The Commute…

For 2 years I commuted by train from Brighton to work in London.

At best, the trip door to door took 1 hour 20 minutes, at worst… well, those who have experienced the exquisite delights of being a “customer” of the British transport system can fill in the gaps.

An article by Nick Paumgarten in the “New Yorker” a few months back describes the
seemingly rational calculus made by many Americans between lifestyle, a good job and time spent commuting. It would seem that for a lot of people the “lifestyle” ends up being several hours each way to work in their car. As the author writes,
“A commute is a distillation of a life’s main ingredients, a product of fundamental values and choices. And time is the vital currency: how much of it you spend—and how you spend it—reveals a great deal about how much you think it is worth“.

Foreign-trained clinical psychologists in the UK: More tips to get through the SoE

Another post about surviving the British Psychological Society’s Statement of Equivalence in Clinical Psychology (see previous entries on this site)….

Joalida Smit writes a personal reflection in Clinical Psychology Forum (Number 169, January 2007) about the “feelings of professional inferiority as the result of subtle mechanisms of ‘othering’ inherent in the SoE”. At the close of her article (a lot of which I could relate to) she lists a number of basic suggestions that would have been helpful when planning to start the SoE:

1] Settle in first - relocation is a huge personal investment. Don’t start before you have stability (externally and internally) .

2] Be realistic - the SoE takes mental and physical energy, don’t expect to make strides in your “real” job until the process is completed.

3] Be practical - have a structured, task focused approach.

4] Don’t get sucked into the emotions of what this further training implies.

5] Beware of the SoE Summer School - refer to 4 above.

6] Don’t make it personal - the SoE requirements do not say anything about you as a person.

7] Don’t expect the Society to make it personal - follow procedures, don’t try to jump the system (it only leads to frustration and anguish).

8] Hold the ambivalence - don’t let the anxiety get the upper hand.

9] Be careful of paranoia - “the Society” are people too.

10] Hold on to yourself and your skills - after all that’s why they gave you the job.

11] Don’t lose your voice - despite your Trust’s investment and support, you have to speak up if things are not working for you. People will listen.

12] Buy a car - you will be required to travel. Public transport is not a good idea.

13] Remember to enjoy the journey - after all, you are getting paid to learn more.

Acceptance and Commitment Therapy in the United Kingdom

For the past 6 months or so I have been working on a committee to set up a Special Interest Branch of the BABCP that focuses on Acceptance and Commitment Therapy (ACT). It has been good to get involved again in organising training and the promotion of evidence-based psychological therapy, something that I used to do when I lived in Perth (when I was in the West Australian branch of the AACBT). Aside from the appeal of letting others know about ACT, I’ve enjoyed having contact with other therapists and researchers who are keen about the science and therapeutic stance that ACT takes.

In my experience, the ACT community has been welcoming and inspiring, living the values of the approach, which includes emphasising the key role of science in developing methods to help people: the hard graft of research, open to skepticism and debate, and remaining linked to basic research and philosophical assumptions. It has seemed a good fit for me with my background training as a scientist-practitioner in clinical psychology.

I hope that the work of the ACT Special Interest Branch in the UK will continue this trend. For those who are curious, the link to the homepage of the ACTSIB is here.

The enduring legacy of cluster bombs

The April 16 2007 edition of ABC Radio National’s Late Night Live had a disturbing interview with John Rodsted, an Australian campaigner against landmines and cluster bombs (it is the back third of the podcast). 

The interview was quite instructive on the terrible legacy associated with these munitions, especially the phenomena of unexploded ordnance left in areas bombed, killing civilians up to 30 years after armed conflict.

It was reported that these munitions are typically the size of a “D” cell battery, covering the ground, and nestling in trees, buildings etc., having a “failure to explode” rate much higher than the manufacturers claims of 1%. Also reported was that the majority of cluster munitions used by Israel in southern Lebanon in the July 2006 conflict were deployed in the last 72 hours before the declaration of a ceasefire, resulting in many areas becoming uninhabitable due to unexploded munitions.

