Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop

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Editor's Note: The following is an adapted excerpt taken from Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, by Anna Lembke. Published by Johns Hopkins University Press © 2016.  Reprinted by permission of the publisher.

Neuroscientists speculate that brain changes that occur after continuous heavy use of addictive substances can cause damage that does not resolve even after years of abstinence. One of the ways these irreversible changes can manifest is that the brain is primed to relapse to addictive physiology even after a single exposure to the addictive substance. This is called “reinstatement” by neurobiologists, and “relapse” by those who are addicted.

Reinstatement is not triggered solely by the substance that the individual was previously addicted to. Reinstatement can occur with any addictive substance because all addictive drugs work on the same brain reward pathway. For example, animals repeatedly exposed to the addictive component of marijuana (tetrahydrocannabinol, or THC) and then not given THC for a period of time become addicted to morphine more quickly than animals not previously exposed to THC. This phenomenon is called cross-sensitization, or cross-addiction.

Although a history of addiction increases the risk of becoming addicted to opioid painkillers prescribed by a doctor, many people with no addiction history can become addicted to opioid painkillers in the course of routine medical treatment. Furthermore, they can become addicted quickly, in a matter of days to weeks. This is contrary to what doctors were told in the 1980s, 1990s, and early 2000s, when a pro-opioid movement in the medical pain community encouraged doctors to prescribe opioids more liberally and reassured them, based on false evidence, that the risk of becoming addicted to prescription opioids among patients being treated for pain was less than 1 percent. More recent studies reveal that as many as 56 percent of patients receiving long-term prescription opioid painkillers for low back pain, for example, progress to addictive opioid use, including patients with no prior history of addiction.

The gateway hypothesis of addiction posits that using cigarettes and alcohol, which are legal drugs, leads to experimentation with other, “harder” drugs, like cocaine and heroin. Whether this progression is due simply to opportunity costs and ease of access, or to some more fundamental biological mechanism based on the chemical composition of the drug itself, is still being debated.

In today’s world easy access to “harder” drugs through a doctor’s prescription has turned the gateway hypothesis on its head. For increasing numbers of people, especially young people, prescription drugs are the first exposure to addictive substances and the first stepping-stone to future addictive use. My patient Justin’s story provides an example of how a potent and addictive drug prescribed by a doctor can become a gateway to addiction.

Vicodin: A Gateway Drug

Justin had none of the classic risk factors of nature or nurture that we typically associate with increased risk of addiction. The only child of educated upper-middle-class Jewish parents, neither of whom smoked, drank, or used drugs, and with no family history of addiction, he seemed at average risk. (A prevailing misconception is that Jewish people are at lower risk than other ethnic groups for substance use disorders. As told so well by Rabbi Shais Taub in the introduction of his excellent book, God of Our Understanding: Jewish Spirituality and Recovery from Addiction, there are no data to support this stereotype.)

Justin’s childhood was also without trauma. His parents were loving, kind, and devoted to his well-being. He was in good physical health. Sometimes he was teased about his weight—he’d always been pudgy—but he never felt bullied. He had friends. He was neither impulsive nor prone to excessive emotionality. If anything his emotional expressions were muted. He was smart and schoolwork came easily to him. He especially liked science. He fondly remembers dissecting a cow’s eye, and mixing cornstarch and water to make “oobleck,” in the fourth grade. Anything having to do with computers was always of interest, in particular building computers and playing video games. He grew up in his parents’ single-family home in a white middle-class suburb of San Francisco.

The risk factor that Justin encountered, contributing to his later development of addiction, had everything to do with neighborhood, and not neighborhood in the strict sense of geography, but neighborhood in the sense of context, culture, and technology. Justin, like many teens today, especially compared with previous generations, had early exposure to scheduled drugs (opioids) through a doctor’s prescription, thereby developing a “taste” for them, followed by virtually unlimited access to drugs through peers at school and on the Internet.

During his sophomore year in high school, Justin went to the dentist to get his wisdom teeth removed. He lay back in the dentist’s chair, the bright white lights slowly fading into blackness as he lost consciousness from the concoction of drugs the dentist had given him. When he awoke, it took him a moment to realize where he was. He heard the high-pitched whine of the drill and smelled the pungent odor of burnt enamel, and then he remembered: wisdom teeth. “Despite his mouth being pulled apart by several sets of hands and a metal drill spinning near his flesh, he felt good—incredibly good, like no kind of good he could remember ever having felt before.” He soon floated back into unconsciousness.

In the waiting room after the procedure was over and the drugs had mostly worn off, Justin felt nauseated, and his mouth was sore. Through a residual haze of the drugs’ effect, he saw the dentist write out a prescription for Vicodin for pain relief. The dentist explained that Justin should take one pill every four to eight hours as needed for pain.

Once Justin and his mother arrived home, he took one pill and put the rest on his bedside table. He immediately felt relief from the pain in his mouth—and something else—an echo of that good feeling, that better-than-normal-for-him feeling. He lay in bed and again drifted off to sleep.

In the days that followed, Justin took one Vicodin every four hours. On the surface of things, his life had returned to normal. He was back at school, going through the motions of being an average high school student at the average California public high school in the mid-2000s. But inside, under the influence of Vicodin, he felt energized, worry free, and completely at ease with himself. He recalled the man who had visited their third-grade classroom to talk to them about the dangers of drugs and alcohol—part of the DARE project.* The man had told them that people took drugs to alter mood, to “feel good.” Justin knew the man had meant it as a warning, but thinking about it now, the idea sounded like pure genius.

Justin began doubling up on the Vicodin, seeking to maintain the good feelings that had started to wear off with repeated use. “When he ran out of his prescription, he asked his mother to take him back to the dentist to get more, telling her he still had pain.” (His pain was mild and tolerable. What he was really looking for was a way to extend that sense of well-being that Vicodin provided.) His mother took him back to see the dentist, and the dentist readily prescribed Justin another month’s supply. It surprised Justin how easy it was to get a refill and that no one questioned his motives.

An Epidemic of Overprescribing

The prescription drug epidemic is first and foremost an epidemic of overprescribing. Potions and elixirs have always been part of a doctor’s trade, but today the extent to which doctors rely on prescription drugs, especially scheduled drugs, to treat their patients for even routine, non-life-threatening medical conditions is unprecedented.

“In 2012, some 493,000 individuals aged 12 or older misused a prescription drug for the first time within the past twelve months, an average of 1,350 initiatives per day.” Of those who became addicted to any drug in the previous year, a quarter started out using a prescription medication: 17 percent began with opioid pain relievers, 5 percent with sedative-hypnotics, and 4 percent with stimulants. Prescription drugs now rank fourth among the most-misused substances in America, behind alcohol, tobacco, and marijuana; and they rank second among teens.

Teens are especially vulnerable to the increased access to prescription drugs. Adolescence is a time when the rapidly growing brain is more plastic, and therefore more vulnerable on a neurological level, to potentially irreversible brain changes caused by chronic drug exposure. Teens are more vulnerable to social contagion pressures to experiment with drugs. Also, most importantly, ready access to heroin and methamphetamine equivalents in pill form has blurred the lines between soft and hard drugs for today’s youth.

When the second refill ran out, Justin was reluctant to ask for more. But despite daily use for more than a month, he didn’t suffer any acute physical opioid withdrawal. However, that single exposure to opioid painkillers set him on a new course. He began experimenting with a variety of prescription pharmaceuticals, which was normative among his peers, who generally viewed prescription pills as safer than illegal drugs. He obtained all his pills from school friends, mostly for free, but sometimes for cash. His friends got pills from a combination of doctors, relatives, and drug dealers. Justin liked prescription opioid painkillers best of all.

Justin ingested drugs almost exclusively during school hours, so by the time he went home, the effects had worn off and his parents didn’t notice. Amazingly, neither did his teachers. One day in the middle of class, Justin took SOMA, a potent muscle relaxant. As he began to feel its effects, he had an uncontrollable desire to stretch out and extend his muscles. Sitting at the back of the class, he began gyrating in circles with his upper body, leaning far over his desk, to the right, then the left, then backward, almost sliding off his chair in the process. As he remembers it, no one noticed, or at least no one commented. Either way, it’s disconcerting to think such behavior can go unremarked.

“Justin was slated to graduate from high school in 2006, but he failed an English class his senior year, and never got around to making it up.” Instead he spent the next couple of years hanging out with friends and using drugs, mostly cannabis, alcohol, and whatever pills they could easily get from one another. He took a couple of classes at the community college, but didn’t really apply himself. He finally took and passed his GED in 2009.

His parents weren’t sure what to make of his desultory lifestyle in those years after high school. Justin believes they knew about the marijuana, which they were okay with because his dad had used pot on weekends in his youth; but they were oblivious to Justin’s use of other drugs and to the extent of the pot use, and they were unaware that the pot Justin smoked was much more potent than anything his dad had access to in the 1970s.

It’s easy in retrospect to condemn parents who seem not to notice that their kids are using drugs, but I’ve met too many caring parents over the years to stand in judgment. Kids using drugs go to great lengths to conceal their use, and even watchful parents can miss the signs.

Cyberpharmacies

After high school, Justin gradually lost contact with his drug-sourcing high school friends and thereby lost a ready supply of pot and pills. Being risk-averse by nature, he was reluctant to seek out drug dealers, try to get drugs from doctors by feigning illness (doctor shop), or do anything else overtly illegal to get drugs. Instead, he discovered a new source that was convenient, cheap, and didn’t require him to leave the safety and comfort of his own home: the Internet.

Justin’s parents were both at work, and though he was supposed to be spending time online looking at courses to enroll in the local community college, or looking for a job, he was instead typing “Vicodin,” still his drug of choice, into Google. That query pulled up links for online pharmaceutical companies. He clicked on Top Ten Meds Online, which looked like a legitimate pharmaceutical company, but just to be sure, he googled it on SafeorScam.com, an online resource that would tell him whether this site was some kind of sting operation or scam. It checked out, so he went back and searched for Vicodin. None was available. Next, he typed in “opioids” and found codeine as a cough medicine. He put it in his cart. He typed in “tranquilizer/hypnotic” and put Valium and Xanax in his cart. Just before heading to checkout, he added the dissociative anesthetic ketamine. He entered his credit card information and clicked the purchase button. “Within the week, his “medications” were shipped to his house, delivered by FedEx, no prescription required.”

Law enforcement agencies first became aware of online pharmacies selling controlled substances without a prescription in the mid-1990s, coinciding with reports on the rapid increase in prescription opioid abuse and misuse and prescription opioid–related overdoses, especially among young people. These websites conduct business in the United States in direct violation of the United States Controlled Substance Act (CSA).

Despite operating in violation of the CSA, websites that sell controlled medications without a prescription are difficult for law enforcement to monitor or prosecute. As described in the article by Forman and coauthors, “The Internet as a Source of Drugs of Abuse,” the web page for such a site may be physically located in Uzbekistan, the business address in Mexico City, money generated from purchases deposited in a bank in the Cayman Islands, the drugs themselves shipped from India, while the owner of the site is living in Florida. Law enforcement from multiple countries would have to collaborate to enforce and prosecute the owner of a single site, and the entire operation can be dismantled, erased, and reestablished elsewhere in a single day. Furthermore, marketing techniques used by the sites make it difficult to find them. Some of these no-prescription online sites camouflage themselves as something other than a drug-selling site. One such site went by the name “Christian Site for the Whole Family,” with links to “bible study group” and “Easter Drugs Sale: Buy Codeine without a Prescription.”

