature. They had reliability problems, and doctors and nurses weren’t sure about the best ways to use them. Aside from the inconvenience, many physicians were affronted by the suggestion that they should use data from medical instruments to inform their diagnoses. Previously, physicians had diagnosed a fever by touching various parts of the patient’s body with their hands and making a determination from their blend of intuition and experience. Some worried that use of thermometers would lead to the “deskilling” of physicians.
A century and a half later, psychotherapy metrics and feedback systems have met with much the same reaction. Dozens of studies attesting to the benefit of metrics and feedback have been published since the systems were first introduced. Yet therapists have been slow to adapt. One 2003 study led by Ann Garland of UC San Diego found that, among a sample of therapists in San Diego County who received client- outcome scores, 92 percent didn’t use them. And a 2013 paper by SUNY Albany’s James Boswell and colleagues— citing research published in 2002, 2004, and 2008—noted, “Surveys spanning different countries indicate that few clinicians actually employ [FIT] in their day-to-day work.”
Few, if any, more recent studies contain solid data on FIT usage, but my anecdotal impression is that use of FIT today remains dis appointingly low among therapists. In my experience talking with peers, the most common reason for nonadoption is the belief that quantitative data—or worse, a computer— cannot possibly capture the nuances of psychotherapy; accordingly, many therapists feel that the whole idea of psychotherapy metrics should be rejected at face value.
The first part of this argument is correct: A single mental health measure can’t identify the full range of psychological illnesses any more than a thermometer can detect cancer, diabetes, or heart disease. Moreover, the FIT systems can give false positives and false negatives, thereby overstating or understating risks. But that isn’t a good reason to entirely ignore the data— just as the thermometer still provides valuable information even if it isn’t the final word on whether a patient is sick.
“It is probably true,” the historian A. J. Youngson wrote, “that one of the commonest features of new ideas— certainly of practical new ideas—is their imperfection.” Two hundred and fifty years elapsed between the invention of the thermometer and Wunderlich’s creation of a reliable protocol for clinical thermometry. Similarly, the refinement of FIT will take time. For example, a recent meta-analysis suggested that the systems do not automatically improve therapy outcomes for all clients, only for clients at risk of deterioration (a limitation Michael Lambert had previously acknowledged). And, of course, the metrics are not helpful unless clinicians know how to use them to improve treatment. Collecting psychotherapy data is a key step in better understanding our patients. But it can’t cure mental illness any more than sticking a thermometer in a patient’s mouth can, by itself, treat the flu.
ROBBIE BABINS-WAGNER has experienced both the extraordinary potential and the severe growing pains associated with using metrics. She’s the CEO of the Calgary Counselling Centre, a large community mental-health organization in Western Canada with 24 staff therapists and 55 trainees. I first heard of the CCC when, a number of years ago, I asked Scott Miller for examples of clinics that were implementing FIT. “You’ve got to talk with Robbie,” he said. “She’s at the leading edge, a decade ahead of everyone else.”
Babins-Wagner had 14 years of clinical experience when the CCC hired her as director of counseling in 1992. Looking for ways to improve the center, she read about the new metrics system created by Michael Lambert, and initiated a plan to implement psycho therapy metrics at the CCC—working collaboratively with the staff along the way. As Babins-Wagner put it in a paper she later co-authored, the hope was to use the FIT data to help create a “climate for therapist improvement.”
At the conclusion of a four-year trial, Babins-Wagner aggregated and analyzed the data the CCC had collected. While the average outcomes were good, it turned out that only half of the therapists were using FIT—even though everyone had been asked to. Because of the thick cloak of privacy that protects the therapy room, skeptics had been able to ignore the instructions they’d been given.
The most common complaints from therapists were “the data is wrong, we shouldn’t have to do it, and I know better,” Babins-Wagner says. “Meaning that my intuition tells me—my experience in the sessions tells me—that I know how my client is doing.”
Babins-Wagner listened to the therapists’ concerns and requested feedback on how to improve the metrics system. She also clarified that collecting outcome data was mandatory. Within a few months, 40 percent of the therapists resigned.
Yet Babins-Wagner was unyielding, and her perseverance has paid off. Simon Goldberg of the University of Wisconsin at Madison recently examined data from the CCC (I was one of eight co-authors on the study, but Goldberg did the vast majority of the work) and found a tiny but steady improvement in clinical effectiveness every year for seven years. As far as I can tell, this is only the second time year-over-year improvement in therapist effectiveness— measured by improved client outcomes— has been empirically demonstrated in psychotherapy research. (Other studies do show improvement in therapists’ “competence” in using models or “adherence” to those models— but a meta-analysis of 36 studies showed that “therapist adherence and competence play little role in determining symptom change.”)
