Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?

Sunday, June 23, 2013

On Humility, and the Limits of Formal Education, or More on Arrogance

I know everybody's watched it, but have any of you read the series A Song of Ice and Fire? I'm on Book Four, A Feast for Crows. When I'm not working, I think, I live more in Westeros than I do in America. It's that intriguing, enchanting, absorbing. And the other night, I came across this passage, in the Prologue: 

"The night before an acolyte says his vows, he must stand a vigil in the vault. No lantern is permitted him, no torch, no lamp, no taper . . . only a candle of obsidian. He must spend the night in darkness, unless he can light that candle. Some will try. The foolish and the stubborn, those who have made a study of these so-called higher mysteries. Often they cut their fingers, for the ridges on the candles are said to be as sharp as razors. Then, with bloody hands, they must wait upon the dawn, brooding on their failure. Wiser men simply go to sleep, or spend their night in prayer, but every year there are always a few who must try."  

". . . what's the use of a candle that casts no light?"

"It is a lesson," Armen said, "the last lesson we must learn before we don our
maestcr's chains. The glass candle is meant to represent truth and learning,
rare and beautiful and fragile things. It is made in the shape of a candle to
remind us that a maester must cast light wherever he serves, and it is sharp to
remind us that knowledge can be dangerous. Wise men may grow arrogant in their wisdom, but a maester must alwavs remain humble. The glass candle reminds us of that as well. Even after he has said his vow and donned his chain and gone forth to serve, a maester will think back on the darkness of his vigil and remember how nothing that he did could make the candle burn. . . for even with knowledge, some things are not possible."
That stopped me in my tracks. I read it again. And then once more. And I wished that (or something like it, since we have neither dragons nor dragon glass in 21st-century America) had been our last lesson, perhaps the night before our hooding ceremony, since we don't don chains like the maesters of Westeros.

How I wish they'd taught us how to simply sit with the dark. 

I have been a therapist for 33 years, and in that time I have seen many who have grown arrogant--in their knowledge, if not their wisdom. I have seen a few use their knowledge in dangerous ways. And I have seen not a few who think that because they have the terminal degree, they must know everything. I have known psychologists trained in the scientist/practitioner tradition who abandoned all pretense at critical thinking the evening of the day they defended their dissertations. I have known psychologists who thought they had nothing else to learn and shut their minds to new ideas and new data. And I've met very few who didn't hold themselves above the less-educated. The whole profession has come to think of itself as wholly superior to masters-level practitioners, and spends a lot of time dissing them and expending energy defending turf from them that might be put to better use elsewhere. But that is another rant for another day.

Worse, and there is another rant coming on this one in a future post, psychology has come to believe that they have the power to change people. Therapy has become and "intervention" to be "delivered" as if to a  retail consumer and its success is to be measured in "behavioral outcomes".

Our clients believe this, too, and will say to us, "What do we do about it?" or, "I am ready to be fixed, now." And when we can't, they ask us, "What is the use of a candle that casts no light?" So we are seduced into trying, only to bloody our fingers once more.

As the next passage in the Prologue to A Feast for Crows makes plain, the obsidian candle can give off light -- but that's not under our control.
 "I know what I saw. The light was queer and bright, much brighter than any
beeswax or tallow- candle. It cast strange shadows and the flame never
flickered, not even when a draft blew through the open door behind me."

Armen crossed his arms. "Obsidian does not burn."

"Dragonglass.'' Pate said. "The smallfolk call it dragonglass." Somehow that seemed important.

"They do," mused Alleras, the Sphinx, "and if there are dragons in the world
again . . ."

"Dragons and darker things,'' said Leo.
The dragonglass candle is in this sense a metaphor for healing, and gives another bit to the lesson Armen describes. Illness, unhappiness, neurosis--whatever you may wish to call it--is contained within us, and so is healing. There are things we may say or do, or not say or do in a session, things that grew out of our learning (not all of which is formal, by the way) that enter into a person in the same way that a maester's antidote enters the body to combat a poison, and we may contribute to a person's healing in that way. But in the same way that the antidote and the poison do battle inside the victim's body, with the body itself as one of the combatants, so, too, is psychological healing an inside job. We have very little power compared to what resides in you.

And powers far greater than either of us may determine whether that candle burns.
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Monday, June 17, 2013

From the In Box

The most recent edition of Professional Psychology: Research and Practice landed in my In Box this week, and in it was an interesting study on a multifamily group program for vets with PTSD at the Oklahoma City Veterans Affairs Medical Center (VAMC). 