It is pretty difficult not to come to the conclusion that these weapons are really used for the long-term strategic aim of limiting the economic and social recovery of the areas bombed.

The US on the slippery slope to fascism?

An alarming piece in the Guardian last week by Naomi Wolf, regarding the actions of the Bush administration who appear to be “using time-tested tactics to close down an open society”. Worth a read, here.

I recently asked a senior colleague (who is American) what life was like during the Nixon years, he told me: “you don’t need to use your imagination, we’re living in them all over again… except it’s worse.” Ouch.

Understanding Borderline Personality Disorder

The latest podcast from “All in the Mind” (the excellent ABC Radio National program about the mind, brain and behaviour) concerns borderline personality disorder (BPD) and is really worth a listen if you want to understand BPD in a sympathetic and informed way. The program explores the histories and motivations of people who attract this diagnosis, as well as providing a sobering look at the limitations of traditional psychiatric treatment with these problems.

The program features the testimony of several women who have been diagnosed with BPD, talking about their disappointing experiences of treatment from the psychiatric system, the stigma attached to the label “borderline”, and providing unflinching descriptions of childhood trauma and abuse as triggering experiences for the problems they have faced as adults. There is an excellent bit that describes the reasons why a person might use self harm to cope with powerful emotions and painful memories.

Interestingly, the program describes the treatment approach at the Spectrum Personality Disorder Service in Melbourne. It is reported that this treatment involves, amongst other things, skills training from Dialectical Behavior Therapy to help clients to learn self-soothing and emotional regulation, as well as Acceptance and Commitment Therapy (particularly values clarification and commitment).  It is nice to hear about Australian mental health services developing approaches based on these contextual cognitive behavioural therapies.

BF Skinner on YouTube

Aside from the millions of adolescents talking to camera in their bedrooms, entertaining peers with their unoriginal observations on life (unlike keeping a blog, eh?) or lip-syncing to 80s pop songs, who would have thought that YouTube could have some educational benefit?

I recently discovered a couple of YouTube videos of BF Skinner, for those of a behavioural bent. First, a general discussion of his career:

And second, an excerpt from his final public speech (for the American Psychological Association), days before his death. Controversial to the end he describes cognitive science as “the creationism of psychology” (3:20 mins into the video).

Contextual Cognitive-Behavioural Therapies

I have a terrible confession to make about my background as a clinical psychologist: I trained as a behaviourist.

Why is this “terrible”? Well, because I now work in the UK, where it seems that behaviourally-oriented clinical psychologists are scarce (at least in my field), and I am a member of the British Association for Behavioural and Cognitive Psychotherapies, where the dominant paradigm is cognitive.

The dominance of the cognitive paradigm to CBT is so complete in the UK that it appears trainee clinical psychologists and CBT therapists are taught very little about basic behavioural principles, functional analysis, or therapeutic approaches that have developed from the behavioural wing of CBT. Behavioural criticisms of a cognitive approach are seen as out-dated, equated with stimulus-response psychology, or just plain weird. BF Skinner is treated with as much disdain as Freud. Behavioural methods are regarded as part of a CBT package, but it is widely believed that the “really effective” components are cognitive (thought challenging etc.). Proponents of modern behavioural approaches presenting their work in the UK are liable to experience harsh (and most times, ill-informed) criticism from the custodians of the CBT approach.

Professor David Richards writes in the March 2007 BABCP magazine about the apparent arrogant and inflexible attitude displayed by CBT therapists toward other therapies (in response to Henck Van Bilsen’s article in the previous edition encouraging CBT therapists to celebrate the field’s successes, particularly the evidence base). This attitude unfortunately also extends to the behavioural approach:

“Nor is this attitude confined to an arrogant dismissal of other supposedly ‘non evidence-based psychotherapies’. Despite Henck claiming that CBT is a ‘large house with many rooms’ the voice of the cognitive lobby within CBT has drowned out most other approaches. At a meeting recently [of the BABCP] I was astonished to hear a very senior person in our fraternity unable to comprehend that a member of the CBT family of treatments could be conceptualised outside of a cognitive paradigm, could even regard cognitions as inconsequential private events. All this despite the treatment in question – a contextual, socialbehavioural one – being the subject of nearly 20 randomised controlled trials demonstrating at least equivalent effectiveness to cognitive therapy. Henck makes the same mistake by asserting that ‘A core element of all cognitive behavioural interventions is that they work towards change by influencing thinking.’ Not so Henck.”