Despite these impressive results, adjusting to the use of data remains difficult for many. Michelle Keough, a counselor at the CCC, told me she had been skeptical of the system when she’d started as an intern a few years back. “I had some apprehension in terms of how a graph and how stats could be used in a way to benefit clients,” she recalled. She also worried that it could cause tension and impair her relationship with patients. But over time, she said, she came to realize the system actually improves communication: “Now I can’t imagine not using it in my practice.” She told me many of the trainees she supervises go through a similar journey—from early apprehension to embracing the system.
The intuitive reluctance to use metrics is something I understand well. It’s never pleasant to have my blind spots pointed out. It’s humbling at best, and humiliating at worst. It requires a daily fight with my own brain, which persistently tells me to ignore or distrust any new data that don’t fit my assumptions and expectations.
But while I know how difficult it is for therapists to override their gut instincts in favor of cold data, I also know, firsthand, how difficult it is for a patient when a therapist simply cannot see his or her condition accurately. In my early 30s, before I became a therapist, the anxiety and depression I had confronted as a teenager returned, and I started using drugs to selfmedicate. When I realized I was in trouble, I reentered therapy with the psychologist who had previously helped me so effectively. However, this time around, our sessions didn’t seem to help. As had happened with Grace and me, I sat squarely in the middle of my own therapist’s blind spot. He did not use metrics, and he simply never believed that I was deteriorating, even when I started coming to sessions high.
Luckily, I had friends who encouraged me to seek out more effective therapy. I used to be angry at my former therapist. But now I’m more understanding: I’ve failed to anticipate plenty of deteriorations and dropouts among my own patients. We therapists need to always remain aware that there is much we can’t see in the fog—and be open to tools that might compensate for our limited vision.
IN JUNE’S CASE, metrics and performance feedback may have saved her life. Like a psychological homing beacon, the feedback program drew my attention to her deterioration. And being alerted to the problem opened the door to finding a solution. I got June’s permission to record one of our sessions, and showed the video to a consultant, Jon Frederickson. Originally trained as a classical musician, Frederickson switched careers in his 30s. In graduate school, he was surprised that psychotherapy training didn’t use some of the principles—such as frequent performance feedback—that form the foundation of musical training. Now, with a few decades of experience as a therapist, Frederickson specializes in helping other therapists improve their effectiveness.
We watched the video of June’s therapy session together, and Frederickson spotted a few problems. For one thing, he observed that June was holding her stomach—suggesting that her anxiety was making her nauseated. He also noticed that during the session, June diligently practiced the skills I taught her, but never talked about how she actually felt while doing so. “You’ve unintentionally gotten into a top-down relationship with her, where you are in the teacher role, and she is trying to be a good student by minimizing her symptoms,” he explained. “She isn’t telling you about her discomfort out of deference to you.”
USING METRICS REQUIRES A FIGHT WITH MY BRAIN, WHICH TELLS ME TO IGNORE OR DISTRUST ANY NEW DATA THAT DON’T FIT MY EXPECTATIONS.
When I asked how I could help her, he counseled me to get out of the authority role, approach June as an equal partner, and help her acknowledge her pain and anxiety rather than defer to me. When I saw June next, I told her what Frederickson had said, and asked what she thought. She was quiet for a moment, then I saw a faint glimmer of a smile on her face. “He may be right,” she admitted.
We agreed to approach our work together with more attentiveness to her anxiety and more equal collaboration. This was not easy for either of us. June felt a constant internal pull to adopt the submissive role of a good student and minimize her painful symptoms, and I frequently felt a pull to teach her more skills rather than listen to her more carefully. Throughout this process, the feedback program served as an indispensable guide, helping us see what we were both tempted to ignore. Every time the system gave me an alert that June’s symptoms were worsening and she was back at risk of deterioration, I videotaped a session and got a consultation to help fix my errors.
Over the following year, June’s anxiety gradually eased. Two years later, she graduated from college with honors. In our last session, I asked her what about our therapy she thought had helped her the most. “You saw me,” she said with a shy smile, “from so far away.” Then she reached out and shook my hand for the very first time.
Panic Attacks
Imagine being in a pandemic, isolated and inert. Your life feels out of control, and you are stressed, not sleeping well. Then a raft of bewildering new symptoms arrive – perhaps your heart races unexpectedly, or you feel lightheaded. Maybe your stomach churns and parts of your body seem to have an alarming life of their own, all insisting something is badly wrong. You are less afraid of the pandemic than of the person you have now become.
Most terrifying of all is the invasive flashes of fear in the absence of any specific threat.
