Algorithms in Psychological Health Care

On the one hand, I see the value of having general guidelines for health care providers to follow.  But on the other hand, I see that there are more fundamental principles, such as establishing trusting relationships, practicing listening and interviewing skills, etc., that are far more important as standards of care, than following some kind of mechanical algorithm.   Most of the so-called "algorithmic" elements in managing psychological distress are things that most any clinician or therapist would have studied extensively in their long years of schooling, hence it is potentially quite redundant (and wasteful of time) to dwell at length on the preparation of such standards.    But I do think there are many ways in which care standards could be improved in a caring and collaborative community.  For example, I think that regular multidisciplinary "rounds"-style meetings to jointly discuss ways to manage particular problems, could be a fruitful, meaningful,  immediately useful, intellectually stimulating and robust process.  
 

Preamble

Algorithms of care can improve the efficiency of treating disease in a population, particularly when resources are limited, and when individual practices may have idiosyncratic variation.   Good examples of care algorithms which can lead to vast reductions of illness and death, and vast reductions in cost (both in terms of money and of effort), include those for treating cholera or for treating insulin-dependent diabetes.    For cholera, a simple standardized pathway of giving fluid and electrolyte replacement can be readily learned by all caregivers, and can very simply prevent death by dehydration.  For diabetes, standardized glucose monitoring regimes with basic guidance for insulin type and dosing can similarly be learned by all members of a care team (including the patients), leading to great improvements in safety, reductions in diabetes-related medical emergencies, and improvements in long-term morbidity. 

In managing mental illnesses, it can be valuable to consider a similar style of care algorithms. 

Patient Preference

In many cases, a given person may wish to have a certain type of care for a psychiatric problem.  Many patients simply want to talk to someone regularly, and do not necessarily wish to do CBT exercises.   Some patients strongly desire a medication therapy.  Other patients are strongly opposed to having a medication therapy. 

We cannot push patients into a care algorithm which is too rigid to account for patient preferences.  It is, however,  fair to introduce all patients to the various options available. In most cases, different varieties of care (such as different styles of psychotherapy, different specific medications, etc.) have far fewer differences in effectiveness than one might expect.  There are certain generalities for almost all psychiatric syndromes, however:  while all types of psychotherapy are helpful, there is good evidence that ideas from CBT should be encouraged irrespective of the style.  “Formal” CBT is not necessarily superior to “informal CBT,” particularly if a particular patient does not actually wish to have “formal CBT” but rather simply wants a supportive therapist to talk to, or perhaps a trial of psychodynamic therapy.  In practice today, most therapists use eclectic styles, such as a psychodynamically-informed variation of CBT, etc.  

Therapist Preference

Different individual therapists have different backgrounds, personality styles, areas of interest, and strengths.  Some particular therapists may excel in CBT-style therapies.  Other therapists may be experts in meditation.  Others may have a unique eclectic approach.  All of these individual therapist strengths and variations should be nurtured.  While it is good to have some unifying features of care, in the form of care algorithms,  it would be bad for the morale of the staff, and bad for patient care, for all therapists and physicians to have to conform to an identical pathway.  

Once again, patient preference may also guide which therapist would be most suitable; this fact should be respected deeply, especially for such an intimate matter as dealing with a mental health issue. 

Most of us, if were to start seeing a therapist, would want to choose the person we see, based on a variety of personal and professional factors.  

Especially in a university such as UBC which values the notion of diversity and personal autonomy, we should emphasize the ability for students seeing a mental health worker to choose the style of care that they would prefer, within the constraints of the system, as opposed to be sent on a rigidly observed care algorithm. 

 Comorbidities

Some of the most common clinical presentations in mental health care are of people who have so-called comorbidities.  These are people who meet criteria for more than one formal diagnostic category at the same time.  

Prevalence of comorbidity:  According to Brown et al (2001) a patient with an anxiety disorder diagnosis has a 57% chance of having additional DSM-IV Axis 1 comorbidities; a patient with a mood disorder diagnosis has an 81% chance of having additional DSM-IV Axis 1 comorbidities.  This figure does not even account for Axis II (personality), Axis III (physical health), or Axis IV (psychosocial) comorbidity. 

Barlow’s “Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders” in an example of a therapeutic system which addresses comorbidities, by recognizing what Barlow considered an emotional syndrome which underlies many of the specific diagnostic manifestations.  In their words,

heterogeneity in the expression of emotional disorder symptoms (e.g.,individual differences in the prominence of social anxiety, panic attacks, anhedonia) is regarded as a trivial variation in the manifestation of a broader syndrome. (Farchione et al, 2012)

The example of Barlow’s system carries highly relevant practical wisdom, in terms of running an efficient mental health service:  it is possible to offer a quite similar treatment strategy  to individuals with a broad range of diagnoses and comorbidities. 

In many other cases, a given person may not wish to receive a diagnostic label at all, and a suggested treatment regime for a given diagnosis may be problematic.  Some people may find such labels and ensuing label-specific streams of care to be objectionable or even discriminatory. 

Therefore, given the issue of comorbidities and of clients’ reservations about labeling, it is important to view  “algorithms” with extreme flexibility and sensitivity, and perhaps consider not using them except as a very rough guideline. 

Readiness for Change

A therapeutic philosophy called  “motivational interviewing” is intended to address the fact that many people with the same diagnosis (such as an addiction, a mood disorder, or a relationship problem) may differ in their willingness to participate in a change process, whether this be psychotherapy, medication treatments, or even environmental change (e.g. dropping a course, seeking financial aid, etc.). 

All treatment algorithms must consider the differences between people in their degree of insight about their health concerns, and their willingness or readiness for change. 

It is highly counterproductive to prescribe a change strategy to someone who does not desire it.  And it is also highly counterproductive to simply send such a person away, if they do not choose to participate in a given program of action. 

Therapeutic Alliance

The goodness of the relationship between a patient or client and a caregiver (a therapist, physician, or other support) is strongly related to clinical improvements in all psychiatric conditions.  It is intuitively obvious that this so-called “therapeutic alliance” must be tended to as the highest priority in any care regime.  An algorithm of care must begin by developing a positive, trusting relationship between the patient or client and the caregiver, and the algorithm must not be applied in a mechanical manner which could harm the “therapeutic alliance.”  The research literature about this stretches back for decades.   Martin et al (2000) in a meta-analysis, show that therapeutic alliance is strongly related to outcome.   A more recent research example is Arnow et al (2013), who show that therapeutic alliance is strongly related to improvement in a group of chronically depressed adults; of note, this effect was particularly strong in a subgroup receiving a type of therapy called CBASP, which is similar to the varieties of therapy most commonly recommended in standard care algorithms in the past decade.  