The international nature of the drug trade today gives the old opium wars a new twist, wherein cyberpharmacists are drug dealers for the modern age. Support for this claim comes from a report out of Columbia University, which gathered data showing that 11 percent of the prescriptions filled in 2006 by traditional (brick and mortar) pharmacies were for controlled (scheduled) substances, whereas 95 percent of the prescriptions filled by online pharmacies in the same year were for controlled substances.

The Internet is not merely a passive portal for controlled prescription drugs. Once Justin, for example, has purchased drugs online, the site remembers him and may send unsolicited e-mails alerting him to new products or special deals. This aspect makes it especially difficult for addicted individuals to stop using drugs. Short of changing his e-mail address or utilizing filtering software, Justin cannot avoid being found and targeted once again for drug use by Internet sellers.

Initially Justin looked only for prescription drugs through online pharmacies, but gradually he became interested in new and experimental drugs in the pharmaceutical pipeline, often sold as “research chemicals.” He learned about new drugs by spending time on the website Pipemania.com, a splinter group of Lifetheuniverseandeverything.com. Pipemania, one of many Internet communities like it, is a forum where users talk about what drugs they are using and what those drugs feel like, including lots of newly synthesized drugs and newer drug combinations. People using these sites refer to themselves as “researchers” and to their drug use experiences as “research findings.”

Examples of newer synthetic drugs include Methoxetamine, or MXE, an analog of the drug ketamine, labeled as a “research chemical product” and taken for its hallucinogenic and dissociative effects. Purple Drank, or Lean, another popular new mixture consumed primarily by young people, combines Sprite, Jolly Ranchers, and codeine (an opioid). If prescription codeine is unavailable, DM (dextromethorphan) cough syrup is often substituted.

The buying and selling of illegal drugs, outside of online pharmacies, occurs primarily in the “deep web,” a term used to refer to a clandestine part of the network where online activity can be kept anonymous. Most of these drug-selling underground sites use Bitcoin as their only currency, providing customers with anonymous access to drugs from all over the world, without even a pretense at legality. One such site, now dismantled, was Silk Road, allegedly operated by 30-year-old Ross W. Ulbricht, who went by the pseudonym Dread Pirate Roberts, a character from the movie The Princess Bride. Mr. Ulbricht was recently convicted of narcotics trafficking, computer hacking, and money laundering.

Heroin—the New Vicodin

In 2012, despite engaging in daily, now mostly solitary, drug use, Justin attended community college and got a job at Oracle in the shipping department. With his new job, he was suddenly in possession of cash, and much more than he had become accustomed to with his parents’ allowance. One night in the summer of that year, he went to a small get-together at a friend’s house, where he met someone whose brother knew a heroin dealer. Justin had never tried heroin before; he had always shied away from illegal so-called street drugs and from drug dealers. But he was curious, and eager to use opioids, which were increasingly difficult to obtain online in any form. Through friends he met Sean, the man who would become his heroin dealer, his business partner, and his housemate. Justin bought a gram of heroin, telling himself it was no big deal; it was just an experiment, and he could handle it.

Heroin was originally synthesized in 1874 by C. R. Alder Wright, an English chemist working at St. Mary’s Hospital Medical School in London. Wright added two acetyl groups to morphine to form di-acetylated morphine, which was largely forgotten until twenty-three years later, when it was independently synthesized by Felix Hoffmann in Germany. Hoffmann, working at what is today the Bayer Group’s Pharmaceutical Division, was instructed to find a less addictive alternative to morphine. Di-acetylated morphine was marketed by Bayer alongside aspirin from 1898 to 1910 as a non addictive morphine substitute and cough suppressant, as well as a cure for morphine addiction. Bayer named di- acetylated morphine “heroin,” based on the German “heroisch,” which means “heroic” or “strong.” Strong it certainly was. By the early 1900s an epidemic of heroin addiction raged in the United States, prompting passage of the Harrison Narcotic Act of 1914 to control the sale and distribution of heroin and other opioids. Today in the United States, heroin is considered a schedule I drug, meaning it is considered highly addictive and is not approved for any medical purpose.

Justin intended to use his heroin sparingly, just now and then. Instead he used it daily for two months, not stopping till he had run through the entire $1,600 he had earned and saved from his job at Oracle. He lost his job and quit school, unable to meet the demands of either. Then he went into acute heroin withdrawal. He remembers heroin withdrawal as “the most horrible feeling in the world, like you’re gonna die.” Elaborating further, “I wouldn’t wish it on anyone, not my worst enemy.”

“The number of Americans aged 12 and older who used heroin in the past month rose from 281,000 to 335,000 between 2011 and 2013, a significant increase from the 166,000 using heroin in 2002.” According to the Centers for Disease Control and Prevention, heroin-related overdose deaths also rose in that time frame, with a 39 percent increase between 2012 and 2013 alone. The majority of new heroin users cite prescription opioids as their first exposure to opioids, a clear generational shift. In the 1960s, 80 percent of opioid users reported that their first exposure to opioids was in the form of heroin. In the 2000s, 75 percent of opioid users reported that their first exposure to opioids was in the form of prescription painkillers. Increases in heroin use have been driven mostly by 18–25 year olds.

Justin went to Sean and told him he was out of money, but desperate for heroin. Sean offered Justin an arrangement in which Justin would work for Sean, and in exchange, get cheap access to heroin for his services. Sean wanted Justin to sell for him, but Justin wasn’t willing. As an alternative, Sean offered that Justin could work in “his lab,” an offer which Justin accepted.

For the next nine months, Justin spent most of his time at Sean’s house, running Sean’s lab. Sean lived in a rundown house in a rundown neighborhood in East Oakland, a place with hardly any furniture besides a TV, a plastic kitchen table with plastic chairs, and a couple of worn mattresses. Justin had dropped out of school, unable to keep up with his courses while strung out on heroin. He told his parents he was “staying with a friend,” and he returned home every two or three days for a visit, just to reassure them all was well.

On a typical day during those nine months between the summer of 2012, when Justin first tried heroin, and spring of 2013, when he would first attempt to quit, Sean and Justin would wake up around one in the afternoon and share a light breakfast. This breakfast did not consist of food; it consisted of heroin. They both preferred snorting to injecting. They lined the heroin up on a smooth, clean surface and passed it between them till they were sated, just as if they were passing a basket of rolls. Sometimes they “chased the dragon,” a way of ingesting heroin that requires putting the heroin on a bit of tin foil, putting a source of heat—a match or a lighter—below the foil, and inhaling the vaporized powder. The term “chasing the dragon” refers to the plume of smoke that rises up off the foil, like a mythical dragon’s tail, as well as the high that addicted persons seek, as elusive as the mythical creature whose name it bears.

“Justin recalls that he was never hungry when he was using heroin. In fact, he didn’t want anything. He didn’t want to eat, read, bathe, exercise, watch TV, or even play his beloved video games.” He was living in a “dump” with no furniture, no food in the refrigerator, no family, no job, and no prospects for the future, and despite the ever-present threat of legal consequences from dealing in illegal drugs, he felt “complete.”

He spent his days cooking heroin from morphine, and when the stink of the chemicals made his eyes burn, he joined Sean on the porch. Every hour or two they snorted heroin. “Because we were distributors, we didn’t even wait till we were feeling sick to use. We’d use to get even higher than we already were.”

The First Step to Recovery

One day in the spring of 2013, Justin was sitting in Sean’s house filling balloon bags of heroin for later sale, when he realized that he had been using heroin daily for exactly nine months. “I was thinking in my head, ‘Wow, it’s been almost a year. If I let this year go by, it’s going to be five years, ten years, maybe my whole life.’” At that moment he decided to quit. He also recognized that he would not be able to act on his decision without help, primarily due to the physiologic withdrawal associated with stopping opioids.

Again he turned to the Internet. While the latest batch of heroin was still cooking in the oven, Justin looked up treatment for heroin addiction on his laptop. He found a website for BAART (Bay Area Addiction Research and Treatment), a methadone maintenance treatment clinic in Oakland, and immediately set up an appointment. Justin recalls that BAART required their clients to be in active withdrawal when initiating methadone, so he stopped using in the hours before his appointment and was plenty sick when he went in and received his first dose of methadone.

Justin also decided to tell his parents. He realized he’d have to be living at home again, and traveling every morning to Oakland to get his methadone dose, and there was all the paperwork he needed to fill out. There was no way he could hide it from them any longer.

The same day he started on methadone, Justin told his parents that heroin was something he’d always wanted to try and thought he could handle. He said he’d been sucked in, and he blamed no one but himself. He knew his parents felt guilty anyway, as if they had failed him. Justin almost cried remembering their conversation. “They were very supportive,” he said. “They’ve always been very supportive.”

Justin did well on methadone. He enrolled at the community college again, made new non using friends, and joined a study group. When he did relapse six months after being in the BAART program, he relapsed hard—which is common—and was smoking crack at the same time he was using heroin. He dropped out of the methadone program at BAART, but bought methadone on the street to ease his comedowns. “For months he managed to use crack and heroin on the weekends and methadone to get through his classes during the week.” One day, unable to reach his methadone source, he started to go into withdrawal. “I realized ‘I’m at the whim of my dealer.’” He bought some Suboxone, a medication with similarities to methadone, also used to treat opioid addiction, from a friend, and used that the same way he had used methadone, that is, to tide him over when he couldn’t get heroin.

But Justin was getting tired. Tired of chasing down heroin, methadone, and Suboxone. Tired of feeling anxious and sick, wondering if he’d have enough drug to keep going. Tired of lying and living the double life—pretending, as he says, “to be sober, but having this second actual life where you’re keeping secrets from everybody, lying, and having to keep track of all the lies. It’s all just so hard to keep up.”

Again he looked on the Internet, this time for someone to prescribe Suboxone, which is how he found me. When he told me his story, I agreed that Suboxone made sense, given the severity of his opioid addiction. But Suboxone treatment requires close monitoring, including regular clinic visits and urine toxicology screens to test for the presence of other drugs. If other drugs are detected, I explained, ongoing Suboxone treatment might be compromised. I also encouraged him to seek some kind of psychosocial intervention to treat his addiction as well.

Justin agreed to Suboxone treatment and monitoring and to a Narcotics Anonymous (NA) meeting. He did not find twelve-step groups helpful; they just weren’t for him. He quit going after a few weeks. But Justin came to appointments regularly and never tested positive for other drugs, except for a couple of small slipups with benzodiazepines, the most recent when, while cleaning his room, he came across an old stash of Valium pressed between his bed and the wall. He took the Valium for sleep for the next several weeks, then stopped. He felt guilty about it. A year later, he is still doing well.

