I have a special interest in psychological trauma and its treatment. I was reading this article in Psychology Today by Jonathan Shedler, a clinical professor at the University of Colorado School of Medicine. This article has been doing the rounds in various professional circles this week and I thought it was interesting enough and accessible enough to share here. Basically, he is highly critical of the new guidelines issued by the American Psychological Association for treating people with posttraumatic stress disorder (PTSD) and other types of psychological trauma. The new guidelines recommend that therapists use brief forms of trauma-focussed cognitive behavioural therapy (CBT), that are highly manualised. The recommendations were developed based on randomised controlled trials (RCT's) of psychological therapy with patients conducted over 16-week periods. Shedler asserts that because RCT's are the only type of study looked at, they ignore other forms of evidence available. In fact he is even so critical to argue that in many other areas of science (particularly the hard sciences of chemistry, biology, and physics) do not place such heavy reliance on RCT's. RCT's are often looked at as the "gold standard" in psychology for psychological treatment outcome studies. He argues that in many other areas of science RCT's have not been relied upon to provide important evidence regarding things we now take for granted and provides some compelling examples. One major problem that Shedler has identified with this approach of limiting research to only brief CBT, is that there is considerable evidence to show that (especially in the case of persons with significant psychological trauma) psychological therapy is "dose responsive", in that it takes time for people to get better. Generally, it takes at least 20 sessions or six months of weekly therapy before half of patients show any meaningful improvement in psychological functioning and about 40 sessions of weekly therapy before approximately 75% of people show any meaningful improvement. His criticism is that given the studies that have been relied upon are of only 16-weeks duration or less, they are essentially studying therapy that is of inadequate duration, especially in the case of psychological trauma. Shedler argues that the new guidelines seem to be driven more by economic concerns, rather than what is best for patients. He also cites some significant problems associated with relying exclusively on evidence collected from RCT's. Shedler observed that in many of the best studies that have been used to study brief forms of CBT for trauma, most of the patients did not get any better. Another interesting finding is that at least half of the patients dropped out of treatment in these studies; about 60% of patients still had PTSD at the end of the 16 sessions of treatment; and all of them were still clinically depressed at the conclusion of these studies. Additionally, when patients were assessed six months later they were no better than the patients who were assigned to a control condition. He further argues that many successful longer-term therapies have been excluded from the guidelines and provides some further critique of the guidelines along with some general well-established principles in the treatment of psychological trauma. It all makes for some very interesting reading. I have provided a link to the article below.
More On The Value Of Dreams In Therapy.
This is a continuation of my last blog topic on dreams in psychotherapy. In the video below, Jungian psychoanalyst James Hollis talks about the use of dreams in therapy and what working with a dream in therapy might look like.
The Value of Dreams In Therapy.
An article in Psychology Today has brought to my attention that the month of November marks the 118th anniversary of Sigmund Freud's The Interpretation of Dreams. This was of course, the book that started the popular idea that dreams could be useful in therapy. It is always a pleasure when someone comes into my consulting room with a dream to share. An old mentor of mine used to call it "an invaluable gift the patient gives". In my experience working with a dream in therapy can often help to clarify things for people and even help people get unstuck when they get stuck in therapy. Dreams can help us get in touch with our inner wisdom and point the way forward. Even in my own life I have found that dreams can point the way forward with certain problems, remind us of the things that are important in life, challenge us when we have not lived up to our values, reconcile internal conflicts, reveal things to us about ourselves that we might not like to see, and help add a richness, depth, and meaning to life. Recurring dreams often have very important messages for us. One of the reasons that they keep recurring is because we are not getting the message they are trying to give us. The article below is an excelent reminder of how wonderful dreams can be in adding another dimension to our inner life. To read the article from Psychology Today, just click the link below.
Dreams Help Us Connect with our Inner World
Should I Just Ignore My Negative Feelings and Just Think Positive? Well Not So Fast.
This post is related to my last post and is connected to the avoidance of emotion and how we really feel. At different times people have come to me and have said something similar to the following: "Should I try to ignore my negative thoughts and feelings and just think positive? I have tried to do this but I still end up feeling bad, why is this?" or they might say "I'm a positive person and I just think positively". When people tell me they "just think positively", I often notice that when telling me about themselves and their life history, that they have had fairly traumatic lives and that they often seem to be barely holding it together. So to the question "Should I just ignore my negative feelings and just think positive"? Well the short answer is no. Whilst having a positive attitude towards life can be a good thing, many people use so-called positive thinking as a way to avoid very troubling and painful feelings. In these cases "being positive" so to speak, can end up being a very negative thing. In doing this, people end up being negative by avoiding their real feelings and can consequently intensify their negative experience of life. Surprisingly, the positive thing to do in these cases is to accept our negative and unpleasant feelings, without trying to avoid them. Some research has found that people who habitually try to avoid negative feelings often feel worse and people who are able to accept their negative feelings without judgment or criticism generally are less troubled by negative emotions. Good mental health often involves being able to accept ourselves as we are "in the moment" and have a good tolerance of different emotions and ambiguity. Mindfulness practice often encourages people to do this, as does psychoanalytically based therapies. Being real with ourselves about how we really feel, can help us to have better relationships with others and accept ourselves as people. After all, we don't have to be perfect people, just real and true to ourselves. I have included a link below to an article on this that cites some recent scientific research published in the prestigious Journal of Personality and Social Psychology on this very topic. I hope you enjoy reading it. Just click the link below to read about how avoiding bad feelings can make you feel worse.