Back in 1927, this was 24-year-old Claire Weekes. A brilliant young scholar on her way to becoming the first woman to attain a doctorate of science at the University of Sydney, Weekes had developed an infection of the tonsils, lost weight and started having heart palpitations. Her local doctor, with scant evidence, concluded that she had the dreaded disease of the day, tuberculosis, and she was shunted off to a sanatorium outside the city.
‘I thought I was dying,’ she recalled in a letter to a friend.
Enforced idleness and isolation left her ruminating on the still unexplained palpitations, amplifying her general distress. Upon discharge after six months, she felt worse than when she went in. What had become of the normal, happy young woman she was not so long ago?
Flash forward to 1962 and the 59-year-old Dr Claire Weekes was working as a general practitioner, having retrained in medicine after an earlier stellar career in science during which she earned an international reputation in evolutionary biology. That year she also wrote her first book, the global bestseller Self-Help for Your Nerves.
The book was born from the furnace of the two years of high anxiety Weekes had endured in her 20s. Back then, her saviour came in the form of a soldier friend who had fought in the First World War. He explained how shellshocked soldiers had been programmed by fear and suffered similar physical symptoms to her own. Her heart continued to race, he told her, because she was frightened of it. Don’t fight the fear, he advised her, but try to ‘float’ past it. For Weekes, this was a revelation and a huge relief. She took his advice and recovered quite quickly.
Weekes believed that fear was the driver of much nervous suffering, and that many had simply been ‘tricked by their nerves’
The bitter experience of her youth – buttressed by her studies in biology, the nervous system and medicine – contributed to her becoming a doctor deeply attentive to her anxious patients. Weekes soon found herself in huge demand. Her phone rang day and night. Other doctors came to recognise her gift for treating what she called ‘nervous illness’ and sent her more patients.
Critical of Freudian psychoanalysis with its emphasis on sex and tracking down the original cause of distress through talk therapy, Weekes boasted of getting patients off ‘the old Viennese couch … [and out] into the world’. She believed that fear was the driver of much nervous suffering, and that many had simply been ‘tricked by their nerves’. An original cause certainly needed attention if it was still fuelling distress, but Weekes discerned that often it took second place to people’s fear of ‘the state they were in’.
Weekes exposed fear’s vast menu of bewildering and distressing symptoms, and became famous for explaining the mind-body connection. People recognised themselves in the words she used, borrowed from her patients: ‘All tied up.’ ‘Headaches.’ ‘Tired and weary.’ ‘Palpitations.’ ‘Dreadful.’ ‘Nervous.’ ‘Sharp pain under the heart.’ ‘No interest.’ ‘Restless.’ ‘My heart beats like lead.’ ‘I have a heavy lump of dough in my stomach.’ ‘Heart-shakes.’ The nervous system seemed infinitely inventive. Then, bewilderment and fear of ‘what happens next’ took over.
Yet far from being possessed or crazy, Weekes explained to her readers that they were ordinary people who could cure themselves once they understood how their nerves had been ‘sensitised’ and then, by following some simple steps, learn to control the savage flame of fear. ‘It is very much an illness of your attitude to fear,’ she counselled in Peace from Nervous Suffering (1972).
Weekes was effectively treating the panic attack before it even had a name. She also believed that fear is the common thread that runs through many different psychological ‘disorders’, such as obsessive-compulsive disorder (OCD), phobias, general anxiety disorder, depression and post-traumatic stress disorder (PTSD), to use the formal diagnostic terms that had yet to be invented in her time. In this sense, Weekes anticipated contemporary ‘transdiagnostic’ approaches to mental health that acknowledge the commonalities across supposedly separate disorders. Weekes credited her scientific training with allowing her to see what she called ‘the trunk of the tree’ rather than being distracted by the branches.
A circuit-breaker was required. The one she picked was the one she learned from her friend, the soldier: don’t fight fear
In the 1930s, the US president Franklin Roosevelt memorably observed that ‘the only thing we have to fear is fear itself’. This concept is at the heart of Weekes’s unique work. ‘[Th]e nervous person must understand that when he panics, he feels not one fear, as he supposes, but two separate fears. I call these the first and second fear,’ she wrote in 1972.
Five years later, in her address to the Association for the Advancement of Psychotherapy, Weekes explained that the first fear is easy to identify. It is survival mode, that automatic instinct that means you duck a falling brick or a punch without thought. You don’t have to think. The body thinks for you. Today it would be called by its shorthand ‘fight, flight or freeze’. In what she calls a ‘sensitised’ person – someone who has been ill, burdened by worry or, say, fought in the trenches – it can come out of the blue, and be electric in its swiftness and ‘so out of proportion to the danger causing it’ that ‘it cannot be readily dismissed’.