Justin ascribes his year of recovery from addiction to Suboxone, his relationship with his parents, and interactive role-playing tabletop games. “Suboxone stops the cravings and I can feel normal. I don’t lie anymore. Role-playing games help by giving me the escape and excitement that I would usually get from that whole street life.”

Today, Justin spends most of his weekdays studying. On the weekends, he spends some time on the computer, but he no longer visits online pharmacies or spends nearly the amount of time he used to playing video games. Instead, with some sweet irony, he is much more likely to be on a site called Penandpaper.com. There he is able to interact with other players of so-called tabletop, or role-player games. Tabletop games simulate the quest story lines so popular among video gamers, but without the video. There is often an online version of the role-player games, but Justin much prefers the face-to-face version. He claims the story is richer that way.

On a typical Saturday, Justin’s five tabletop teammates, now a stable crew he meets with on a regular basis for gaming, come to his house around eleven o’clock to spend the day playing. Collaborative storytelling is the essence of the game. They sit around a table, sometimes for as long as eight hours at a time, and together describe the world their characters will inhabit and what will happen to them in that world. Sometimes they may even act out a scene or engage in a small role-play, as if creating theater, though none of them would ever describe themselves as actors.

They are currently playing ShadowRun, set in a futuristic world populated by magical beings and cyborgs. Justin’s character is an Ork, a troll-like creature with robotic enhancements and cybernetic abilities named “J-Rez.” Their latest story line bears an uncanny resemblance to Justin’s own life—and it can be read as the narrative of Justin’s alter ego.

J-Rez has just heard from his female crime boss that his next mission is to travel to Seattle to obtain a new synthetic drug called Novacoke. In Seattle, J-Rez meets up with the other members of the organized crime ring, and together they venture into a high-crime neighborhood to deliver a package of research chemicals needed to make Novacoke. In exchange, they get a sample of the drug to take back to their boss. However, right after getting the package they came for, they are nearly killed by a detonated bomb, saved only by J-Rez’s robotic enhancements. The team then combs the neighborhood and, through diligent detective work, including deciphering a tattoo, identifies their would-be killer—a man who has eluded them because he has the ability to turn into a dragon. J-Rez and his gang embark on their next assignment: chasing the dragon.

Justin continues to chase mythical creatures, but for now, not through the medium of addictive drugs.

The Gateway Now a Runway

Young people today don’t just experiment with cigarettes, alcohol, and marijuana. They try everything, especially if it comes in the form of a pill. They even try chemicals newly synthesized in a laboratory without any idea of what these chemicals might do to them. They obtain these drugs from friends at school, from the Internet, from their own home chemistry kits. The gateway, in other words, has become a runway, telescoping the progression from recreational to addictive use. That first prescription for opioids, stimulants, or sedatives is the boarding pass, in some cases, to a lifelong struggle with addiction.

*The unintended consequences of drug use education are salient here. Drug Abuse Resistance Education (DARE) was a school-based prevention program, adopted throughout the United States in the late 1990s and early 2000s, in which police officers provided information on the dangers of drug use to students in the classroom. In retrospect, DARE was ineffective at preventing or even delaying drug use, and in some cases it may even have promoted use, as exemplified by Justin’s experience. DARE illustrates the broader challenge of using didactic and mass media educational campaigns to target drug use.
 

Anna Lembke on the Opioid Epidemic

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The Problem of Access

Deb Kory: Dr. Lembke, you’re the program director for the Stanford University Addiction Medicine Fellowship and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. You recently published a book, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked and Why It’s So Hard to Stop, which focuses on people who have become addicted to opioids as a result of having them prescribed by doctors. It’s a shocking book, to say the least, but very informative and also deeply compassionate toward addicts of all kinds.

Let me begin with some startling statistics from the book: From 2000-2014, almost half a million people died from drug overdoses. And between 1999 and 2013, 175,000 people died specifically from prescription opioid overdoses. That’s an enormous number of people and my sense is that it’s rising very quickly every year, with prescription opioids being the lead killer, is that right?
Anna Lembke: Right. In 2016, somewhere between 50,000 and 60,000 people died of a drug overdose, and of those, 50-75% were attributable to opioids. And about half of those opioids were prescriptions. But I think it’s important to recognize that what began as a prescription opioid epidemic has greatly expanded the number of people using heroin as well.
DK: Heroin addiction has become more mainstream because of prescription opioids. Can you explain why?
AL:
In 2016, somewhere between 50,000 and 60,000 people died of a drug overdose, and of those, 50-75% were attributable to opioids. And about half of those opioids were prescriptions.
Well there are so many opioids out there in the community because of the over-prescribing problem and that access alone has meant that many more people have taken opioids. From teenagers taking it out of their parents’ or their grandparents’ medicine cabinets, to kids trading pills at school, to having it prescribed by your doctor for some minor procedure—this has normalized opioid use and made it relatively easy to obtain.

People are getting exposure through a prescription—either their own or somebody else’s—and, particularly for young people, transitioning to heroin isn’t that big a leap. They want more and it is easy and cheaper to go to heroin.

The big spikes in heroin use that we’ve seen in the last five years or so have mostly been among the 18 to 25-year-olds, and I think some of that is driven by a cultural phenomenon in which young people aren’t as afraid of heroin as the older generation. People in their 40s, 50s and 60s, for them to go to heroin would be crossing some kind of line that doesn’t fit with their identity.

On the other side, in the last five years or so there’s been a crackdown on opioid prescribing, and some people who had been receiving very high doses for a very long time all of a sudden have found themselves unable to get the opioids that their body and brain had gotten used to. Some of those people then turn to heroin.
DK: These are the older generation folks?
AL: Yes, they are.
DK: The depth of the agony kind of drives them there.
AL: Right.
DK: From reading your book I got the sense that doctors are finally beginning to understand the enormity of the epidemic and there has been a crackdown in the last few years which, as you said, can push people to seek opioids elsewhere. Were you at all afraid that there would be a crackdown in response to this book?
AL:
Young people aren’t as afraid of heroin as the older generation.
Unfortunately that has happened. In trying to highlight the dangers of over-prescribing, one of the unintended consequences is that the pendulum swings too far in the other direction. Doctors decide they’re not going to treat pain patients or prescribe opioids for anyone anymore. It’s unfortunate. A lot of my professional time right now is taken up with educating physicians about the “middle path”—prescribing judiciously while not enabling an addiction, and not reacting or retaliating in a way that means people aren’t getting the care that they need.
DK: Having gone through a PsyD program, I was shocked at how little training in addiction there was. I am someone who struggled with a prescription opioid addiction when I was younger and I found recovery in a twelve-step program, which was really transformative for me. I had been introduced to prescription opioids young because my mother had terrible rheumatoid arthritis and was herself hooked on pain killers, so in many ways I match the description of people in your book. Yet all through graduate school addicts were talked about as “others”—as if there couldn’t possibly be addicts “among us.” Thankfully there was a teacher who’d been in a twelve-step program for years and was very open about it, but that was really the exception. There was no specific class on addiction and it would just come up here and there in other classes or case conference.

One of the things I appreciate most about your book is how it destigmatizes addiction. It’s obviously an enormous problem and one that the medical establishment has played a big role in escalating. I think the book will make it easier for people struggling with addiction to ask for help and, hopefully, for clinicians like me with a history of addiction to be able to be more transparent about it with each other and with clients when they are struggling with addiction issues.
AL: Thank you so much for saying that. It means a lot to me. And thanks for your openness about your own struggles.
DK: I actually think there is a lot of addiction among mental health practitioners, but many feel too ashamed or embarrassed to get help because we are “professionals,” healers. We’re not supposed to have problems ourselves. I feel like this is a small way that I can help destigmatize it.

My understanding is that medical doctors get even less training in addiction than psychologists. Is that true?
AL: You can say that again. I went through medical school in the 1990s, and the extent of my addiction training was being instructed to attend one AA meeting. Honestly, it hasn’t gotten much better.
DK: It’s so surprising given how many people are struggling with addiction.
AL:
I’m so embarrassed when I look back at the kind of doctor I was.
I’m so embarrassed when I look back at the kind of doctor I was. I mean, I’m a psychiatrist. Here I was purportedly wanting to help people struggling with mental illness, yet I really did not consider addiction an illness of any kind, and I didn’t think it was in my purview to treat people with addiction. I thought that was somebody else’s problem.
DK: Whose problem did you think it was?
AL: I don’t even know. Just not me. What’s so fascinating is that my dad was probably, in retrospect, a functional alcoholic. He was a surgeon, and he was a very serious binge drinker. He was never professionally diagnosed or treated but he had a serious drinking problem, so part of my rejection of this patient population came out of a negative transference—“I’m not going to deal with those people.”

We all have a story like that. Whether it’s our own addiction or somebody in the family, we don’t want to look at that piece of ourselves or that part of our family history, and our patients suffer because of it. And we’re in a system that to a large extent still doesn’t view it as an illness but rather as a form of moral corruption or a weakness of will. It makes it hard for us to look at our own stuff.
DK: It strikes me that there is basically no way to have a therapy practice that totally excludes addiction. Even if you tried really hard, you often get clients who present a certain way when they come in, or might even really believe they don’t have a problem, but then over time as the relationship develops, you learn that they drink to blackout 4 nights a week or smoke pot first thing in the morning, all day and last thing at night every single day. These things aren’t often part of the initial intake.
AL:
We know at least 50% of people who show up in the emergency room with severe trauma have been using substances.
It’s such an exercise in denial for psychiatrists to think that they could make a complete diagnostic evaluation and not ask about substance use, but that happens more often than not. And it’s not just psychiatrists, but other types of physicians, too. We know at least 50% of people who show up in the emergency room with severe trauma have been using substances. Primary care doctors and oncologists see addiction problems. People with cancer get the big C-card pass, but I know a lot of people with cancer who have serious substance use problems. So we all need to be asking those questions of our patients right from the start.

We're Not Asking the Questions

DK: Since our readers are primarily mental health clinicians, I’m wondering how those of us who see patients in therapy and other non-medical settings can help with this and also interface with doctors who may be enabling our clients’ addictions?
AL: Psychotherapists and other non-prescribers in the mental health care field can play an absolutely vital role. In many instances, doctors today are so pressed for time and often don’t have the kind of trust that counselors have built up over time seeing patients regularly. You guys hear the real stuff that I, as an MD, often don’t. But I would also say that in my experience, even in the limited time I have with patients, on some level they’re dying to talk about it. All you have to do is just ask the question, and they will tell you, and they’ll be so relieved to be able to share it.

The bigger problem is that we’re not asking the questions. All of us, including psychologists and non-prescribers, need to ask about substance use, including prescription drug misuse. Then the vital role you can play is—with the patient’s permission—call the prescriber. In most cases, if it’s done with a reasonable amount of humility, the prescriber will be grateful and even thrilled.

Let me just give you an example from my clinic just today. I had a man come in, and he is in recovery from an alcohol and cannabis use disorder, has been in recovery for many years. He also has Attention Deficit Disorder. He went to see a psychiatrist at Kaiser who prescribed him 30 milligrams of Adderall. He stayed at 30 milligrams for about six months, and slowly the dose was creeping up. And now he’s at 90 milligrams a day, running out two weeks early, having to white-knuckle it until he goes back and sees the psychiatrist, who then fills his prescription for Adderall.