However, it should be noted that problems with the therapeutic alliance are more likely if the severity of symptoms is higher.  In many cases, a factor which impacts care of any serious psychological problem is a difficulty establishing trusting relationships with a caregiver, regardless of the quality of care offered.  Therefore, we may see that therapeutic alliance is excellent in many cases, for particular cohorts, but this may simply be due to the clinical problems in this cohort being mild, rather than the care being somehow exemplary.  Conversely, a clinician dealing with severely symptomatic clients may have lower therapeutic alliance measures, but this could be due to the severity of the clients’ problems, not to problems in the quality or propriety of care.  

But another good recent research paper by DelRe et al (2012) shows that therapeutic alliance is more strongly determined by the therapist than by the client; here is a quote from their conclusion:

In summary, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes (as assessed with the PTR moderator). This relationship remained significant even when simultaneously controlling for several potential covariates of this relationship. These results suggest that some therapists develop stronger alliances with their patients (irrespective of diagnosis) and that these therapist's patients do better at the conclusion of therapy. (DelRe et al, 2012)

Other recent research shows that a poor therapeutic alliance can not only cause a regime of therapy to be ineffective, it can cause it to be actively harmful.   Goldsmith et al (2015) show that early psychosis patients can benefit from psychotherapy, but are harmed by attending therapeutic sessions with poor therapeutic alliance. 

Therefore, it is important in this “algorithmic” process to remember the massively important issue, which transcends all other issues of technical details, decision trees, etc.–of attending to the therapeutic alliance, by fostering compassionate, wise interpersonal skills in all counseling professionals, as the cornerstone of any algorithm. 

But how to do this?   There are many ideas, but in a collaborative model, it would be a good idea to focus on collaborative teaching and feedback between different clinicians who have varying degrees of experience and skill, as an important element of any care pathway.  

Does Conformity to a “manualized” standard improve clinical outcome? 

There are many so-called “manualized” therapy techniques.  These are designed as an attempt to standardize care, and are particularly useful in research, to determine and measure whether particular styles or techniques are actually better or worse than alternatives.

Yet, existing evidence does not support the notion that variations in therapeutic style strongly impact clinical outcome.  While it is wise for therapists to follow and learn new therapy ideas, such as CBT, the most important thing, once again, is for therapists to develop ways to optimize the therapeutic alliance, rather than focus on particular details from a manualized approach. 

This is also an evolving area of research, one example being Tschuschke et al (2015), who demonstrate that therapists’ adherence to a prescribed treatment regimen should be flexible, particularly for people who have more severe symptoms or problems.  According to the authors, such flexibility is more consistently present in more experienced therapists, and may reflect, in general, the degree of competence in the therapist. 

We can speculate that therapists might have to make sure that the therapeutic process can continue and that the relationship is improving or at least stabilizing on an acceptable level, so as to assure that the treatment can continue. This probably includes therapists easing their treatment protocol temporarily. Thus, treatment adherence in psychotherapy is not always a stable factor but instead depends on therapists’ level of professional experience, clients’ abilities to establish a good enough working alliance, and the climate of the therapeutic cooperation in the dyad, although it might, on average, remain on a relatively low level in most sessions. Nevertheless, the flexibility of therapists treatment adherence reactions seems to impact treatment outcomes substantially if clients’ severity of psychological problems hampers the working alliance. (Tschuschke et al, 2015)

Therefore, with respect to algorithms of care, it should be emphasized that flexibility must be called for in their interpretation, particularly for the many clinical situations in which there are complications or difficulties due to higher levels of severity, complexity, therapeutic alliance problems, or limitations due to low readiness for change. 

References

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of abnormal psychology, 110(4), 585.

Del Re, A. C., Flückiger, C., Horvath, A. O., Symonds, D., & Wampold, B. E. (2012). Therapist effects in the therapeutic alliance–outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32(7), 642-649.

Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, J., Carl, J. R., ... & Barlow, D. H. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial. Behavior therapy, 43(3), 666-678

Goldsmith, L. P., Lewis, S. W., Dunn, G., & Bentall, R. P. (2015). Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis. Psychological medicine, 45(11), 2365-2373.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology, 68(3), 438.

Tschuschke, V., Crameri, A., Koehler, M., Berglar, J., Muth, K., Staczan, P., ... & Koemeda-Lutz, M. (2015). The role of therapists' treatment adherence, professional experience, therapeutic alliance, and clients' severity of psychological problems: Prediction of treatment outcome in eight different psychotherapy approaches. Preliminary results of a naturalistic study. Psychotherapy Research, 25(4), 420-434.

Addendum (March 9, 2017):

Here's an interesting Pew Research article, looking at the pros and cons of algorithms in health care and other areas:  http://www.pewinternet.org/2017/02/08/code-dependent-pros-and-cons-of-the-algorithm-age/
The authors argue that algorithmic approaches, while improving efficiency in some ways, also carry the risk of deepening divides and creating filter bubbles.  They can rely on biased data, may particularly have negative effects on people who are poor, less educated, and disadvantaged, and can limit freedom of choice.

Feeling Trapped in a Life You Don't Want: Hopelessness & Chronic Depression

I originally published this post in March, 2009.  I was just looking at it again today, while browsing through my blog...I thought I would re-publish this, and maybe work on adding to it.   I have been reviewing treatment guidelines for mental illness, and have been asked to help prepare some official guidelines for my workplace...while I find this task, of preparing "guidelines,"  meaningful or useful in some ways, with some worthwhile observations and tips to be discovered in the existing research, I finally find the task a great source of weariness and frustration.  This particular post really represents something that is much, much closer to the "core" of who I am, or who I want to be, as a psychiatrist.  And it reflects more deeply--than any "guideline" could-- my beliefs about caring for people who are suffering.   


This post is in response to a comment on my previous post "What to expect from an antidepressant".

What is the purpose of a life?