Feeling Bad About Feeling Bad? Embrace Negative Emotions Instead, Study Says.
Why Are Emotions Important? And Why Should I Talk About My Feelings?
Sometimes people wonder why we psychologists and psychotherapists want people to take about their feelings rather than just ignore them. The simple reason is that we psychologists and psychotherapists want people to have healthy emotional lives. Having access to a rich emotional experience is often a sign good mental health. This does not mean that your emotions are all over the place but, that you are able to have access to your emotions and express them as appropriate. It helps make you a better friend, lover, spouse, parent and even co-worker. Some people try to ignore and even deny their emotional experience and this means that emotions can come out in other less acceptable and even troubling ways, such as taking your anger about something at work on your partner and/or children. Some people deny their emotions so much and become so cut off from their feelings that they become almost emotionally numb and a bit like robots. This often makes it hard for others to get close to them and consequently these people can have impoverished relationships with others. The reasons for ignoring, repressing, numbing out, and citing off emotions can be many but, often it comes from how we learned to cope with our feeling when we were very young. In some cases parents or significant care givers may not have been responsive to our needs and may not have allowed emotional experience in us as children. In other cases parents or care givers may not have done anything wrong and may have just been overwhelmed by events in their own lives at the time when we were young and may not have been able to even take care of their own emotional needs. In some cases we may have been exposed to significant traumatic events as children or even later and this can have significant consequences for our emotional lives and wellbeing. Whatever the case, psychotherapy can be a good opportunity to reclaim our emotions and get healthy. Our emotions can often give us clues as to what our needs are. The trick then is to find healthy ways to get our needs met and connect better with others and ultimately ourselves.
The following video shows how it is important to pay attention to our emotions.
Am I Enough? Excessive Hope, and What Is Good Enough.
Whilst it is good in life for people to have hope, some people tyrannise themselves with excessive hope. These people become perfectionistic and unfortunately, they can become very depressed as a result or feel faulty as people. In my work it is not uncommon for people to come to me feeling that they are somehow just not enough as people. This often involves busy parents feeling that they are not good enough and need to be more, or they may not feel good enough as a romantic partner, son or daughter, as an employee, or even as a boss. People often have unrealistic expectations of themselves. This can even present itself in the therapy room with me and they may feel worried that I will judge them as not being good enough in some way. The British psychiatrist and psychoanalyst, D.W. Winnicott often noticed this in people and emphasised that people did not need to be perfect, but just good enough. This however, is often a very difficult feeling to come to terms with and it can be hard to feel the level of self-acceptance needed to feel good enough. Sometimes when growing up our parents, teachers, and even society itself can place unrealistic expectations on us that negatively impacts our self-worth and people often struggle with these feelings of inadequacy all their lives, believing that they can and should be more. This feeling can even persist in people when they achieve the very goals that they think will make them better and give them what they want and need. Sometimes it is very hard to feel satisfied with our accomplishments in life, even when those accomplishments result in high accolades and all of the trimmings of success that they dreamed of. In these cases, it is often valuable to look below the surface into the inner life or unconscious world of the person to see what it is that causing them to suffer from excessive hope and unrelenting high expectations of themselves, that prevents them from finding self-acceptance. After all, nobody is ever perfect. The following video looks at how not feeling good enough may play out and how sometimes even ordinary accomplishments are indeed good enough.
What Causes Repetitive Patterns In Our Lives and What Is The Dynamic Unconscious?
People often wonder why they keep finding themselves in dysfunctional relationship after dysfunctional relationship. This is often very distressing for people, especially when they promise themselves that their next relationship will be much better and healthier. Likewise, they may wonder why they do things as a parent that they found upsetting when their parents did it to them and feel guilty about it. They may also wonder why they keep having similar negative experiences with bosses at work. The answer to these repetitive patterns is generally explained in psychoanalytic theory by the concept of the dynamic unconscious. Whilst the concept of the dynamic unconscious was popularised by Sigmund Freud, the idea is older than Freud. Psychoanalytic/psychodynamic psychotherapy and psychoanalysis tries to help people look at what might be motivating these repetitive patterns by the therapist and client/patient working together in a collaborative manner to understand these patterns in terms of the unconscious mind. The unconscious mind cannot be observed directly, so the therapist and client/patient look for what is in the unconscious mind, by looking at how the unconscious reveals itself. This is often in the form of repetitive patterns, mistakes, dreams, symptoms, emotions, daydreams, fantasies, and other experiences that might seem unusual. In the following video, psychiatrist and psychoanalyst Dr Chris Heath explains a little about repetitive patterns and the dynamic unconscious.
Psychodynamic Psychotherapy Found To Be Equivalent Across Disorders.
This article from The American Psychiatric Association's "Psychiatric News" reports on a recently published study from The American Journal of Psychiatry Advance, that found psychodynamic/psychoanalytic psychotherapy to be equivalent to most other forms of treatment when it came to a number of different psychological disorders. The study employed a meta-analysis to look at a number randomized controlled trials of common treatments for a range of disorders. They employed a methodology that is even more stringent to many other studies that have found similar results. Psychodynamic/psychoanalytic psychotherapy was found to be at least equivalent to cognitive behaviour therapy (CBT) with a range of psychological disorders and in some cases even superior to CBT. It makes for interesting reading and you can read the report from Psychiatric News by clicking the link below.
Psychodynamic Psychotherapy Found to be Equivalent Across Disorders
What is Psychoanalysis?
This Is a Fun Video Explaining Some Basic Concepts About Psychoanalysis and Psychoanalytic Psychotherapy.