How about if I call your doctor right now while you're here?
I asked him, “Have you talked about this with your psychiatrist?” And he said, “No, I haven’t. I know I should. I just haven’t been able to get up the courage to tell her that I’ve essentially relapsed on the pills that she’s prescribing.” And then I said to him, “Well, now that you’ve told us about it, would you be willing to talk with her and let her know?” He said, “Yeah. I really need to. I really want to. I would be willing.” But there was some hesitation in his voice. And then I said to him, “Well, how about if I were to call her? Would you be comfortable with that?” And he said, “That would be so great. If you could just call her and tell her that—because I’m not sure if by the time I get to my appointment I’ll be able to do it.”

And then I said to him, “Well, how about if I called her right now while you’re here? Would you be okay with that?” He said, “That would be great. I would love it if you would do that.” So I called her up, and I said, “Hey, I want to let you know patient X is here and he’s really appreciated your care, and he feels so much shame and embarrassment, but this is what happened, and he wants you to know.” And then I said, “This is my name, this is my number. Please call me. We want to help.” It’s not, “You’re so dumb that you missed this. You’re a bad doctor and I’m good doctor.” I’ve been duped a million times. I’m not a mind reader.

Of course, it’s not that every patient every time will say, “Oh, yes. Please call.” Many times they’ll say, “Oh, no. That’s okay, don’t tell my doctor. I’ll take care of it.” But the truth is, sometimes they will say, “Yes, I’m ready. Please help me with that.” And if you don’t ask and you don’t offer to interface, then they won’t suggest it.
DK: So much of what keeps addicts in their addiction is a deep sense of shame, and what I like about your approach is that you’re cutting right through it. You’re giving them an opening and also modeling a total lack of judgment. You’re just very business-as-usual about it.
AL: Let me tell you something else that I’ve learned to do over the years regarding this whole issue of shame. I have a patient who had been in recovery from her alcohol addiction for six years, and just relapsed in the last six months, and she gets sober for a week and relapses, back and forth. She had been sober for about a month and then I just heard that she relapsed again. She left a message and just said, “I relapsed and I’m not going to come in today because I need to go to rehab.”

Somebody who has the disease of addiction and relapses is exactly the same as somebody who has cancer that was in remission and gets a recurrence of their tumor.
One of the things I’ve learned is when you get that kind of message, don’t just be okay with them saying, “I’m not coming in. I’m going to rehab.” What that actually means is, “I’m going to sit at home drinking until somehow, by some miracle, I get into rehab.” So I said to my residents, “Call her. Tell her we need to see her at her appointment, and tell her to bring her family.” So she showed up at her appointment and she brought her family and the first thing that I did when I walked in the door was to give her a big hug, and I said, “I’m so sorry. I’m so sorry.” Because to me—and this is the key take-home message—somebody who has the disease of addiction and relapses is exactly the same as somebody who has cancer that was in remission and gets a recurrence of their tumor.

What would you do if you walked into the office and somebody had a recurrence of their cancer? You would say, “I am so sorry,” and you would give them a big hug. And that’s exactly what we need to do with addicted patients, because that’s exactly how it is for them. It’s exactly like that. And they’re so appreciative. “Oh, my God,” she said, “Thank you, thank you,” and she was crying. She was devastated, absolutely devastated that she’s relapsed. She’s not going, “Oh goody, I relapsed. I got to get high.” It’s not like that.

A "Cunning and Baffling" Disease

DK: That’s such a beautiful story. It can be really disheartening and challenging for clinicians to work with addicts because relapses can be so devastating and all the shame around it leads to lying and coming in and out of treatment. Do you have any advice for therapists around dealing with the pain and frustration that brings up?
AL: Conceptualizing it as a disease is a really helpful way to maintain a compassionate frame of reference. And then the other piece of it is just being really transparent with patients. “If you lie then I can’t really help you. At least tell me the truth about what you’re doing, and let’s talk about some strategies or what we might do.” In general I find that if patients show up, they’re happy to talk about it.

Compassion can also open up a sense of awe. It’s like, “Oh, my God. What a horrible disease. You really don’t want to be doing this, and yet here you are.” As they say in AA, the disease is “cunning and baffling.” And it is. Awe may not be the right word, but to really recognize the power of addiction, the grip it can have on people.
DK: I like the word awe. Addiction is kind of the grand leveler. It can destroy the hopes and dreams of people from every walk of life.
AL: Yes. And it’s important to be able to really witness the tragedy of that.
DK: Are you able to predict at all who will be able to recover and who won’t?
AL: You know, the more I’m in this strange profession that we’re in—it’s kind of a wonderful and weird job—the more convinced I am that I have no idea who’s going to get better. When I was younger I thought I could tell, but I’ve had too many experiences where someone comes in and I totally identify with them and think, “Oh, a slam dunk. I know exactly what to do. They’re going to be better in a month.” Those have been some of my worst outcomes.

And then I get people who walk in my door and I just think, “Train wreck.” And I literally pray for them. I don’t know what you do; I pray to God. I’m like, “Please, God, help me, because I don’t think I’m going to be able to help this person.” They’re telling me their story and wanting me to help them, and I’m thinking to myself, “I have no idea how I’m going to help this person.” Can you relate to that?
DK: Oh, of course.
AL: Sometimes those people are the ones who get better. It’s so unpredictable.
DK: As a recovering addict myself, I tend to pick up on addiction issues pretty quickly, but I’ve heard from so many people that they were addicted for years without their therapists picking up on it, or in some cases the therapist just didn’t think it was a big deal. Do you feel like it’s incumbent upon mental health professionals of all sorts to have more training and expertise in this area?
AL: Oh, absolutely. Addicts will often see psychiatrists and therapists and talk about everything under the sun—every last thing their mother or father ever did, every dream they’ve had—but they won’t talk about their substance use. People who are shooting up heroin. It happens so often. It’s not a minor issue.

Across the country, medical schools are working hard to try to revamp their curriculum to incorporate more addiction training. We’re certainly doing that here at Stanford, working very hard to at least get the basics to our medical students so they can go out and not harm patients because of ignorance.

That’s the state we’re in right now: Patients are actually being harmed.
But that’s the state we’re in right now: Patients are actually being harmed. Not because most doctors are bad people, but because most doctors are very ignorant about this disease and so, inadvertently, cause harm by ignoring it—or worse yet, aiding and abetting it by prescribing in a way that’s not safe for the patient.

The former director of the Office of National Drug Control Policy, Michael Botticelli, is in recovery. I went to a symposium at the White House where he was one of the main speakers, and he said something along the lines of, “I look forward to the day when I, as somebody in recovery, don’t have to explain to my doctor what recovery is and how he or she should treat me.” I thought that was eloquently said.

Evolving Conceptions of Pain

DK: It’s very common for people in recovery to go to the doctor and say, “I’m in recovery. Please do not prescribe me any narcotics.” And, literally against their wishes, they’ll come out of some procedure and they are prescribed Vicodin. Many hard drug users end up relapsing after having some kind of surgery where opioids are prescribed.

You describe in your book how these prescriptions became heavily incentivized in healthcare. Or, rather, you would be penalized for not treating pain. The Joint Commission, which accredits healthcare organizations, announced that pain was “the fifth vital sign,” and made reimbursement funds contingent upon asking about and treating pain in every patient. Of course, the primary treatment of pain was opioid prescriptions so those skyrocketed. Given what we know now, is the conception of pain and how to treat it beginning to change?
AL: No.
DK: No?
AL:
This new ethos of people being fragile and pain being dangerous has really helped drive the over-prescribing of all kinds of potentially addictive drugs, from benzodiazepines to opioid analgesics.
I mean, pain has gone through a fascinating evolution in the history of medicine. Prior to 1850 or so—which is also prior to anesthesia and convenient forms of analgesia or pain relief outside of drinking some whiskey—doctors actually believed that pain was healthy for the body, that experiencing some degree of pain, let’s say during a surgical procedure, would boost the cardiovascular system, the immune response. And there was a very prevalent idea that, on a spiritual level, pain had benefits for people. This idea that “what doesn’t kill you makes you stronger.” Over the course of the last century and a half or so, that has really changed, not just in medical culture but in society as well. We now consider pain to be a dangerous phenomenon in part because, well, it’s painful in the moment. But there’s also a widespread idea that we’re very fragile creatures, and that if we experience pain in the moment it will set us up for future pain.

The quintessential example of that is Post-Traumatic Stress Disorder (PTSD). It’s based around the idea that if we have some kind of emotional distress, it will leave a psychic wound that will cause emotional distress and suffering in the future. I think it’s important to recognize that that is a very modern idea. Prior to about a hundred years ago, people never thought about emotional distress and pain in this way. I’m not saying they didn’t have plenty of traumatic experiences but it wasn’t conceived of as “trauma.” They dealt with it in different ways and it may even have been kind of a badge of honor to be a wounded warrior.

But that is not at all how we think of it now, and I think that this new ethos of people being fragile and pain being dangerous has really helped drive the over-prescribing of all kinds of potentially addictive drugs, from benzodiazepines to opioid analgesics. This idea that we have to eliminate all pain and we have to do it immediately and, especially as healthcare providers, that we are remiss in our duties if we don’t. Not all healthcare providers agree with that mentality, but it is so dominant and pervasive in medicine, and especially in the mental healthcare field, where, if we’re causing them to feel distress or suffer in some way, then we’re not doing our job.
DK: I wonder how this relates to the rise of positive psychology and our cultural obsession with happiness. Pain seems like something that falls outside the realm of happiness.
AL: Absolutely. And yet, these paradigms are dialectics. The pendulums swings one way, and things don’t quite work, and then they swing back. Dialectical Behavioral Therapy (DBT)—speaking of dialectics—has been enormously helpful for certain types of patients, in part because what it teaches is distress tolerance.

It’s not just people with mental illness who need distress tolerance, though, it’s all of us.
We’re so insulated from any kind of painful or distressing experience that we’re deficient in distress tolerance.
We’re so insulated from any kind of painful or distressing experience that we’re deficient in distress tolerance. DBT puts it front and center and says: We’re going to teach you distress tolerance. When you’re suffering physically or emotionally we want you to sit there. Sit in that moment. Or we want to have you stick your hands or your face in an ice bucket to distract yourself. This is a fascinating movement and a potential antidote to this idea that all pain needs to be eliminated.

There's No Magic Pill

DK: What is a good comprehensive course of treatment for someone struggling with addiction? I know that there are a lot of different modalities that you use for various kinds of patients, but I’m assuming there’s an intake process and then you make decisions about treatment based on people’s financial resources, emotional resources, the severity of the addiction, whether to send them to a rehab or to 12 Step programs. How do you make decisions about where to send people, and is there some kind of standard treatment that you see as the most beneficial?
AL: Great question. Thanks for setting it up that way, too, because there’s no one-size-fits-all treatment. Having access to a bunch of different modalities is the ideal situation, because what works for one person is not going to work for someone else. AA may be the secret to recovery for one person and be an absolutely terrible fit for another.

