BLOG: Reflecting Surfaces

Moneyball

April 11, 2017

Anger gets a bad wrap. Violence gets to mask itself whenever anger is named as a problem. I’ve been told I have an anger problem since I was 11 years old. I no longer believe anger is a problem. I do believe violence is a problem. As I write this, news of a chemical bomb in Syria is coming over the TV. An image of an ashen father rocking and kissing his dead toddler daughter in his arms is devastating to witness. I can imagine, if I were him, not caring about the difference between anger and violence. It’s a privilege to care about distinguishing anger and violence. 

 

I am very fortunate to have a life where I can think about separating anger and violence. At the moment, I am angry about an Atlantic Magazine feature I just read titled, “What Your Therapist Doesn’t Know.” It was written by a therapist named Tony Rousmaniere. I want to express my outrage about the ideas brought forward in this article, but I want to do it in a non-violent way.  To do so requires distinguishing between critique and criticism. I want to critique the ideas, not criticize Tony, the person who wrote them, or the magazine that published the article. 

 

Briefly, the article is about Tony’s response to one of his clients committing suicide when he was a young clinician. This client, who he calls “Grace,” struggled in a relationship with substances.  At the time he explained, “I tried every therapeutic technique I could find, but nothing stuck.” He writes that he was devastated after her death and wondered, “What could I have done differently? How could I become a more effective therapist?” I feel compassion for the suffering he reports and appreciate the care it suggests he feels about Grace’s life. 

 

I share Tony’s desire and ongoing commitment to become a better helper. Tony’s crisis following Grace’s death led him to learn that 25 percent of clients drop out of therapy while 5 to 10 percent “deteriorate” in therapy. He acknowledges therapy on the whole can be effective but, “Unnervingly, I couldn’t predict which clients would stall, drop off, or deteriorate.” He reports that 30 years of research does not suggest any one model is overall any more effective than any other, including emotional-focused therapy and CBT. He then unfortunately supports a research binary that divides theory and relationship skills: “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?” Relationships skills are no more innate than whatever professional theory is held up as best. 

 

Tony then posits he’s discovered the problem. The reason therapists are not more effective is because of their resistance to certain technologies that have offered most fields “dramatic advancements over the past century.” These technologies include “performance feedback” and “the use of metrics to forecast likely outcomes.” He not only names the problem, he gives the reason for the problem: “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.” (Hmmm, could a Narrative Worldview be useful here?) 

 

Tony then references Michael Lambert at BYU who has drawn on big data to create “algorithms for when clients are at risk of deterioration.” This requires clients to take a 45-question survey before each session. This approach is referred to as FIT – Feedback Informed Therapy.  According to Tony, FIT “provides an element of blunt performance feedback that therapists too often lack .. . (that) can help them compensate for natural overconfidence and clinical blind spots.” 

 

We then learn Tony began using FIT with his clients, including June who was “seeking help with anxiety, depression, and social isolation.” He explains, “Our 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 therapy was helpful.”  [emphasis added by me] 

 

Using his FIT data he was then “shocked to discover June’s symptoms had not improved since their first session and showed she was actually at high risk of deterioration or suicide.” Tony thought at first, “There must be a mistake in the software… June had repeatedly told me therapy was helpful.” Thanks to his new FIT knowledge, the next time they met this is what he reported happened: 
 

I asked her how she was doing. Looking into the corner of the room, she replied “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?” 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 mine1.  You’ve been really helpful.” June was deteriorating, but I never would have seen it without the program. [emphasis added by me] 

 

Tony then had the audacity to write, “My experience mirrors that of therapist’s around the world.” (Am I slipping into criticism here?) He has no right to speak for me. He goes on to add, “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 patients mouth can, by itself, treat the flu.” 

 

He attributes metrics for possibly saving June’s life because it drew his attention to her deterioration. He responded to this knowledge by taping a therapy meeting with her and getting a consultation with someone who “specializes in helping other therapists improve their effectiveness.” The consultant “noticed June diligently practiced the skills I taught her, but never actually talked about how she actually felt while doing so;”  then added, “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… she isn’t telling you about her discomfort out of deference to you.” 

 

The consultant suggested Tony “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.” Tony shared the consultant's advice with June and, “She was quiet for a moment, then I saw a smile on her face. ‘He may be right,’ she admitted.” Tony concluded the feedback program “served as an indispensable guide, helping us see what we were both tempted to ignore.” With this new effort to meet her as an equal, Tony reported, “Over the following year, June’s anxiety gradually eased…In our last session, I asked her what about our therapy she thought had helped her most. ‘You saw me,’ she said with a shy smile…  Then she reached out and shook my hand for the first time.” 

 

Are you kidding me?! Let me get this right. In 2017, in what is supposedly an elite magazine, we are still in a place where it is radical news that we should not be doing therapy in top-down ways where we impose universal learning techniques over people because we know better than them what they need to navigate the problems in their lives! We need help to know imposing professional knowledges over people might not be an effective approach! We need surveys to know that we need skills to inquire about the real effects of our practices on people’s lives and how to build relationships where clients feel safe to be honest! What about all the buzz about client-based, strength-based, and collaborative approaches being all the rage?! We are supposed to celebrate that a therapist learned to “see” his client? We need help to realize that internalizing problems is a dominant Western incitement?! 

 

We need metrics to know not to assume anything about another person’s experience?! We need metrics to engage in practices of curiosity rather than practices of control?! The take-aways from this article are (1) don’t be authoritative, (2) be sure to ask a client how they are really doing, and (3) effective therapy involves helping people acknowledge their feelings. I’m going to throw a non-violent temper tantrum! 

 

I certainly support an understanding that normative discourses help position therapists to act as experts and clients as passive agents in therapy. I certainly appreciate how normative discourses can make it uncomfortable for therapists to engage in reflections on their own work. I certainly believe we need to develop skills that allow us to be accountable for the real effects of our work. I’m just stunned that any of this is significant news!   

 

I prefer to relate to my anger now with an interest in how it is linked to what matters to me. At this moment, what matters to me is how grateful I am that I found the Narrative Worldview 25 years ago. What matters to me is accepting we obviously still have a long way to go to make therapy a place where people can expect to be met in ways where their knowledges and lived experiences are seen as central and precious. What matters to me is shifting therapy from a site of social control to one of radical collaboration. What matters to me is lifting up skillful curiosity as a practice of love and respect, and a pathway to more effective therapy.

 

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