It has long been known that while good family support helps people recover from PTSD, the PTSD itself can alienate the sufferer from family members, depriving them of support. Bad family relationships actually interfere with treatment. With this in mind, the Oklahoma City VAMC set out to adapt a multi-family group approach to the specific needs of veterans. They call it REACH, for Reaching out to Educate and Assist Caring, Healthy families. 

They've collected data from about 95% of their participants, over a period of a little over four years, and they believe that it works. But it's the first such study specifically with veterans diagnosed with PTSD, and it's a small study so these results are very preliminary.

This was a longitudinal study with no control group, meaning there were no vets wait-listed for it or in some other form of treatment (comparison groups of both types would have been ideal). And the data on improvement was reported by the study participants themselves, to the therapists who both provided the treatment and conducted the research. As with any study of this nature, it may appear to work better than it apparently does, for a couple of reasons:
  1. People can get better over time, either because 'time heals all wounds,' or due to other things occurring in their lives during the course of the study. The authors performed a statistical test for this, but still, a control group would have helped to tease out how much improvement is due to the program itself, and how much due just to life going on. And since some study participants were receiving other treatments at the same time, there's no telling exactly what improvements are due exclusively to REACH.
  2. It is well known that when people invest a lot of time and energy in something, there's a psychological bias towards finding it worthwhile. This is true for researchers and participants, and is bound, in this kind of study, to influence the reporting and interpreting of results.
One thing that makes the results stronger in this case than in some studies to come out of the VA system in recent years is that the researchers didn't "cherry-pick" their participants, which is to say that nearly everybody who wanted in, got in. Cherry-picking is frequently a problem with treatment efficacy studies, as anyone with co-existing conditions, or who is taking medications, is ruled out, and definitions of the diagnoses that get you into the study are very narrowly defined. This results in the study population not looking much like a typical clinical population. For the purposes of this study, persons with active addictions or who were suicidal or homicidal were screened out, but these are criteria that are almost universally applied in clinical practice as well, so does not much affect the applicability of the results. 

Even better, their definition of "family" was open and welcoming: A veteran could bring her or his adult significant other of nearly any description -- a lover, a spouse, a parent, a sibling, an adult child, or even a friend. 

Veterans ranged in age from 22 to 85, which would include the Korean War if not World War II, and that both adds to and detracts from the strength of the study. Different "cohorts" (age groups) serving in different wars could have widely varying backgrounds and combat experiences and therefore respond very differently to a treatment. Also, older vets, by definition, have a more chronic form of PTSD. An average age, as in this study, of 55.8 years means that this is something that may not work as well for very young folk just back from Afghanistan or Iraq with their differing upbringings, combat experiences, and acute onset of PTSD as it does for VietNam-era or Persian Gulf veterans.

Unfortunately, the study population wound up being almost all white (non-Hispanic) straight males, so we don't know, pending further study, whether this program would be equally helpful to people of color, women, LGBTQQI folk -- never mind veterans or family members who fall into all three categories at once! 

Of course, there's no reason to believe that it wouldn't work for a wider range of folk, since groups in general have been studied for over half a century now and the results are consistent. It works for nearly everybody, for nearly every problem. It's just that with this study, the authors could not claim with any certainty that this particular protocol would work for other than adult, straight, white males of a certain age.

From the description, REACH appears to be a nicely-structured program, with a generous time allowance for assessment and engagement with the program, and a nice consolidation/follow-up phase to help families maintain and elaborate on their gains. At the same time, it does not appear to be so structured as to be a cook-book-y, overly technical approach. And folks liked it! Some of them reported that the meetings were the high point of their weeks. Participants knew more about PTSD when it ended than they had when it began, and some of their symptoms improved. They learned coping skills, and their relationships improved. 

The authors note that in a study of this sort, while you can say you're pretty sure the program helps, it's hard to say exactly what components of the program are most -- or least -- effective. That makes it a bit of a crapshoot whether you can replicate the results elsewhere. What if, for example, one of the only four psychologists running the study is just especially talented, and no matter what she did, her people would get better? On the other hand, if the standard curative factors of all effective groups were in operation here, you could do REACH or any other variation of multifamily group and get the same results anywhere. This is why we like to see multi-center studies, or studies replicated elsewhere producing similar results. However, when you are running only 4-6 vets and their families through at a time, and the whole process takes nine months, as this one does, we'd be waiting a minimum of four more years for the next study -- and that's not counting the time to organize and fund a study, write it up, and get it into print! So I think you will see a lot of psychologists running with this one, and soon. 