A lot of patients will come in and want some kind of magic pill. We do use pharmacotherapy medications to treat addiction—although they’re generally underutilized by healthcare providers and should be utilized more—but there is no magic pill.
DK: When you say pharmacotherapy, do you mean drugs like methadone?
AL: Not just that. Also Antabuse, Vivitrol, Suboxone, Naltrexone, Campral for alcohol use disorders, nicotine replacement and other modalities for nicotine use disorders. These medications are underutilized, but they are not magic pills.

We have to talk a lot about how addiction is a biopsychosocial disease, and that the best treatment for the biological part is abstaining—not using the drug of choice for a period of time or maybe forever, depending upon the person, so that the brain can reset itself. And then the psychosocial piece, the long-term psychological and social interventions that are really the most important pieces.

We’re moving increasingly away from recommending that people go to 30-day rehabs.
We’re moving increasingly away from recommending that people go to 30-day rehabs. There’s definitely a time and a place for that, but we’re emphasizing, “Can we find a way to help you not use addictively in your regular life?” If we remove you and put you in a residential facility, you might do great during that time, but when you get out you have to return to the real world and your life. So initially, and also for the long term, we're looking for how to help people change their lives while they’re still in their lives.

That requires a lot of creativity from patients, too. So much of their substance use is ingrained in their daily living and so the key is to figure out, “How can I change my routine, my environment, the people I connect with? How can I change my internal life, my external life, on a very deep level?”
DK: So let’s say I’m a middle-aged patient who got hooked on Oxycontin for a pain disorder. I come in, and I tell you, “No way will I ever come off pain medication. It’s too painful, and I’m not going to a stupid 12-Step program.” Where would you go with me?
AL: For someone like that who doesn’t necessarily self-identify as having an addiction but who strongly self-identifies as having a pain disorder, and who has been on opioids for a long time, prescribed by a physician, I probably would go to buprenorphine, which is a special opioid that we can use for pain. It’s FDA-approved for the treatment of pain, and also FDA-approved for the treatment of an opioid use disorder.
DK: Are there people for whom long-term opioid use is an appropriate treatment?
AL:
For some people, the risk of relapse is just too high when they try to go off of opioids.
Yes. Absolutely. Because, number one, the data are convincing that, for some people, the risk of relapse is just too high when they try to go off of opioids. And from a biochemical or neurological point of view, it just makes sense that after years of exposure to opioids, that the brain, no matter how much time off of drugs you give it, is not going to reset itself. And those are people for whom opioids is the only way that they can feel normal in the world.
DK: What about for pain?
AL: Well, for pain theoretically, too, if you have the right kind of opioid. Both buprenorphine and methadone have unique properties, but the problem with methadone prescribed in pill form is that it has a really high overdose risk, so it’s not safe. It’s only safe when prescribed from a methadone maintenance clinic. But buprenorphine is a really unique drug, which makes it pretty good for pain, though many people develop a tolerance and end up needing more and more. And there may be—God forbid I say this—some people for whom chronic opioids for pain work. I don’t see those people, but I believe they’re out there.
DK: What do you think about the “stages of change” model for addiction?
AL:
If we waited until every pain patient on opioids was ready to change, we’d have even more people dying.
I don’t want to throw the baby out with the bath water. I think the "stages of change” idea can be very helpful for clinicians as well as patients, but I think it can also inadvertently provide an excuse not to get in there and move toward treatment. There’s no actual evidence that the stage of change that somebody is in predicts their engagement in treatment or their outcome. When people are mandated or forced for one reason or another to engage in treatment, even if they’re in a pre-contemplation stage, they don’t necessarily do any worse than people who are in an action stage.
DK: Oh, that’s interesting.
AL: Isn’t it? it’s a fallacy that people have to be “ready for change.” I mean, if we waited until every pain patient on opioids was ready to change, we’d have even more people dying.

One of my great mentors in the addiction field felt that one of the most important things that he could do when he walked into the room with a patient was to shake them up. Get them off balance instead of agreeing with them and throwing soft balls. He’d be like, “You know what? That’s just ridiculous.” Often he would just leave, and they would be angry at him. But that’s the kind of unsettling experience that sometimes—if it’s done empathically, obviously—can make a big difference.

Big Pharma and Institutional Denial

DK: Since we’re focusing on the opioid epidemic, how does treatment for prescription pain pill addiction differ from alcoholism?
AL:
About a quarter of patients who are prescribed an opioid for more than three months, even for a bona fide medical condition, will develop some type of prescription opioid misuse problem.
One of the big differences is that in many instances, patients have been getting their heroin equivalent from a doctor, so it’s very hard for them to shift from self-identifying as a pain patient who is getting treatment to somebody who’s become addicted. The way that I work with that is to really normalize the process and just say, “Hey, I totally get that you have pain, and this was started by a doctor for a real medical condition, but it happens that this is also a very addictive medication. And what we’re seeing now is that many people—even when receiving this from a doctor—have gotten addicted.” And then I always emphasize that it’s nothing to be ashamed of, that it’s not their fault and that they’re not alone.

Big Pharma did a good job teaching doctors something that wasn’t true, which is that the risk of getting addicted was less than one percent, as long as it was prescribed by a doctor. Now we know that’s not true. Probably about a quarter of patients who are prescribed an opioid for more than three months, even for a bona fide medical condition, will develop some type of prescription opioid misuse problem.
DK: Wow.
AL: Yeah. Twenty to thirty percent of people prescribed opioids daily for more than three months will develop some kind of opioid misuse problem. The longer it’s prescribed and the higher the dose, the more likely they are to develop a problem.
DK: So you’re saying that the primary difference in treatment between prescription opioid addicts and alcoholics is of self-awareness around having an addiction. You think alcoholics are more likely to identify as such?
AL: Well, not always. That element of denial is part and parcel of addiction. I think the difference is that the opioid epidemic has involved institutional denial. Now things are shifting as we realize that people can get addicted to opioids even if the doctor prescribed it. On the other hand, alcohol really has not ever been considered medicinal, except in rare instances.

We have the same problem now with cannabis.
Because we have medical marijuana, someone will come in, a young person with no identifiable, objectively verifiable disease process, telling you that their 12-times-a-day cannabis use is “medicinal.”
Because we have medical marijuana, someone will come in, a young person with no identifiable, objectively verifiable disease process, telling you that their 12-times-a-day cannabis use is “medicinal.” It’s very hard to combat that narrative because it’s a prevalent narrative in our culture. This is where this biopsychosocial model of addiction is so interesting and important. None of us lives in a vacuum. We live in the world, and our autobiographical narratives about our lives and why we do things are informed by the culture and the economics and the time in which we live. And we live in a time in which we believe in better living through chemistry. Whether it’s a medicine that a doctor prescribes or a medicine that I get from my friend in my study group at college, we have this idea that using chemicals to change the way you feel is perfectly okay.
DK: That’s an interesting point. Most people don’t believe that it’s possible to become addicted to pot or that it much matters if you do.
AL: Very true. But every day in my clinic, I see many examples of people who do get addicted to pot and who realize it and are coming in for help.

Twelve-Step Programs

DK: I noticed on your website you talked about bringing a spiritual approach to your work, and I wanted to ask you your thoughts on twelve-step programs. There’s a lot of division in the mental health field about their effectiveness and I’ve encountered a fair amount of contempt among clinicians for twelve-step programs, usually among people who have never really interfaced with them. There’s a common critique that they require you to believe in God, that it’s a cult, that the steps are irrelevant, etc.

I appreciate your emphasis on spirituality because many clinicians are afraid to use that word. The drive in the last couple of decades has been toward “evidence-based approaches,” and these are often touted as the counterpoint to twelve-step programs. There have been lots of articles lately about how twelve-step programs don’t really work but such and such evidence-based therapy does. What are your thoughts about this?
AL: I think it’s important to recognize that we’re in an era of twelve-step bashing. It’s very clear that twelve steps is down and getting kicked. The program came into being in part because the medical profession wasn’t doing anything to help people with addiction. People had to figure it out for themselves and it turns out that the AA movement is one of the most remarkable social movements in modern history. It’s really an incredible, incredible movement. You can go to an AA meeting pretty much in any country in the world. How many things can you say that about? It’s absolutely amazing.

But I think this sort of one-size-fits-all dogmatic approach to problems of addiction is what caused this quite vituperative backlash toward AA, and as a result, people are throwing the baby out with the bath water. The truth is that for people who actively participate in AA—AA in particular, but other twelve-step programs probably as well—they have very good outcomes. Their outcomes are better long-term than engaging in individual psychotherapy or group psychotherapy or really any professionally mediated treatment you can identify. So it’s a very robust phenomenon for those who actively participate—and that’s a key feature because not everybody does.

If someone goes to three AA meetings and then doesn’t go anymore and says, “AA doesn’t work,” that’s a misrepresentation because that person hasn’t actually engaged in the program. Those who engage have better outcomes. I’m always thrilled if I have a patient who’s actively engaged in AA because I know already the culture that they’ve been immersed in, the learning that they’ve done. It’s so helpful for me as an addiction specialist to be able to tag onto that and dovetail with that and reinforce that.
I’m not in recovery myself, but I’ve personally worked the twelve steps in part to understand what they’re all about, and in part because I think they’re really useful for a lot of different problems.
I’m not in recovery myself, but I’ve personally worked the twelve steps in part to understand what they’re all about, and in part because I think they’re really useful for a lot of different problems.

So I can converse with my patients on a pretty good level for somebody who’s not in recovery about what step they’re on, if they’re working with their sponsor, how that relationship is going, how meetings are going. I think it’s really important to be able to do that. It creates continuity between their twelve-step life and their professionally mediated addiction treatment.

Do I think twelve step works for everybody? Absolutely not. But another great advantage of twelve steps, which I think is underappreciated, is that it has incredible access. It’s everywhere and it’s free. And you can go when you’re intoxicated. There aren’t many clinicians who can say that. I also say to patients, “If you get yourself a good sponsor, that’s somebody you can call at midnight. Can you call me at midnight? No. I’m not going to pick up, and I’m probably not going to respond until later the next day. You call your sponsor at midnight, and they will be there for you.” That’s pretty amazing. There’s so much wisdom in the twelve steps—the cumulative wisdom of people in recovery, it’s awe-inspiring, really.
DK: I agree and I really appreciate your take on it. Also that you’re not forcing it down anyone’s throat.
AL: Right. I can’t. If I could, I probably would. But I can’t.
DK: That doesn’t work. Anyone who has ever encountered serious addiction knows that. It seems to me like the big lesson here is that there are many effective roads to treating addiction.
AL: Many roads to the top of the mountain. And we should really appreciate what each one has to offer.
DK: Well, you are a gift to the world and I have no doubt that you are helping save so many lives. Aside from reading your book, are there any other tips for people to get educated and get training?
AL: I put together a free online CME course through Stanford, which talks about the neurobiology of addiction and the prescription drug epidemic. That might be helpful. And then we’re making a course now that should be coming out soon about how to taper patients off of opioids, benzos and really anything that’s habit forming. It’s focused on the psychological aspects of preparing patients for it and I think even non-prescribers might find that helpful.