Well, for the sake of balance my little blog is going to list some of the modern behavioural approaches to CBT, in the vain hope that UK CBT therapists will chance upon it and follow some of the links. It seems a shame to me that UK CBT therapists are not at least made aware of the work that is being done by behaviour analysts that speaks directly to the reasonable theorectical and technique-based concerns about cognitive therapy (see here for a blog discussion of a recent meta-analysis regarding the empirical status of thought challenging; Longmore & Worrell, 2007).

The modern behavioural approach to CBT is contextual, and this philosophical stance informs how cognitions (private events) are viewed. Cognition is not assumed to be causal for overt behaviour, instead cognition is regarded as a form of behaviour itself, and the interest for contextualists is in the historical and current environmental variables that may influence the occurrence, incidence, prevalence, or probability of behaviour, both overt and private. Contextualists take a pragmatic approach, being interested in what predicts and influences behaviour. Models of psychological problems that have predictive power but do not identify how to influence or change problems are of limited use pragmatically. A contextualist will focus on identifying potentially manipulable environmental variables in the functional analysis of a client’s problems; the behaviour of the therapist is considered a “manipulable environmental variable” and the social context of therapy as an influential environment to produce change, hence the focus in these therapies on creating powerful therapeutic relationships.

Enough philosophy and theory. Below is a list of these contextual CBT approaches, with links to discover more about them:

Acceptance and Commitment Therapy - incorporating mindfulness, acceptance and behaviour change methods to enable clients to live valued lives, ACT is based upon a behavioural account of cognition (Relational Frame Theory) and has a developing evidence base of both randomised controlled trials, mediational studies, that links to basic science about language. (check out the link here)

Dialectical Behavior Therapy- originally developed for the treatment of women with emotional vulnerability who coped with self-injury or suicidal behaviour, DBT incorporates acceptance and change methods, including mindfulness and CBT emotional regulation skills. DBT also involves an explicit program for the psychological care of therapists who work with challenging clients. (check out the link here)

Functional Analytic Psychotherapy - based upon a behaviour analytic approach to the therapeutic relationship, FAP focuses on how therapists can create powerful, influential therapeutic contexts through functional analysis of in-session behaviour. (link here)

Behavioral Activation Therapy- demonstrating equal or superior effectiveness to cognitive therapy in the treatment of depression, the contextual approach of BA does call into question the assumption that cognitive methods are the essential component in CBT for depression. (see a description here)

Happy Reading!

The “do as I do, not as I say” approach to therapy supervision

The other week I participated in a training workshop for supervision in cognitive behavioural therapy, which was well-attended by the psychologists in my Trust. It was a useful workshop - with some theory in the morning, going through the (albeit limited) evidence for CBT supervision, and then the afternoon spent doing roleplays of supervision issues (such as scenarios where the supervisee departs from the cognitive model unnecessarily, or feels hopeless about progress in therapy, or dislikes their client).

The workshop got me thinking about a paper I had read soon after qualifying in the mid 90’s, that described a behaviour analysis account to therapy supervision. The main argument of the paper written by William Follette & Greg Callaghan (see reference below and available here) was that it is difficult to train therapists to do therapy well if you only rely on direct instruction (verbal descriptions of how to behave, in written form or face to face supervision). This type of supervision has the potential to produce rigid therapist behaviour, where the trainee carefully follows the supervisor’s instructions regardless of the client’s presentation or description of new problems. Follette and Callaghan describe that this in-session therapist behaviour, that is not necessarily sensitive to changes in the therapeutic relationship, is not necessarily the fault of the trainee but perhaps an unintended consequence of the training method.The supervision setting can inadvertantly strengthen this process if the focus is based solely upon retrospective descriptions of the content of the therapy sessions.

