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.