Also, the California Society of Addiction Medicine (CSAM) is a great resource for learning more about addiction. We have an annual conference every fall. This year it’s in San Francisco in August. For any practitioner, PhD, MD, MFT, etc., who wants to learn, it’s a three-and-a-half-day blitz course on addiction. It’s a great resource and taught me a lot about addiction treatment.

DK: Well thank you so much for taking the time to tell us about your important work.







* Read an excerpt from Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop here.
AL: It was a pleasure.

Alcoholics Anonymous Founder Bill Wilson’s Long-Lost Treatment Paradigm

Posted on by Psychotherapy.net Team

When I gear up to read a blog I invariably have the same thought: Tell me something I don’t know. In this blog I am going to fulfill that promise for my readers since I have never encountered a psychotherapist or addiction counselor who knows what I am about to share. (If you are the one in a million exception, please accept my apology.) So make yourself comfortable and let’s get this party started. Let’s begin with something you do know. In the summer of 1935 Bill W (aka Bill Wilson) and Dr. Bob (actually Dr. Bob Smith, birth name Robert Holbrook) conducted the first Alcoholics Anonymous or AA group. Since this initial meeting AA has helped more individuals than any group on record. Make no mistake about it. Bill Wilson loved AA and he believed in it with every fiber in his body. But two key factors prohibited this from being the end of the story. First, although AA helped Bill W deal with his alcoholism, it did nothing to curb his anxiety and depression. Second, as powerful as AA was it didn’t work for everybody. Now fast forward from 1935 to the year 1960. Bill Wilson decided to attend a parapsychology conference in New York City. It was there that the famed British Writer and AA supporter, Aldous Huxley, introduced Wilson to two esteemed psychiatrists, Abram Hoffer and Humphrey Osmond. These psychiatrists shared with Wilson a promising new treatment for alcoholics and schizophrenics dubbed vitamin B3 or niacin therapy. He was fascinated by their research. Wilson began ingesting a bomber’s load of the nutrient, 3 grams daily, only to report that his lifelong battle with depression and anxiety lifted in just 14 days! Is that amazing or what? I mean, seriously, it sounds like something right out of an infomercial airing at 2 AM after the one for Tony Robbins’ self-improvement materials. Here was an ordinary over-the -counter vitamin that when ingested in the proper dosage was a fast acting remedy for alcoholism, depression, anxiety, and schizophrenia. And, as a side effect it helped lower the so-called bad cholesterol. Wilson took immediate action and prescribed his miracle like intervention to AA friends who were described as educated. Others were said to be celebrities. According to Wilson, the results were nothing short of amazing. Wilson was brimming with enthusiasm and forged on to share his knowledge with the doctors of AA. These were physicians who were alcoholics and therefore attending AA groups. But here is where the gauntlet began to fall and nothing was ever quite powerful enough to reverse the pattern. The International Organization of AA, despite the fact that the members were appointed by Bill W, and he considered them friends, were not happy campers. Wilson, as they pointed out, was not a licensed physician and thus had no business extolling the virtues of vitamin therapy. Bill Wilson spent the last eleven years of his life spreading the word about vitamin B3 therapy as a treatment option or supplement to AA groups. Wilson tried to rally the troops by creating three powerful booklets over the years to AA physicians, but it fell on deaf ears. So who killed vitamin B3 or niacin therapy? Why was AA embraced by millions, while B3 niacin therapy never made it out of the starting blocks? Certainly, I don’t pretend to have the answer. Scores of reasons could be cited, but here are a few that just seem to make sense. Also keep in mind that nearly everybody is a great Monday morning quarterback. Had I been in Bill W’s shoes at the time I might have done exactly what he did.

Who killed vitamin B 3 niacin therapy?

The niacin flush. Unlike the tiny amount of B3 included in a typical multiple vitamin supplement, in order to import a clinical impact, the dose of niacin (also known as nicotinic acid) generally has to be high enough to induce a flush replete with itching and profound warmth. The effect is so pronounced that individuals taking niacin often mistake these symptoms for a heart attack or stroke and end up in the ER or an acute care facility. In all fairness, a very small percentage of the population finds the experience pleasurable. AA traditions. Tradition six suggests AA won’t endorse, finance, or lend the AA name to any outside enterprise or facility. Tradition ten suggests that AA has no opinions on outside issues, hence AA cannot become involved in a public controversy. The American Psychiatric Association. In 1973 the organization revealed they could not duplicate Dr. Hoffer’s data and therefore could not promote niacin therapy. Rumors surfaced that large doses of niacin caused liver problems. Hoffer, who boasted he took more B3 than anybody on the planet, remained healthy until he passed away at age 91. He denied all claims that niacin was responsible for liver difficulties and went as far as to say it promoted longevity. Before he passed away he discovered a Canadian woman named Mary MacIsaac who took massive doses of B3 for 42 years. She practiced cross country skiing at age 110 and lived until age 112! Okay, I think I’ll have what she was taking. Yes, it’s clearly N=1 data, but I think it’s safe to say that most supercentenarians don’t spend the better part of the day on a ski slope. Morbid fears related to the practice of orthomolecular psychiatry. Orthomolecular psychiatry (I’ll pause while you Google it), a term coined by two time Nobel Prize recipient, Dr. Linus Pauling in 1968, is basically individualized mega-vitamin/nutrient therapy. B3 or niacin therapy fit neatly into this treatment category. The idea that patients might be diagnosing themselves and then heading for the nearest pharmacy or health food store to buy niacin on a BOGO sale just didn’t sit well with mainstream psychiatrists. To be sure, the pharmaceutical companies marketing psychiatric medicinals were not overly thrilled either. Forget the doctors of AA, Bill Wilson should have taken his message to the masses. I am thoroughly convinced that Bill W pitched his ideas to the wrong population. In my humble opinion if he had penned a self-help book on the topic B3 niacin therapy might well have become a household word. This was the 1960s and early 1970s for gosh sakes and titles like I’m O.K.—You’re O.K., How to be Your Own Best Friend, and Born to Win were shaping American culture, not to mention the landscape of mental health. Today, vestiges of niacin treatment live on in the minds of longevity seekers, the alternative health movement, and nutritionally minded cardiologists hell bent on shaving another silly little point off your LDL cholesterol score using straight niacin or a modern slow release version which may or may not eliminate flushing. Had Bill W been successful in his mission to incorporate vitamin B3 niacin therapy into AA the entire face of addiction and mental health treatment might have looked very different today. The story goes that before Bill Wilson passed away he was asked what he would like to be remembered for in the history books. Much to the chagrin of experts and those who have benefited from 12-step groups he chose niacin therapy over AA. Who knew?

Psychotherapy “Terminations” and Beyond

Posted on by Psychotherapy.net Team

Often when I “terminate” with a client (what a horrendous term for the conclusion of a meaningful human encounter) I let them know that I don’t see therapy as some kind of permanent cure to the concerns that brought them in to see me. At best it offers some meaningful relief, and some expanded awareness and resources that they may draw on when they inevitably face future challenges.

I usually tell them I’d be happy to be of help in the future, whether seeing them again, or referring them to a colleague, often adding that I’d be delighted to hear from them with any update on how things are going for them. 95% of the time I never hear back, but of course certain clients run through my mind at various time. I may walk by a building that a client had done the architectural plans for. Or I am riding my bike, and I remember their joy in a bike tour they once took in New Mexico. Or a client springs into my mind for no apparent reason at all, and I wonder whether their marriage—that I had some role shepherding them into—gave them the love and sense of safety they craved.

And then there are those clients that I mark down on my inner scorecard as failures. Yes, I might have given them some support, maybe I helped marginally change the trajectory of their lives, but I felt that somehow I just couldn’t help them break through to achieve the types of changes that they desired—or I desired for them. How were they doing? Were they still as depressed as when we parted ways? Or worse…had they given up entirely? Committed suicide?

I notice that I hesitate before I type the word “suicide” as if somehow that reflects poorly on me that I’d even have this worry. Why the hesitation? Is it that I should be omnipotent, and never have clients, or even former clients that might commit suicide? Or is it that I shouldn’t admit that clients occupy my thoughts even years after I stop seeing them? Has the pernicious concept of therapeutic “neutrality”—one that we thought started and ended with psychoanalysis—become so rooted in our profession that we carry it with us without awareness? As if it’s wrong to care about our clients as actual human beings, as individuals!

There is one specific client that I do worry about from time to time—yes, worry whether he did decide to put an end to his tormented life—but I was somewhat reassured recently when I ran into a colleague at a conference whom I had entirely forgotten was the original referral source. She knew the client personally, and related to me that he was still alive, although still very much struggling day to day, but that she was grateful for the help I provided her friend. Given my feeling of failure with him, I was pleasantly surprised that my efforts were appreciated.

Just a few days ago I got an email out of the blue from a client I’ll call Penelope whom I saw several years ago. She said she just wanted to say hi, thank me for the help I had provided, and let me know that things were going well for her. She was a classical musician who was starting to achieve some success in her highly competitive field, and for the first time in a stable relationship.

I recall that the course of therapy was not an easy one—for the client, as well as for me. We all have our own tricks of the trade, some we like to think of as our own, or at least ones we’ve customized to fit our own personality. I like to work in the “here-and-now” when I can, drawing attention to how the two of us are engaging, with the idea that this will shed light on the client’s interpersonal relationships. Of course this is not a proprietary technique—I learned a great deal about this from my father—but I like to think that I have achieved some mastery in this.

In this case it failed repeatedly: Every time I asked Penelope how she was feeling towards me, she bristled, got angry, and didn’t see how this was relevant to her issues. I recall various responses on my part. One time I made an impassioned plea, relating her difficulty in trusting me to problems she was experiencing with a friend or co-worker. Or I would try to push back, again in the here-and-now, saying something like “I really sense that when I ask you how you feel towards me, it hits some sort of nerve for you. Can you tell me what is triggered?” Again, this got nowhere fast. Finally, I took this prized technique and stuffed it back in my toolbox where it belonged. Was that a failure? Or a brilliant realization that there is no one-size-fits-all in this work?

My memory is a bit hazy, but I recall we worked on and off for a year or so. I don't remember exactly how things ended, but it certainly wasn't one of those Hollywood therapy endings where her neurotic puzzle was solved, and I was left with a warm glow that I had performed my craft with precision. So thank you Penelope for being one of the 5% who let me know what has happened in your life. I go on faith that most of those I work with have some lasting benefits from our work, but it’s sure nice to hear it from you.

* * * * *

That was going to be the end of my musings, so I sent this piece to Penelope to make sure she felt comfortable with me publishing this (even though identifying details are changed). She wrote the following:

“I think that even though it made me pretty mad when you asked me how I was feeling towards you, I realize now that I was mad because that’s what I needed to work on. It took me a few more years to not get mad when people asked me stuff like that, but once I got more comfortable having conversations like that it was a lot easier for me to have close relationships.”

Wow! If I had known at the time that my apparent misfires would ultimately yield results, it would certainly have reduced my anxiety during the therapy. Would that have made me a better therapist? Perhaps not. Uncertainty is inherent to the process, and something we need to learn to live with. But how heartwarming it is to know now that my efforts with Penelope planted some seeds that are now blooming.