What needs to be present in a life to make it worthwhile?

If a life is like a work of art, a giant canvas that you have been working on for decades--what if you feel that the canvas has already been wrecked? The damage may have been caused by "bad genes" (e.g. an inherited tendency to be depressed, etc.), which in the canvas metaphor might mean the canvas itself is fragile, thin, easily damaged, doesn't hold pigment very well, etc.

Or the damage may have been caused by "bad environment" (e.g. a traumatic childhood, lack of support, lack of opportunity, natural disasters, war, poverty, etc.), which in the canvas metaphor might mean the canvas itself has been damaged by others, or by environmental adversity, causing it to be very difficult or painful to work with in the present.

Or the damage may have been caused by your own past efforts (e.g. a history of spending years trying to develop oneself-- in school, in relationships, in work, etc.--but where these efforts have ended in failure, pain, breakups, sorrow, regret, guilt, or a sense of having burned your bridges--and where the past failures obstruct future opportunities, e.g. via a poor academic transcript, work record, etc.). In the canvas metaphor this might mean there is a lot of paint on the canvas, but none of it is what you want, none of it is where you wanted it to be, none of it you actually like, it all looks like a collection of mistakes. If it was a literal canvas, you might feel like the best action would be to just throw the painting away, and either start fresh, or give up painting altogether. You might feel like you never wanted to paint in the first place, that the task was forced upon you by the fact of your birth, and by the social expectation that you are supposed to live out your life.

For many people who struggle with chronic depression, I think there is some combination of all these three possibilities: genes, external environment, and personal efforts which haven't worked out, all contributing to a state of hopelessness, tiredness, exhaustion. It can feel like a daily struggle just to make it through the day, a yearning for time to pass just for things to be over. Life can feel like a trap, a life sentence to a prison term, a forced existence that you never really wanted, or have long since stopped wanting.

The idea of a medication somehow "treating" this problem can seem absurd. Or the idea of so-called "cognitive therapy" changing this problem can seem insulting. It is like observing a painting you don't like in an art gallery, and then being told that you have to do some exercises to change your thinking, so that you will start to like it, then have it up on your living room wall for the next 60 years. In some ways this dynamic reminds me of salesmanship, in which case it can feel like the therapist, or even the whole external world, is trying to "sell you" the idea that your life is supposed to be worthwhile, when all you see is something you hate and want to get rid of.

I don't have easy answers to this problem.

But here are some of my beliefs about approaching it:


There are people who will care about you, and who will sit with you through your suffering. A role of a therapist in this type of situation, I think, is to sit quietly, to be gently and consistently present.

The world is full of possibility. No matter how bad conditions have been--internally or externally, past or present--growth and change are possible. The brain is a dynamic structure. It is as powerful and consistently active when alive as is the heart. But the brain reinforces its own pathways. If these pathways give rise to feelings of despair, hopelessness, and futility, then every moment of life can become experiences of despair, hopelessness, and futility. If these pathways of thought, emotion, and felt experience, have been trodden for decades, it can be hard to forge new pathways within the mind.

Immense, profound life change is possible, regardless of how severe problems have been, how long they have been present, or how much damage the problems have caused.

Such changes may require an enormous amount of energy and time, and may require a lot of external support.

There are many individual life stories of profound life change, stories of journeys through chronic hopelessness towards meaning, energy, and joy. Historically, some of these stories are of mythical proportion, and are present in literature and the other creative arts. Many religious stories contain themes of this sort.

Contemporary examples include stories of individuals overcoming lifelong addictions which had devastated their previous life histories (here I am not saying chronic depression is an addiction, but that addictions and depression can both be characterized by feeling very stuck in something bleak and hopeless). The lore in addiction treatment has wisdom to share about making radical life change--in "12 step" models, for example, individuals are called upon to admit "powerlessness" over their problem, and to make a set of statements of faith about a "Power greater than ourselves", etc. While I am wary of the potential for dogmatic religiosity in such statements, I also see that if dogma can be set aside, the "12 steps" can be seen as a sort of "leap of faith", a new contract with life, to live--and work-- with the help of a supportive community. It admits, powerfully, that one must reach out to connect with the possibility of change, it is almost impossible to do alone (the "higher power" idea can simply be an admission that one needs external help).

Psychiatric medications in chronic depression usually do not lead to "profound life change" (sometimes they do, but really this is in a small minority of cases). However, often they help a small to moderate amount. Either to relieve some suffering or pain, or to potentiate energy that might then help to effect a new course in living. I do not feel that any effective treatment leads a person to become resigned to an unpleasant status quo, and then to learn how to "accept a bad life". I feel that effective treatments allow unpleasant circumstances to feel more bearable, then to facilitate the hope and actions that are necessary to improve the unpleasant circumstances.

Cognitive therapy can help. The goal, however, in cognitive therapy, cannot be simple "salesmanship". I think the goal has to be building a satisfying life, where there are healthy, stable relationships: meaningful work, meaningful love relationships, and meaningful activities that bring joy or happiness.

With any type of process that causes deep changes in the brain, the pathway may require you to go right back to the simplest foundations.

I'm reading Norman Doidge's book about "neuroplasticity" right now (The Brain that Changes Itself), which incidentally I recommend highly. The evidence he presents is quite convincing, to some degree surprising, but on another level intuitively very obvious--the brain can change itself, sometimes very radically.

But if new paths are to be formed in one's "mental forest" one may need to start with tasks that seem extremely simple, even infantile, perhaps even "insulting" in their simplicity. Cognitive therapy can seem extremely trite, or even a ridiculous exercise in mental manipulation--an exercise to comform oneself to how society as a whole expects you to think or feel, trying to convince you to think good thoughts about a bad situation.

The thing is, though, these seemingly ridiculous tasks (such as cognitive therapy, etc.) can start new paths forming. In conjunction with this, new connections can begin with the external world, in the form of new friendships, new involvements in creative work, new involvements in education, etc.

There may well be burned bridges, but there is a vast energy available to build new bridges, if you so wish. And your past experiences may eventually become more useful to you than they are right now.