Although VA is mandated to provide some form of family education, the REACH program specifically does not appear to be available at our local (Atlanta) VAMC yet. However, the study's authors will make the materials needed to conduct the group available to any psychologist who wishes to lead one. If a half-a-dozen or so of you are interested, I think we could have one up and running by the end of summer. Just let me know!
Fischer, E. P., Sherman, M. D., Han, X., & Owen, R. R. (2013). Outcomes of
    participation in the REACH multifamily group program for veterans with PTSD and
    their families. Professional Psychology: Research and Practice (44), 127-134.
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Monday, June 10, 2013

Think With Your Whole Body

We like, in Western society at least, to think of our mental or spiritual selves as "me" and our embodied selves as separate, an "it". One effect of that is that we get out of touch with what's going on with and in our bodies, and wander off in our minds--into the future, the past, or some parallel universe that is neither past nor future, but which is certainly not here or now either. And the primary effect of that, I have found, is bodily neglect and abuse along with a good deal of unnecessary tension and stress. 

But what if we treated our minds and bodies as the unified experience that they are? What if we thought of our minds as one with our bodies, and rested and fed it like the organism it is? What if we treated our bodies like part of our minds and attended to what it was telling us about our selves and the world all of the time? Our bodies are powerful sources of constant streams of information and wisdom, and when we only think with the frontal lobes, we're only using a fraction of the potential available to us. 

Next time you are, say, eating breakfast, and notice that your mind is wandering, try bringing it back. Take a nice, normal breath in and attend to it -- really attend to it. Notice what it feels like coming in -- how the air feels passing over your upper lip, into your nostrils, down your throat. Notice the rise of your chest. Can you scent your breakfast? Taste it? Bet you hadn't even noticed your breakfast while you were doing all that wool-gathering!

When you breathe out gently, slowly, naturally, also notice what that's like. Then, what do you see? If you are like me, you might have been completely blind for some time to the look of the morning sun slanting through the trees in your yard, or to activity of animals or people around you. What have you not been hearing that you can become aware of now?  The refrigerator humming? The dog's toenails on the kitchen linoleum? Or perhaps you were numb to the warmth of the mug in your hands, the feel of the chair under your butt or your elbows on the table.

And as you do all this, notice how your body relaxes. I'll bet where your mind was before wasn't fun. You were missing someone or something from the past, regretting something you had done or failed to do, planning your workday, or worrying about something in the future that might not even come to pass. And your body was responding by becoming tense. (All that tension, over time, besides not being much fun is rough on your health.) You may find that 99 times out of 100 when you check in using this technique, your mind was yelling that the sky is falling but when you listen to your body it will tell you that right this two seconds it's actually all quite good. 

And while you were in that place that is neither here nor now, you may have neglected to notice that your body was stiffening in its current position and needed to adjust, or that you were tired, or cold, or needed to pee. That kind of neglect leads to abuse. We don't rest our bodies, or feed us, or clothe us warmly enough, or move ourselves around to keep limber and strong. Or if we do feed ourselves, we eat stuff we don't even enjoy because we're not paying attention to what we have a taste for or when we're full. We put ourselves and leave ourselves in situations we don't like, with people who are not good for us, in the meantime bypassing or at least not fully attending to good relationships and pleasurable activities because we are trying to think our way through life with our frontal lobes and ignoring what our bodies are telling us. We're where we think we should be, doing what we think we should, and we've doped that out with a fraction of the data we need to make genuinely good decisions.

It's a really powerful skill, thinking with your whole body. And although the daily practice of sitting meditation or yoga helps you get better at it, neither is absolutely necessary. You can do it any time you notice that you are all in your head and someplace else: Just take a nice, normal, gentle breath in, following it, and then let it out, again simply being aware of it. And then become mindful of the rest of your body as well. Mindful -- as in, fill your mind with this and kind of let all the thinking activity go for a minute. What's your belly doing, saying? Your feet? Your hands? Your skin? and so forth until you have developed an awareness of all of your senses and parts and systems. Hold all of that in your mind at the same time for a bit. If you do it often during the day, you'll find it becoming more natural to do more of the time. 

Try it. You'll like it.
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