Follette and Callaghan describe this as the unfortunate effect of rule-governed behaviour, where the trainee is reinforced for following the verbal instructions of the supervisor, rather than reinforced for effectively “tracking” contingencies in the therapy relationship. Rule governed behaviour is useful when you want behaviour to be fairly immune to situational contingencies; however, in the case of therapy you want to develop trainees who effectively attend to changes in the client’s in-session behaviour. Follette and Callaghan describe the mathematical and practical limitations of providing “rules” to trainees, as effective therapy cannot be reduced to simple formulae to be slavishly followed.

The authors describe an alternative/associated training technology: using direct feedback to the trainee within the therapy session by the supervisor, giving moment-by-moment feedback through the use of a computer monitor in the room. The monitor shows graphically the supervisor’s rating of the quality of the therapy provided by the trainee.The aim of this method is to direct the trainee to be sensitive to the emerging contigencies in the therapeutic context, as inflexible application of techniques and focus will result in low ratings by the supervisor. This is contingency-shaped behaviour, where the trainee is reinforced for effective tracking in the therapy session. The article is interesting in discussing the advantages of this method, although I did think about the anxiety of the trainee in the process of moment-by-moment therapy ratings!

This approach makes sense if you think about the complex social behaviour that is required when doing psychological therapy. Beginning (and experienced!) therapists can become focused on “doing CBT right”, which can result in paying less attention to the client’s behaviour within the session. There may be many opportunities to strengthen the influence of the therapeutic relationship that are missed when therapists become overly focused on technique. Creating the context for change would seem as important as the methods used to make the change.

This may seem to be at odds with the view of CBT as technique-focused enterprise, with the traditional criticism that in CBT there is less interest in the dynamics of the therapeutic relationship. In contrast, I think it is reasonable to say that a CBT approach considers the therapeutic relationship to be a necessary but not sufficient condition for change to occur. Effective CBT involves therapists who are attentive to the “moment” AND use evidence-based methods to assist the client to change.

Reference

Follette, W. C., & Callaghan, G. M. (1995). Do as I do, not as I say: A behavior- analytic approach to supervision. Professional Psychology Research and Practice, 26, 413–421.

Anthropology and Counterinsurgency

Recently I read an article in the December 18 ‘06 issue of the New Yorker by George Packer called “Knowing the Enemy“, about the involvement of anthropologists and other social scientists in developing strategic alternatives to counterinsurgency.

The article profiles the work of David Kilcullen, Australian anthropologist and Lieutenant Colonel in the Australian Army, who has been seconded to the US State Department as a strategist to develop counterinsurgency methods. Kilcullen’s ideas of how to approach counterinsurgency are based on his view that the “War on Terror” should be considered as an information war. This propaganda war is one that, unfortunately, the US and its allies are losing, while groups like Al Qaeda are much more savvy about setting the agenda for their message and making sure that it is heard.

Kilcullen asserts (while not directly criticising the Bush administration) that the current approach to counterinsurgency involves a number of mistakes being made, such as 1) aggregating all Jihad-inspired conflicts together so that local conflicts become part of a global problem (uniting disparate groups and not understanding the local grievances that might be causing conflict); 2) being clumsy in winning hearts and minds, due to not having enough cultural information about the populations involved in conflict; and 3) not understanding the modern sources of information to people in developing countries (ie., US Forces relying on broadcast media to provide information to local people, while insurgent groups will use text messaging, the internet etc.).

In March 2006 Kilcullen wrote the influential “Twenty Eight Articles: Fundamentals of Company-level Counterinsurgency”, a field guide aimed at company commanders whose units have been deployed in Iraq or Afghanistan. It is worth a look at for the type of approach he advocates. Whether this approach is one that the current US administration will follow is, of course, another story.