Depression can be extremely tenacious. It is so extremely tenacious that in some cases it is almost like a character that wants to perpetuate itself. The depression itself, so to speak, sets up arguments in one's mind about why this or that action (e.g. medication, therapy, life change of other sorts) cannot or should not happen. In the forest path metaphor, it is like the depression not only has become an extremely well-trodden pathway in a dense forest, but it has also put high fences around the pathway, and a deep moat full of crocodiles on the other side of the fence too.

Once again, I emphasize that I have no easy answers. As I look at the above post, I see that it is rambling. Parts of it probably sound preachy or trite. Probably annoying to look at if you are feeling trapped in a depressive state. I think I come off sounding like a salesman myself, trying to convince you to buy that painting you don't really like.

My intention, though, is to convey my belief that change is possible. There is proof that change is possible. I see this proof in my own clinical experience, as well as in the stories of others. Deep change in a chronically unhappy life is possible, but may require a great deal of external help, and may require a type of commitment to change that is extremely difficult or exhausting to initiate. And your depression won't want you to make any such commitment.

Seeing multiple therapists at the same time

It is usually taught, in "therapy school," that clients or patients should not be seeing more than one therapist at the same time.

Here are some of the reasons often given for this policy:
1) seeing more than one therapist could be an inefficient use of resources
2) the multiple therapists could be "working against each other" or perhaps confusing the client or patient
3) the multiple therapists could be part of a larger process of the client being engaged in unhelpfully complex relationship entanglements

There are many case studies describing situations in which multiple therapists appeared to bring about problems. 

But is there more substantial evidence, beyond case reports, about this?

To begin, why not consider other examples in life, where one might have "multiple caregivers":

1) Parents.  Many people have two parents.  While it is often the case that each parent provides different types of care to the child (e.g. one parent providing financial support, the other providing daily care in the home), it is more often the case, especially in the current generation, that parents share all elements of care.  This is not an "inefficient use of resources," and does not lead to a higher risk of the parents "working against each other," it is just better and more enjoyable parenting!

The therapist-client/patient relationship is not the same as a parent-child relationship, but there are some similarities in most cases.

2) Friends.  Many people have more than one friend.  The different friends a person may have do not necessarily provide different types of "friendship experience."  Some individual friends provide the exact same type of "care" as another.  You might have two different friends whom you like to have personal conversations with in the same kind of way, or two other different friends who both like to go hiking with you.  It often works well to have more than one friend, though of course there can be problems between them at times!

The therapist-client/patient relationship is not the same as a friendship, but there are some similarities in most cases.

3) Teachers.  Many people have more than one teacher.  For a given subject, there might be several different people sharing the task of teaching (for example, a professor, a TA, and a tutor).  While there could sometimes be differences or contradictions between the different teachers, it is generally considered beneficial to have more than one teacher!  In fact, being exposed to different teaching styles could improve learning.  Even if different teachers give contradictory advice, this could often enhance a learning process, as it exposes the student to multiple viewpoints, therefore stimulating a more open-minded analysis in the intelligent student.  It would be like reading two different newspapers, instead of just one, in order to better understand current events or politics. 

The therapist-client/patient relationship is not the same as a teacher-student relationship, but there are some similarities in most cases.


Are there ways in which multiple therapists are already accepted as a norm?

I believe there are.  In most health care systems, such as mental health teams, there are multiple people involved in an individual's care.  There may be a social worker, a nurse, a "case manager," a designated "psychotherapist," and a physician or psychiatrist. While each member of this team may have particular specified roles, it is often the case that each person of the team helps most through what I might call "common factors."  These "common factors" are akin to "Item 1 and Item 2" that I have described before (http://garthkroeker.blogspot.ca/2016/06/angry-birds-and-items-1-and-2.html).  Such factors are the foundation of all "psychotherapy."  Hence, in a stratified team setting, each member is already providing psychotherapeutic foundations.  It may often be the case that the client or patient finds some particular member of the team more beneficial than any of the others, not because of the caregiver's designated role, but because this team member is attending more to Item 1 and Item 2.

In other examples, it is very common for a therapist to recommend some other health care resource.  There might be regular psychotherapy sessions, but with referrals to a CBT group, a meditation group, a personal trainer, a yoga class, or a dietician.  While these referrals would overtly be to allow the client or patient to pursue some other type of care which is not taking place in the current psychotherapy frame, they also inevitably lead to a fundamental duplication, once again through Item 1 and Item 2.  Perhaps the yoga teacher or dietician might actually ask about the client's childhood, and offer some kind of empathic feedback!  Perhaps the personal trainer might recommend some behavioural therapy exercises alongside the workout routine!  This would not be unhelpful redundancy, but would rather be ways to potentially consolidate therapeutic ideas from fresh perspectives! 

Are there any neurotic or biased motivations among therapists, which lead to continuing aversion to the idea of multiple therapists?

One possible bias is simply the force of tradition.  It is a long-established belief that having multiple therapists is problematic.  I believe there are roots in the psychoanalytic tradition; here, the theory suggests that a strong "transference" must be formed with the therapist, in order for the therapy to work properly.  Having other therapists would somehow distort this transference process.

This reminds me of jealousy in a close personal relationship.  The assertion from the therapist is something like, "choose me, or choose the other therapist...you can't have both!"

The thing is, jealous behaviour does not actually improve the quality of a relationship; rather, it is a sign of insecurity.  Relationship quality is indeed important, but it must be built on a foundation of trust, kindness, and respect for freedom.


Here are some reasons to have a more relaxed attitude, professionally, about clients or patients having multiple therapists:

1) it is an issue of respecting the free choice of the client or patient
2) it may simply expand a circle of care, or a network of care, for vulnerable people who need or desire support
3) some therapists may have limited availability, or may frequently have absences, despite having a very good connection with a particular client or patient.  It can be good to have other therapists to be involved to cover for such absences.
3) potential problems or conflicts between different therapists can be resolved through dialogue or collaboration, not simply by forbidding the possibility of having multiple therapists
4) pushing different caregivers to have more restricted roles (e.g. for psychiatrists to only have brief medication management visits) causes impairment in morale and in clinical skills among such practitioners.  Psychiatrists who are only advising people about medication, while others do "psychotherapy,"  will become less and less attuned to Item 1 and Item 2, to the great detriment of themselves and their patients.  It will strengthen the stereotype of psychiatrist as detached, medication-prescribing, and superficial.