Are High-Risk Clients Suitable for Online Psychotherapy?

Posted on by Psychotherapy.net Team

Into the Virtual Unknown

When we first began practicing online via the Skype interface, each of us felt a similar trepidation. Four or five years ago when we started, online psychotherapy was in its infancy and there were no supervisors or established authorities to guide us, so there was an understandable fear of the unknown.

We also worried about mastering the technology, as neither of us is particularly skilled in computer matters more complicated than word processing and email composition. Should we use built-in or external cameras? Should we use headsets with boom microphones? How fast of an Internet connection did we and our clients need? And perhaps unnoticed at the time but inspiring a subtle anxiety: “Would we be less skillful as therapists, less confident in our abilities, when we no longer met with a client within the authoritative confines of our own offices?”

Another source of anxiety was deciding which clients to accept for online treatment. Uncertain of our ability to work in this new format, we originally believed that we ought to confine our online practice to high-functioning clients—people who’d be able to sustain the supposedly less intimate form of contact and, with only a screen image for bonding, wouldn’t feel detached or abandoned. High-risk clients such as those who self-injured or posed a risk of suicide were definitely off limits. Today, when we discuss the subject of online therapy with some of our colleagues, we encounter similar questioning, and sometimes profound skepticism.

Over the ensuing years, we’ve both become entirely comfortable with the technical interface offered by Skype and confident in our abilities to provide quality online psychotherapy. With experience, we’ve also come to feel that the population of clients who might benefit is much larger than we first believed. There are still limits, of course, especially when there is a serious risk to life or when a client is psychotic; but based on the past five years, we’ve found that nearly all prospective clients can benefit from online psychotherapy.

Joseph first began to envision a larger scope to his potential online practice during his early work with a client who had concealed the extent of her involvement with self-injury at the beginning of treatment.

Anastasia pushed the scope of her work when an ongoing client she had started treating face-to-face in Spain for acute panic attacks had to return to Russia: Transitioning to online therapy was the only way to continue working with her.

Danielle and Olga are two clients who didn’t at first appear to be good candidates for online psychotherapy as they both displayed ongoing instability in moods and behaviors.

Danielle (Joseph’s client)


Danielle had followed my blog for a couple of years before she contacted me for treatment, not long after I began working by Skype. On her client questionnaire, she disclosed a history of self-injury but described it as minor, under control, and not life threatening. She insisted that she wasn’t suicidal. In our email exchanges prior to scheduling a first session, I told her that I couldn’t see her less than twice a week; otherwise, I didn’t feel we’d have the conditions to manage her issues. If I’d been seeing her in person, I would have required the same twice-weekly sessions.

During our first exploratory session, before we committed to working together, I made sure that she had an adequate local support system in case of emergency. Danielle assured me that, if she did at some point feel suicidal or if self-injury became a much larger issue, she had resources to contact: her pastor as well as a local therapy practice to which her prior therapist had belonged before he moved to another city. Danielle was familiar with emergency medical services and knew whom to call. Although I felt a little apprehensive about her history of self-injury, I felt that we’d established the conditions necessary to begin treatment.

From the beginning, Danielle and I developed a strong working relationship. Because she’d read every one of my blog posts, many of which are quite revealing, it didn’t feel to her as if I were a complete stranger. I found her endearing, engaging, and a pleasure to work with. In her line of work, Danielle managed a team remotely and held daily meetings by Skype, so she was even more comfortable with the medium than I was. We met twice a week on Tuesdays and Fridays. It soon began to feel to me no different from meeting a client in person, as difficult as that is for professionals who haven’t worked by Skype to understand.

Although she didn’t disclose the full details of her past until much later, Danielle let me know early on that she’d been sexually molested by more than one of her stepfathers beginning when she was 7 years old. She also told me that her mother had looked the other way when a family friend began abusing Danielle later on; the mother needed the man’s help and essentially gave away her daughter in exchange for it. This arrangement went on for several years.

A month or so into treatment, it became clear that Danielle’s involvement with self-injury was far from “minor”; she admitted that she’d misrepresented how serious it was out of fear that I wouldn’t accept her as a client if she’d told the truth. In fact, “I probably would not have taken her into my practice had I known.” Relatively inexperienced in working by Skype at that point, I would have assumed that a client who self-injures needed the more immediate contact afforded by in-person therapy.

Minor hair pulling, pinching, and scratching helped Danielle to manage her emotions most of the time—she’d explained this to me at the very beginning. But as I later learned, when conflict arose with her ex-husband or work became especially difficult, she’d cut herself with razor blades to find release from emotions that threatened to overwhelm her. During that stressful period, a month or so into therapy, cutting had become a daily practice.

By that point, I’d already developed a strong connection with Danielle and didn’t feel I could simply stop working with her, although I did feel more anxious about her welfare. At the same time, I wasn’t frightened and didn’t make Danielle sign a contract binding her not to cut as a condition of treatment. I’ve worked with other women who self-injure and understand the dynamics of emotional self-regulation involved in cutting. I felt that together, given our strong working bond, we could help her find healthier ways to self-soothe.

A complicated transference relationship soon developed. While on one level, Danielle idealized me and developed some sexual fantasies about the two of us together, on an unconscious level, she also struggled with a great deal of rage toward me, displaced from all those “fathers” who should have looked after her but instead exploited her as a sexual object. The cutting also had more than one meaning. It provided emotional relief, as I’d seen with other clients, but it also gave Danielle an outlet for the rage she felt. As I put it to her during our sessions, she couldn’t hurt me directly but she could get to me by hurting my client.

To confront these emotional dynamics, along with one’s own anxieties about clients who self-injure, often makes professionals unwilling to take such people into their practice. It can be quite scary, especially when these clients often want to scare you. Sometimes it’s because they want you to come to their rescue; sometimes they want to “prove” they can be more powerfully destructive than you are creative; sometimes they need to express the rage they feel for having been helpless and exploited. Bearing with these emotions without becoming terrified or enraged yourself is a major challenge for the therapist. Most professionals understandably worry about a malpractice suit if a client actually were to kill herself. Nobody wants the guilt and regret for having “failed” a client who committed suicide.

But in my experience, the emotional dynamics and therapeutic methods for understanding and coping with those who self-injure are the same with both in-person and Skype clients. I made the same sort of interventions with Danielle as I’ve done with clients I’ve met in my consulting room. By remaining calm and engaged with her, and not retreating in fear or anxiety, I helped her over several years to find better ways to cope with her emotions.

“We survived a period of intense cutting, when severe blood loss brought on heart palpitations, and she began reaching out to me by email between sessions.” Although I don’t normally encourage email contact, I welcomed Danielle’s communications, just as I would have welcomed emails from a self-injuring client I was meeting with in person. Sometimes that extra contact during breaks is needed to support clients in their struggles to take better care of themselves. By the end of our treatment, self-injury truly had become a minor issue.

Early on in my practice by Skype, this experience with Danielle taught me that distance therapy is suitable for many more potential clients than I would have imagined. If she hadn’t concealed the extent of her self-injury at the beginning, I might never have learned this valuable lesson.

Olga (Anastasia’s Client)


When Olga reached out by email, I’d already had experience working online with complex cases. Olga had fled the war in her country and now lived in Prague as a refugee. Her existence was precarious in every possible way; she did not speak Czech and, feeling isolated, was barely able to navigate her new environment. She complained about panic attacks, depression and an “acute desire to die.” For several days previous to her “cry for help” (these were the exact words she chose for the “subject” of her first email), Olga was unable to leave her room and the only “food” she was able to consume was coffee and cigarettes.

I agreed to meet for an introductory session to see whether I would be able to help her. “While I felt an obvious sense of urgency and a natural desire to rescue her, I also secretly planned that after this first conversation, I would refer her to a local English-speaking therapist.” I usually try to avoid any rigid diagnosis, but I suspected that Olga might be labeled as “borderline” and could probably benefit from medication.

Only later, several sessions into our work, did I realize the full extent of Olga’s issues: She experienced social phobia and agoraphobia, was mildly self-harming, and felt suicidal most of the time. The level of isolation and despair she was experiencing at that point made it impossible for her to get out of her room, to struggle with an unfamiliar language or navigate foreign streets, and to engage with a local in-person therapist in her wobbly English.

There were several occasions in the early stages when I questioned my decision to welcome Olga as an online client. We were in the middle of our third session when she suddenly announced: “I need a break, just for a minute,” and she abruptly disconnected. “I sat there, in front of my painfully empty screen and thought to myself that I had lost her.” The intensity of the emotional response that she had read on my face must have made her panic. To see her own unexpressed pain reflected on somebody else’s face was too much for her.

In the chat box, I let her know that I would prefer to remain online whenever she felt overwhelmed by emotions. I was able to keep calm and stay connected without the sort of unpredictable outburst she would typically have received from her mother. Was it ok if I called back? A few minutes later, when we resumed our conversation, she was ready to reflect on what had happened.

The idiosyncrasies of an online setting allowed Olga to regulate her own risk-taking behavior and vulnerability. Temporarily logging off when she felt overwhelmed and then reconnecting once she had recovered was an empowering experience for someone who had been feeling hopeless and depressed for a long time. Such experiences, if used mindfully in the session, often provide great grist for the psychotherapy mill.

At first when we were connecting, Olga would be sitting on the floor: She felt too weak and too ashamed to hold herself upright. In a more traditional setting, the client is forced to adapt to the therapist’s environment. With clients who carry some deep psychological wounds, this can be simply impossible at the beginning of treatment. “The fact that we meet the client in his or her own environment opens a window into the client’s experience: Seeing Olga curled up on the floor of her untidy room, I could sense her shame and fragility.”

Later in treatment, on the day I saw her sitting upright in a chair, with her laptop on the desk in front of her, I knew we’d made some serious progress.

Several months later, when she had more fully recovered and was resolving her current life situation, I asked Olga to share her experience of working with a therapist online. I also informed her that I would use her account in an article. This invitation offered a therapeutic boost to her broken self-esteem: It let her know that not only was her opinion valuable for me, but it could also be of use to others who might also feel isolated and in desperate need. This is what she wrote:

“I remember that day when in the half fog, in the total despair, I plucked up the courage to write you an e-mail. After several attempts to commit suicide, after repeated uncontrollable impulses to harm myself, after feeling myself to be absolutely unfit to live, after realizing I not only can't carry on living like this but don't want to, and it would be better to die right now, what could I do? I could write an email. I didn't have anyone, anything, I wasn't even myself—that in short is how you could have described my condition. My Internet had been paid for. I talked a lot during our first conversation; you gave me this opportunity. I talked and you listened to me until I could get my breath back. I sat on the floor, leaning my back against the wall. Via Skype I could see on my familiar iPad, the calm, compassionate expression of an unknown face on the screen. I knew that at any moment I could press the button and ‘hide.’”

Olga took a huge risk, reaching out when her trust in herself and the world was broken. Now it was my turn to take the risk and be there for her, even if my support would be limited to the screen during our twice-weekly sessions.