So, shaken badly by this random jolt of first fear, the sufferer inevitably adds ‘second fear’ by worrying about this inexplicably alarming moment. Weekes said that the second fear could be recognised by its prefix ‘Oh my goodness!’ or ‘What if?’ to which any imaginings can be added. This kickstarts the fear-adrenaline-fear cycle, in which heart palpitations, among a medley of other symptoms, play such a powerful part. A circuit-breaker was required. The one she picked was the one she learned from her friend, the soldier: don’t fight fear.
Weekes distilled her understanding of ‘nervous illness’ into a six-word mantra for overcoming anxiety: face, accept, float, let time pass. In Self-Help for Your Nerves, she said that sufferers usually spent their time counterproductively:
Running away, not facing.
Fighting, not accepting.
Arresting and ‘listening in’, not floating past.
Being impatient with time, not letting time pass.
The nervously ill person usually notices each new symptom in alarm, listens-in in apprehension, and yet at the same time is afraid to examine that too closely for fear he will make it worse. He agitatedly seeks occupation to try to force forgetfulness. This is running away, not facing.
He may try to cope with the unwelcome feelings by tensing himself against them, thinking: ‘I must not let this get the better of me!’ He is fighting, not accepting and floating.
Also he keeps looking back and worrying because so much time has passed and he is not yet cured, as if there is an evil spirit which could be exorcised if only he, or the doctor knew how to do it. He is impatient with time; not willing to let time pass.
Of all those words ‘accept’ or, as she would later explain in notes in the margin, ‘don’t fight’, was fundamental. For it was only with such acceptance that this first uncontrollable fear, the primitive fight-or-flight alarm, which was now being triggered in inappropriate circumstances, could be disabled. It was not just ‘putting up with’ the distress. The objective was to yield entirely to first fear, allow it to burn itself out without adding the fuel of second fear.
Weekes set out the science behind her method. Her mantra, with its echoes of Eastern mysticism, was in fact an invitation to the parasympathetic nervous system to do its job and bring the body back into what professionals would call homeostasis, and what the rest of us would understand as peace.
Today, fear has found its way to the front of the queue as a driver of mental distress and trauma.
‘There is no such thing as Dr Weekes’s method,’ she said in her second book. ‘I teach nature’s method. I am showing you what nature will do if you give her a chance.’ She found a huge grateful public, and four more books followed the first. Her advice worked for people who were suicidal as well as for over-stressed individuals.
Weekes found a hungry audience but the mental health professionals of her day were indifferent, or worse. This was painful for Weekes, who was conscious of her academic achievements. One leading Australian specialist admitted to me he had originally regarded her book as the equivalent of ‘advice from grandma’. He recanted years later, acknowledging her pioneering work. Few others conceded the point. To them, Weekes was writing about ‘nerves’ which didn’t sound very modern. Worse, she was writing popular self-help books.
However, the biology of fear and the role of the nervous system are back in fashion now. In a recent interview about emotional regulation, Allan Schore, a neuropsychologist at the University of California, Los Angeles, declared: ‘It’s all about the autonomic nervous system,’ which he noted was ignored for ‘much of the last century’. Today, fear has found its way to the front of the queue as a driver of mental distress and trauma. Brain plasticity has also gained popular currency – and what was Weekes’s emphasis on ‘acceptance’ other than a version of retraining the brain out of its habitual responses?
The notion of ‘acceptance’ has found an unassailable place in modern treatment. It even has its own banner – acceptance and commitment therapy (ACT) – recognised as part of the so-called third wave of cognitive behavioural therapy. The founder of ACT, Steven Hayes, describes acceptance as ‘facing the monster’ and ‘walking towards it’ and, like Weekes, he believes it is a necessary step on the path to freedom from distressing symptoms. The prescience of Weekes’s approach also extends to the contemporary understanding of chronic pain, in which fighting physical pain is recognised as being as counterproductive as fighting mental pain.
Weekes was convinced she was ahead of her time and, decades after her death, her approach to anxiety, grounded in an understanding of neurophysiology, remains fresh. For instance, in the 1990s, the US psychiatrist Stephen Porges coined the influential polyvagal theory, which describes the neurophysiological basis of sensitisation to fear. Later, another psychiatrist, Bessel van der Kolk in his bestseller The Body Keeps the Score (2014), recognised the physiology of trauma.
Echoes of Weekes’s approach can also be found in the writings of the US neuroscientist Joseph LeDoux, who makes a crucial distinction between the system in the brain that detects and responds to threats – the fight, flight or freeze mechanism (where evolution does the thinking, as he puts it) – and the system that generates conscious feelings of fear.
Although Weekes was largely ignored by psychiatry and psychology in her lifetime, the reading public educated the medical professionals about what worked for them. And through her books and public engagements, Weekes slowly and invisibly pioneered a change in the treatment of anxiety that continues to this day.