There are indeed cases in which having multiple therapists is clearly unhelpful for the client or patient, or for the therapist or system.  And, in these cases, as a professional decision, it may be beneficial to take steps to encourage the client to choose one or the other caregiver.  In other cases, it may be beneficial to step back from involvement in a person's care, to allow them to focus on just one strategy at a time.

But I think such decisions should be made on a case-by-case basis, and should not be made as part of a dogmatic policy. 

The Myers-Briggs Type Indicator & its use in the workplace

Myers-Briggs personality typing is familiar to many people, and is often used in workplaces, in career counseling, and even in psychotherapy.  One of the motivations is to help people understand and reflect upon their personality styles.  It can help people recognize that there are a variety of different personality styles in any group, and that it is important to consider this variety respectfully, to affirm various individual strengths or talents, and to anticipate common problems.  Each style is framed as bringing certain strengths or gifts to a group.  But every style can be associated with certain types of problems as well.  Interactions between two particular "types" can often lead to particular issues or problems; it can be useful for groups to reflect on these phenomena, in order to work towards greater harmony, enjoyment, and productivity.

There are various problems with Myers-Briggs typing, and with other forms of personality analysis, particularly when applied in a workplace setting:

 Process Problems

     Confidentiality & Privacy

In some group settings, personality testing is offered as an activity, in which results would be shared with the group.  Immediately, there are serious concerns about confidentiality and respect for privacy.  In some ways, a "personality test" is analogous to a medical test.  Most of us would be uncomfortable volunteering to share our medical test results (such as a chest x-ray or urinalysis) with a group of co-workers, employers, or strangers.

     Peer Pressure 

While this type of activity is often respectfully introduced as voluntary, there is a strong peer pressure element.  A person who would choose not to share or participate would immediately stand out as an outsider.  It would not be irrational to wonder if a non-participant might be doing so because of some sort of personal difficulty, uncooperativeness, or "personality problem."  Such an unhealthy dynamic is due to the activity itself, more than the dynamics of any individuals in the group.

     Labeling

Also, in terms of process, the Myers-Briggs gently applies a sort of "diagnosis."  The 4-letter code each person gets is actually a label.   The label may be an interesting thing to reflect upon, but nevertheless it is a label, obtained from answering a small number of simple questions.

Some of the Myers-Briggs types, such as INFJ, typically occur in only 1-2% of test cohorts.   If test results are shared as a group activity, with a group of 30-50 people, and with the group then dividing up according to type, then the INFJ group could be a group of just one person!  This would literally "single people out," and give rise to an unnecessary experience of isolation or exclusion, rather than celebrating group togetherness or harmony. 


The principle of giving people labels based on a few minutes of superficial assessment is troubling, in terms of process.  It is exactly this sort of pattern that I encourage people to step away from as a practice, particularly with regard to mental health care policy.   As a general principle, I like to be very reserved about diagnostic labels even after spending many hours (or even years) knowing someone; I think it is quite an egregious practice to pull out a label after a 10-minute questionnaire!

When people are given labels of any sort, particularly if such labels are sanctioned by some sort of official test, "clinical wisdom," or group approval, then it can push people into conforming to these labels.  It is a form of typecasting.  If you are told that you are something, you are more likely to believe that as part of your sense of self.  If a teacher you trust tells you that are a talented mathematician, but not a very good writer, and shows you a questionnaire result which "proves" this, then you may be less likely to pursue an interest in writing!   Of course, such feedback could be given in a way which is honest but not discouraging (e.g. "you could be a truly great writer -- but I think you need to put an extra hour of work into your writing every day this year!")

In the Myers-Briggs, the labels are generally benign, each of which laden with various positive affirmations, but the process is troubling, as it is an example of a sensitive, personal identity issue being pushed through forces of labeling and peer pressure. 

Of course, the Myers-Briggs can be used simply as a tool of playful engagement in a group, almost like a "party game."  It can very reasonably help a group acknowledge, respect, and admire the diversity of personal and interactional styles.  And the labels can be taken with a grain of salt.   None of the labels are framed in a pejorative way at all, they are all framed as style variations, which all carry different strengths or gifts that are to be respected in a group.

Yet, these process issues must be considered with great seriousness. 


Validity

Personality traits of any sort occur in a continuum in the population.  Generally, traits such as extroversion are normally distributed.  Most people in any group will be close to the population mean on any trait.  Yet the Myers-Briggs gives people a categorical label (for example "E" or "I") for these traits which are actually on a continuum.  It is a literal example of "dichotomous thinking," which is considered a "cognitive distortion" in CBT theory.   It would be like describing people as "tall" or "short" in a height category.  Or like describing the climate of a place as "hot" or "cold."    Furthermore, because of this dichotomous labeling, there is a huge statistical "fuzziness" caused by the majority of people having traits near the mean.  People in the 48th percentile for extroversion would be considered an "I" while people in the 52nd percentile would be considered an "E."   In reality these two people would have differences in this trait which are not statistically significant, yet they are given labels which are dichotomously opposite, in just the same way as a person with extreme introversion would be considered different from someone with extreme extroversion.



Reliability 

Furthermore, because of this statistical "fuzziness," there will be limited test-retest reliability for the Myers-Briggs, particularly for those people whose scores are closest to the mean.  For those people who were farther from the mean, they would not have needed to fill out a questionnaire to tell if they were introverts or extroverts!  They could have just told you verbally, without any questionnaire at all! 

Carl Jung

The Myers-Briggs system was based on some of Carl Jung's theories.  But one of the wise themes in Carl Jung's thinking was about acknowledging contrary elements, or duality, in personality, both in the course of development through life, but even cross-sectionally in a given moment.  This allows for being an "extrovert" but also having elements of "introversion" at the same time, or in different situations! Personality phenomena can be understood as much more situationally dependent than we might think.  There may be elements of extroversion that can occur in particular contexts, in a particular culture, while the same person may show much more introversion in other contexts, or in another cultural milieu. 

I think this basic wisdom is often missed with testing of this type.   I encourage people to reflect upon all elements of their personality, and to consider how some kind of "opposing" trait is always present, and deserving of nurturance, alongside any "dominant" trait.

Money & Marketing

Test makers are earning money through administering these questionnaires, publishing books about them, leading seminars, etc.  According to some estimates, it is a 500 million dollar per year industry, growing by about 10% per year.  On their very "slick" website, one can enroll to take the MBTI for a fee of $49.95.  The website is introduced by a compelling, poetic quotation by Carl Jung:

Your visions will become clear only when you can look into your own heart. Who looks outside, dreams; who looks inside, awakes.

Carl Jung

It is quite masterful salesmanship to convince people that doing a brief questionnaire, then getting a very questionable 4-letter code based on the results, is actually a form of "looking into your own heart, to allow you to awake from a dream..." 

It is important to acknowledge the marketing agenda at hand when participating in this kind of "corporate" psychology.  Just as in other areas of salesmanship and marketing, the claims made by those administering or grading the tests may be designed to please the audience sufficiently, so that people may continue buying the product.  This is not necessarily unethical, it is simply commerce and free enterprise...but such economic and marketing dynamics should be left to the marketplace, and not imposed uncritically upon a work setting, particularly given the peer pressure dynamics mentioned above.  

For a related discussion of this, see my other post "The Business of Psychological Questionnaires":   http://garthkroeker.blogspot.ca/2015/11/the-business-of-psychological.html

Arguably, a free test could be created with similar motives, to be used in a group setting for the purposes of reflecting upon group dynamics and personality styles.  Actually, no tests need be done at all!  If diversity of personality styles, and respect for different approaches or attitudes is the theme of a group seminar, then this could simply be discussed together, rather than any form of testing be involved!

References

Here are some good references to look at, addressing some of these points:

http://www.indiana.edu/~jobtalk/Articles/develop/mbti.pdf

http://fortune.com/2013/05/15/have-we-all-been-duped-by-the-myers-briggs-test/

https://www.theguardian.com/science/brain-flapping/2013/mar/19/myers-briggs-test-unscientific

http://www.businessinsider.com/myers-briggs-personality-test-is-misleading-2014-6

http://signallake.com/innovation/personality.pdf

Angry Birds, and Items #1 and #2

A few days ago I took my two sons to see a movie called "Angry Birds."  The movie is based on a video game app!

I had pretty low expectations of this movie.  I'm not thrilled with children playing a lot of video games on handheld devices.  When I checked a review site, most of the critiques were very unflattering.  But at the time, we were visiting a small town for a performing arts festival, and we had a few hours free before our trip back home.  This was the only movie available to see.

We ended up really enjoying it!  I thought it was cute, charming, funny, and delightful.  Maybe it was just the kind of light-hearted silliness I needed at the time.

One of the themes of the movie is about how it is possible to over-pathologize anger.  It also pokes fun at  therapeutic cliches.    The main character, Red, has a short fuse, and frequently ends up having tantrums.  The community he lives in is tranquil, peaceful, and happy.  Red ends up getting into trouble, and gets sent to court-mandated "anger management therapy."

Yet, there are changes happening in the peaceful little community of birds.  Red is the only one who seems to question what's going on.  But his concerns are dismissed...

Finally, the story shows that Red's point of view should have been heeded and respected earlier--eventually, of course,he ends up saving the day, thanks to the very anger that he was initially sent to therapy for at the beginning of the movie!   

Politically, I guess we could say Red represents a kind of militaristic position; he is a "hawk," so to speak.  I'm not a fan of this position--I'm much more a fan of diplomacy and "dove-like" peacemaking.

But I am a great fan of free speech.  I believe it is important to have the courage to speak out about something, even if you are the only voice of dissent in a crowded room, or in a community.

I have felt a little bit like "Red" myself this past year.

Part of my personal and family culture is of being gentle, calm, and reserved.  Most people who know me would describe me this way.   I have been very fortunate to have had a peaceful and mostly safe environment to live in, through the course of my life.  I haven't had much to be angry about.  

I also have a wonderful job, which I love very much.  I hear many stories of terrible suffering, but I feel very lucky and honoured to get to spend time with my patients.  It is a privilege and a joy to know them.

In mental health policy,  and in working with my patients, I have some very simple principles which I hold dear:

Item 1
     take the time to know your patients, to hear their stories, and to see them regularly if they desire it
Item 2
     show kindness, gentleness, patience, compassion, humour, empathy, and open-mindedness.  Be willing to listen.  Learn from your patients before trying to teach them anything.  These are the core elements of all therapeutic encounters.
Item 3
      therapeutic tactics or advice  (such as about CBT exercises, meditation, lifestyle changes, or medication) are important, but are far less important than items #1 and  #2... unless items #1 and  #2 are attended to very well, it is often the case that all the therapeutic tactics in the world will be unhelpful.
Item 4
      resist the urge to use labels.  Terms such as "depression,"  "OCD," "schizophrenia," or "borderline personality disorder" can sometimes be useful in a discussion about mental health or therapy, but I believe it is too easy to impose these labels upon someone, or to encourage people to impose them on themselves, even if this occurs in a well-meaning way.  Here, I think a great insight comes from the genre of "narrative therapy," in which people are encouraged to create and mold their own terminology, rather than have a clinician impose it upon them.  Therapeutic guidelines about helping people often focus upon labels of this type, followed by details about item #3, while barely mentioning items #1 and #2! 

Item 5
    see items #1 and #2 again!

I am saddened to contemplate a system which, in an effort to improve efficiency, would neglect items #1 and #2.

How to Spend Ten Million Extra Dollars per Year on Mental Health

Suppose that a community received a large infusion of money to spend on improved mental health.  What would be the best way to spend this money?

The most common situation I see in my practice, which pertains to this issue, is of patients with severe or chronic symptoms, who do not have access to a therapist who is regularly available for them to see on an ongoing basis.

It is not uncommon for patients I've seen to have had a fairly superficial course of therapy with someone who didn't have time for them.

The money, in my opinion, should go towards immediately and directly helping such patients have the type of therapeutic care which they desire.  This might be seeing a psychotherapist or psychiatrist regularly.  In other cases, it might be finding a personal trainer, an art therapist, a massage therapist, or some other specific resource of the person's choice. 


It is not necessary to spend money on new buildings, new office equipment, new computer networks, new meetings, etc.  There are many therapists in the community who are skilled healers -- but who are underemployed.   Extra money in a health care budget could help them survive and flourish. 

I have long felt that public health care providers (such as MSP in BC) or private insurers should allow much more funding for psychotherapy from non-medical therapists. Problems with efficiency and collaboration could be addressed within this regime, without spending any of the budget directly on this. 

Another simple alternative way to spend this extra money would be to simply hire more therapists, particularly if there was evidence in the community that there were fewer therapists per capita than in similar communities elsewhere.


Stepped Care

An evolving trend in mental health care is a system called "stepped care."  Basically, this is grounded on a simple principle, of not "overprescribing" more involved or expensive care than is necessary for a given problem.  This idea is a good one, necessitated by a therapeutic tradition over the past hundred years of prescribing intensive psychotherapy to almost any patient, regardless of the severity of their problems.

Yet, "stepped care" as a modern therapeutic philosophy is, to a large degree, a formalization of the obvious.  In other areas of medicine, one would not, for example, visit a heart surgeon following a first bout of angina.  There would be a rational sequence of steps, to be tried in order, to manage any health issue with the most satisfaction for you, and with the best use of resources for the system.  The heart surgeons would have less time to operate if they were spending more of their time investigating angina! But in order for a stepped care system to work fairly, there should be strong input from all levels of the system, including the heart surgeons, to determine the appropriate levels of care.

One difficulty with a stepped care idea is a subtle one:  mental health care isn't exactly analogous to cardiac health care.  There are some similarities, such as dealing with clearly defined levels of severity.  In cardiac health care, a mild concern would be low exercise tolerance; a moderate concern would be angina; a severe concern would be an acute MI (a heart attack).   In mental health care, a mild concern could be feeling stressed before a test at school; a "moderate" concern could be dealing with a loss; a "severe" concern could be a manic episode or active suicidal ideation.

     Mental Health as an Educational or Developmental Process
 
But part of mental health care is different.  It can be analogous to an educational process.  And it can be analogous to a developmental or relational process.  Here, a therapist can in some ways be similar to a university professor, or to a parent.    A good university professor does not only spend time with students in the class who are having the most severe difficulties.  Part of an efficient process in education is of nurturing all students, and offering special, personalized time and attention to all students, according to the students' wishes for dialog.  And an "efficient" process in parenting is of always being present and nurturing, not only in times of severe distress.   Such a process is not only healthy for students in a classroom, or for children in a family, but it is also healthy for the morale and overall well-being of the professors and parents.   


The Process of Budgeting in Health Care

The process of budgeting is a political negotiation.  Here are some steps typically taken to plan changes in health care expenditure:

     Consultants 

 "Hire a consultant."   Data could be gathered.  Interviews of different groups ("stakeholders?") could take place.  Evidence could be presented about how other health care systems operate elsewhere in the world.

One of the issues with consultancy has to do with the biases inherent to the group which is hired to do this type of task.  Is there a particular political or philosophical agenda which the group brings, despite posing as a neutral assessor?  

In the summer of 2015, I was asked to be part of a "consultancy" team of a sort, to evaluate the mental health care at a large North American university.

I expect that most consultancy groups charge quite high fees for their services.  A first question I would have about spending a new health care windfall on consultants is "how much is their fee?"   The fees should be transparent, evident to all those who are involved in the process.   Is this type of money well-spent?  Who will do the "consultancy" about the consultants themselves? 

The fee I was paid for my role as a "consultant" was zero dollars.  My travel expenses were covered,  though not the cost of missing most of a week's work, plus the time spent afterwards helping to write the report. I suspect that similar fees are not the norm in the consultancy world. 

Consultants can be a little bit like family therapists.   In most cases, the reports are likely to contain very similar themes:  "communicate better!" --   "collaborate better!" --  "encourage self-care!" -- "keep up with technology & cultural trends!"

Optimism Bias

Once a particular plan is put into place, there is another psychological bias which comes into play.   Part of this is motivated by etiquette, and part of this is motivated by a natural process to relieve cognitive dissonance.   One can see this phenomenon at weddings, at funerals, and at political rallies, once a new leader or plan of action has been chosen.  Basically, we tend to say very positive things, about the newlyweds, about the deceased, or about the new political plan!   It would be quite rude to say something negative about the newlyweds at a wedding!

But when a major policy change takes place, we can see leaders in the process, in a reflexive rhetorical habit, tending to be excitedly positive or complimentary about the new changes, even before the changes have even started.    You might hear comments such as

 "what an excellent new model we have!"

or

"Our hard work has really paid off--this is an exciting time of success and change as we implement and operationalize our new ideas!"

This can serve to boost morale, and help the changes to take place more effectively.  But it can also serve to stifle important critical questioning or debate.  Examples of this type are especially alarming in political movements, and we do not need to look far in the world's political history to see examples of harmful changes in a population moving forward at at an alarming pace, fueled by the reflexive excitement and enthusiasm of the citizens, with dissenting voices being suppressed or discouraged.
 
To prevent this phenomenon, it is important to always encourage a devout, reverential respect for the notion of free speech.  Dissent and questioning should not only be allowed, it should be sought out and encouraged as a core part of our value system in a free, healthy society.


     Population Surveys about Mental Health

I am particularly wary of consultants in the mental health area who claim to have surveyed the population, through interviews and similar data collection.

Quite a few of the most severely affected patients in a mental health population would be unwilling or unable to participate in such a survey!

Others might be willing, but are less apt to be aware of the presence of a consultancy group doing interviews.  Interviews of this sort are already biased, due to the very mental health concerns that the consultants are intending to address.

I think the viewpoints of many of my own patients would be valuable to consider in such a consultancy process.  As a specialist, my patients are analogously comparable to the  patients of a heart surgeon, in a discussion of cardiac health (when I say this, I do not mean to say that my patients' problems are necessarily  more "severe," nor do I claim that I am any more an "expert" than anyone else, but it certainly is true that it was harder for most of my patients to have found me, usually after being on a wait list and seeing various other counselors--just as patients of a heart surgeon have usually waited and seen other caregivers before).  If one were conducting a survey about the goodness of cardiac health care, it would be severely remiss to only have open surveys of the general population, without talking to patients who had seen the surgeon!   


The need for humility in consultancy reports

The report generated by my own group last year had a remarkably striking resemblance to other reports generated by other consultancy groups in similar situations, perhaps with some specific infusions of pet interests among the individual members of our group.

My own two pet interests, which I felt were most important to include in the report, were these:

1) I felt it was not possible to adequately understand the dynamics of a place after only a brief assessment period.  I thought it was a bit like visiting a new country, or a new culture, spending a few days there, then presuming to write a report about what you think is wrong with how the place runs!   This is also similar to a psychiatric consultation with a new patient -- the obligatory report generated after spending an hour or two with a person you've just met must be offered with deepest humility about its limitations, especially if the report is making categorical pronouncements about who the patient is as a person, or about "what is wrong."

It is therefore necessary to be very humble about reports of this nature, to acknowledge their limitations, and the limitations of its authors.   Humility is key.  It shows respect for the people and the institution you are visiting.    It is perhaps less compelling to read a report in which the authors admit their own limitations.  But it is more honest.  It is just like seeing a therapist.  Many people want clear, decisive advice from a therapist.  Sometimes it is possible to give such advice.  But a therapist's response to a suffering patient is much, much more powerful if it is patient and humble.  Some advice can be given right away, but in most cases a promise to work together, to learn more, to promise to understand,to empathize, and to admit your limitations, is far more effective.

Empathic dedicated human contact as a foundation of care

2) I believe the foundation of care comes from empathic, dedicated human contact.  It should never come from treating people like  numbers, or like cogs in a system.  Efficiency is important, but personal care must always be the transcendent value.

The wisdom and helpfulness of a family therapist (or consultant) does not come from the report generated from the "assessment."  The assessment is likely to contain bland generalities, which, however, might be framed in assertive or rhetorically engaging ways.   Furthermore, the ensuing interpretation or application of such a report, must not occur in a narrow or dogmatic way. 

 In family therapy, the helpfulness or positive impact comes not from the report which advises communicating -- but from actually communicating, possibly with the help of the therapist as mediator!


What about Economics & Evidence-Based Science? 

It is very difficult to conduct a good scientific study demonstrating a superior way to allot a large sum of money.  One could plan to do follow-up studies to measure health outcomes, but this actually proves much less than it seems!   For example, if the entire extra mental health budget was spent on building and maintaining a new ice rink, or a new flower garden, or on free trips to tropical resorts,  I would expect that we could see improvements in some mental health outcomes!   Surveys of people using the ice rink would most likely show that people were quite happy with the new facility!   This would appear to justify the expenditures.


If the money were spent on a new health care centre, we could generate numbers showing large numbers of people using the service, and perhaps symptom score data showing that people were experiencing relief of symptoms after visiting the centre.

But even larger numbers of people could have been seen, with even larger symptom score improvements, if we had simply given the money directly to the patients, to use as they saw fit, such as with the many struggling, underemployed private therapists in the community.

A core problem with this issue is the difficulty of conducting a controlled prospective study of different budgeting choices. 

The bigger question is about spending wisely, with a view to improving health care in the short term and the long term, with the biggest possible improvements from each dollar spent.


Heart Surgery

 I have often thought of cardiac health as an analogy to mental health.   How should we best divide up a budget windfall to help improve cardiac health?


We could correctly observe that the best improvements in cardiac health come from fostering good lifestyle habits in the population:  to eliminate smoking, to encourage healthy nutrition, and to encourage regular exercise.   So we could spend most of the extra budget on quit-smoking clinics, improving access to vegetables, and improving affordable gym facilities.

The thing is, these lifestyle changes were already possible without spending any extra money!  Gyms are actually not needed to encourage more exercise!

I would not oppose building more gyms, or building a better communication infrastructure, or planning regular meetings between cardiologists, surgeons, dieticians, and fitness instructors...but imagine it was known that the the heart surgeons in the community were under tremendous strain, were having long waiting lists, were having trouble finding available time in operating rooms, and were having declining morale, yet were being told to see more people in a more time-efficient way...

In this situation, I would not want to send the surgeons away to have more planning meetings...I would hope that the surgeons could be given the opportunity to do their work, with the basic resources which they and their patients needed or desired. 
  

Rhetoric and Jargon in Health Care Policy, Part 2: "Evidence Based"

These days we often hear about how a new treatment, or program, or therapy style, is "evidence based."  This gives the listener an impression that the new treatment must be superior in some way.

It is another language construct which has become much more common, especially in mental health care discussions.  Recently, its prevalence has tripled in written language, with a steep increase beginning in about 1993, according to the Google NGram viewer.

 But was does "evidence based" really mean?

We often hear, for example, that cognitive-behavioural therapy (CBT) is "evidence based."  The implication of this statement is that other forms of therapy must not be "evidence based."


It should go without saying that most everything is "evidence based":  

An individual's personal account of their experience is a form of evidence.

A randomized controlled prospective trial of therapy supplies another form of evidence.

An opinion from an expert, or from a mystic, or from a random person on a bus, or from a charlatan, is another  form of evidence.


Ironically, the introduction of the phrase "evidence based" may stifle debate and free thinking about a matter.  It implies that the issue it is describing has already been decided upon.

In psychiatry, the phrase "evidence based" is typically used in the area of CBT research, and in health care policy.  But this can bias opinion away from other therapeutic modalities whose practitioners tend not to advertise themselves with this type of language.

I believe that gathering evidence from prospective, randomized, controlled clinical studies is vitally important--so important, in fact, that we must allow such evidence to cause established opinions about care to actually change.   There are many cautionary tales in medical history, in which good evidence about something new was dismissed by practitioners who were resistant to changing the style of practice they had grown up with.

But in mental health care, the evolving evidence is often much less robust than it seems.  Most studies are of very short duration.   Short-term or superficial care approaches may lead to various symptomatic improvements for many people...but long-term data is often not present.   Also, a great deal of evidence supports the efficiency of  treatments which work for 60-70% of people, but does not support useful options of how to help the other 30-40%.  

Many people may look back and value a short-term course of therapy in some way, but what they really found most valuable and life-changing was something quite different, such as having a dedicated caregiver over a period of many years who didn't practice using modern "evidence-based" methods at all...

It is good to think carefully about evidence, and to be prepared to change our practice accordingly.    But the phrase "evidence based" is often just a slogan, a form of jargon, and a construct which can lead to unwelcome biases in thinking.  Such cognitive short-cuts can often be very efficient, in order to decide on an important matter quickly, but such short-cuts should never be used to make large policy changes in a system.