Such limitations may at first seem like an obstacle to working with more challenging cases, but they often end up playing an important role in containing people who feel torn and fragmented: They allow these clients to regulate the intensity of the contact, and empower them to make choices about the physical conditions of the session. In the case of Olga, the choice about where and how to sit, and how long to stay connected, helped her to become more aware of the process and of her connection to me. This awareness gave us both insight into our quickly evolving relationship.

Working online with clients who are deeply distressed makes therapists keenly aware of the absence of touch. We cannot shake our client’s hand when we greet them at the door, we cannot offer the same warm gesture at the end of each session. Any online therapist is familiar with this frustration. But with Olga, this physical distance helped her to trust me enough so that she could engage in the process. Olga’s mother had touched her daughter in many abusive ways, asking to join her in bed and to give her endless back rubs. At the initial stage of our work, Olga knew she was safe and out of reach.

Like many online therapists, I often work with clients who are experiencing some form of displacement. Olga’s case may seem extreme, but what she was experiencing in an acute form (due to her precarious refugee status, her traumatic history, and a very particular sensitivity) is familiar to many emigrants as an unavoidable part of their lives. The benefits of online therapy for such individuals cannot be over-estimated. In the case of Olga, before we could get anywhere close to her borderline mother and the abuse she had experienced throughout childhood, we had to deal with the harsh realities of her current living situation: her fear of going out to buy groceries, her inability to engage with others, her disrupted sleep patterns and her struggle to feed herself. At this initial stage, the fact that she was able to connect with me from her own room—the only “safe space” she knew—became crucial. This is Olga’s account:

“… [A]t the very beginning, I deliberately focused my attention on ‘my familiar iPad.’ It has a small screen. For the first few sessions I didn't expand the window to full screen, after several sessions, I tried it for the first time, then forced myself and then I wanted to… Skype therapy was the only therapy possible… I am located within my ‘familiar space.’ I look at your face on the ‘familiar screen.’ I can sit there in whatever clothes suit me and with my hair unbrushed, with my legs pulled up under me, and thus I learn what I am and I don't have to pretend. I am not ‘attacked’ by the details of your room, my consciousness ‘does not float away,’ it doesn't get distracted… and when we finish the session, this screen, this room remains with me. Several sessions ago I was unbearably frightened after each session—do you remember the cries for help in my messages: ‘How can I live each minute?’ Then it became a little bit easier to finish a session and leave myself at least a small drop of the sense that I exist, when we aren't talking any more, I am in a familiar place, as before everything threatened me including myself and I was ‘on the lookout,’ but I can stay at home and immediately crawl under my blanket or continue to sit in the same place, giving myself time to get up and go and do something, however small.”

It took us a few sessions before she was able to follow my advice and reach out to a psychiatrist I had located for her in Prague. She agreed to take medication, which quickly improved her sleep and her concentration. The risk she took in leaving her room and meeting the psychiatrist was our first victory, a testament to our growing therapeutic alliance.

As is often the case with deeply troubled clients, Olga’s childhood had been catastrophic: She grew up in a dark, cold and neglectful environment. Her mother was unpredictable, volatile, and emotionally and physically abusive. She had never been diagnosed, or sought treatment, but her behavior indicated some severe personality disorder (probably BPD). Olga’s father was drunk every evening, and later in life discussed his suicidal urges with no regard to his children’s feelings. Her parents divorced when she was seven, and after that, her eight-year-old brother was supposed to take care of her. Both children cooked, earned money as they could, cleaned the apartment and protected their mother from distress. They knew far too well how violent and terrifying she could become when upset.

Throughout her life, Olga had felt completely responsible for her mother. She continued sending her money (often the only money she had) and supported her mother’s myth about her sacrificial parenting. This came at a high cost; her dysfunctional mother had taken up residence deep within her own bowels. Olga’s behavior toward herself and in her relationships with others mirrored her mother’s shaming, persecutory, and abusive manner.

In the course of our work together, Olga began to experience some intense kidney pain and vomiting, which did not seem to have any purely physiological reasons. On a psychological level, it marked the beginning of a separation and liberation process and an important stage in the therapy. As Olga struggled to separate from her mother, I stayed as “close” to her as I could. We met twice a week, sometimes more, when she was feeling particularly fragile. Through my screen, I bore witness as she relived many painful moments from her childhood; as a new narrative of her life emerged, she began to feel more alive.

As is often the case with online therapy, boundaries were easily challenged. Olga would reach out frequently, sending me distressed messages via the Skype chat box. Initially I felt stressed by these intrusions, but once I addressed the issue openly with her, we agreed on some simple rules: I wouldn’t always respond straight away, or would sometimes just confirm that I was there and thinking about her. This reassured her as to healthy nature of our relationship, strikingly different from what she had experienced with her mother who had constantly pushed, violated, and dismantled boundaries with her violent emotional storms.

The fact that I was located at a safe distance, in a different country, permitted her to experience separateness and create a safe space around her. Soon, she was able to fill it with her own thoughts and desires. Our relationship was by definition at a physical distance, so different from what she had experienced with her mother: They had lived together in the same small apartment for more than twenty years. At crucial moments, this distance and our limited physical access to one another kept us both safe.

Olga went on to experience powerful emotions of hatred and anger, which she could never have expressed to her mother. As for me, the “safe distance” offered by the online setting helped me to be “there for her” at those difficult moments without letting these emotions sweep me (and our relationship) away.

Towards the end of our work Olga regained the ability to deal with her every-day reality. She slowly resumed her daily activities and began engaging with others in healthier ways. For the first time, her life felt like it was actually her life, separate and apart from her mother.

Taking the Risk


In the process of dealing with such difficult cases, we’ve developed some useful strategies. At the outset, we always discuss the limitations of online therapy with new clients, stressing the fact that it doesn’t allow us to be physically present when we might like to be. Addressing this reality openly allows us to model ways of dealing with the frustrations and the limitations of a distance relationship. This modeling is extremely beneficial, particularly for those clients who have little healthy experience with appropriate emotional bonds or are confused about their own personal boundaries.

While we typically meet with our online clients weekly, we tend to offer a more intense rhythm in more challenging cases. In the two cases described above, we met with our clients twice a week, and sometimes more frequently when major shifts or breakthroughs were occurring.

We also found that online clients reached out to us between sessions more often than usual, and responding to their emails turned out to be a very important part of the therapeutic process. While we usually expect in-person clients to cope with the inevitable lack of contact between the sessions, this is sometimes too much to ask of online clients, giving the physical distance. Responding, briefly but mindfully to their emails, helps these individuals to maintain the sometimes-fragile connection. While this places an additional demand upon the therapist’s time, it can be crucial at some stages of the client’s recovery. Once the client starts to feel stronger, the email flow usually diminishes naturally.

In cases involving some serious disturbance, we can also insist that the client meet a psychiatrist in person. We typically raise this subject several sessions into therapy, once a good therapeutic alliance has been established. Even with the most resistant clients, this strategy eventually works out well once they’ve developed enough ego strength and trust in our support to take this challenging step of consulting with a psychiatrist and eventually taking a prescribed medication.

“Expanding one’s practice to the online realm can feel risky, and to accept clients with major disturbances can feel even riskier.” As with any venture into the unknown, however, the effort may widen our perspective: What we had felt to be out of reach suddenly becomes possible, at least with some of the people who approach us for treatment.

And in taking such a risk, are we not modeling something important for our clients?

Bruce Wampold on What Actually Makes Us Good Therapists

Posted on by rezendevknowfully.com

The Zero Percent Difference

Greg Arnold: Bruce, you’ve been in the field of psychotherapy for over 30 years and have made a tremendous contribution to our understanding of psychotherapy from empirical, historical, and anthropological perspectives through what you call the “contextual model of psychotherapy.” Your fantastic book, The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work is in its second edition, and I highly recommend it to our readers.

I want to start right out with what I see as the most significant thing to share with our readers. In your research, you’ve found that the difference in effectiveness of various types of psychotherapy is zero percent. Is that right?
Bruce Wampold: With some qualifications. I would put the differences between various types of psychotherapy at very close to zero percent. That statistic comes from clinical trials comparing treatment A to treatment B—often CBT to another form of CBT or to a dynamic therapy, a humanistic therapy, an interpersonal therapy—and there we don’t find any differences that are consistent or very large. Sometimes they’re small differences. The other area of research, “dismantling studies,” takes out the ingredient that is supposed to be the most important element of the treatment. It turns out that treatment is just as effective without the particular ingredient.

But here’s the qualification. There are a number of trials that compare a coherent, cogent, structured treatment to what’s often called “supportive therapy,” where the patient just sits with an empathic therapist, but there’s no treatment plan, there’s no explanation to the patient about what they’re going to do in therapy to help them get better. And we know, all the way back to Jerome Frank, that we need a coherent explanation for what’s bothering the patient and a believable treatment for them—something for the patient to do so that they work hard to overcome their difficulties. Supportive therapies are a lot more effective than doing nothing, but they’re not as effective for targeted outcomes as those that have a coherent explanation and treatment plan.

As long as what they’re doing is believable, accepted, is given by a therapist who’s skilled and believes in the treatment as well, the treatment tends to go well.
So if a patient comes in with problems in interpersonal relationships, depression, anxiety, we have to come up with a cogent explanation and a believable treatment to overcome their difficulties. As long as what they’re doing is believable, accepted, is given by a therapist who’s skilled and believes in the treatment as well, the treatment tends to go well.
GA: Regardless of the treatment?
BW: That’s right. So that’s the long answer to your question about all treatments being equal. Of course, not all treatments are equal—there are harmful treatments. In my workshops, I show Bob Newhart doing “stop it” therapy.
GA: Yes, I’ve seen it. It’s hilarious.
BW: You can Google it on YouTube. He just keeps saying to the patient, “Stop it!” When we say all therapies are equally effective, we need to be clear that we are not talking about harmful or sarcastic therapy.
GA: Of course. So let’s take a case example, say someone with severe OCD. Most people think exposure with response prevention is far and away superior, its treatment rationale is better than anyone else’s treatment rationale, and that it’s the only therapy that will cure it.
BW: OCD is an interesting one to bring up.
Exposure and response prevention is pretty good, with some provisos, but it’s never been compared to another bona fide, legitimate treatment for OCD.
Exposure and response prevention is pretty good, with some provisos, but it’s never been compared to another bona fide, legitimate treatment for OCD. I would like to see a focused dynamic treatment for OCD, and I would predict it doing just as well.

The other thing about OCD is if you read the literature, outcomes are almost exclusively measured in terms of symptom reduction. There’s a failure to measure quality of life or interpersonal functioning. OCD is a terribly disturbing disorder, and the people who suffer from OCD often have a terrible quality of life—they’re isolated, they’re alienated from people, they’re not integrated into social networks because their disorder interferes, or they have other issues as well. So it’s very misleading to just measure targeted symptoms.
GA: It’s stacking the deck a little bit.
BW: I had a debate with a psychologist here in Wisconsin who has an OCD clinic, and he said the same thing: We know how to reduce symptoms. But the people are not back to work, they don’t have romantic or intimate relationships. So now we’re starting to augment the exposure and response prevention with vocational therapy and counseling for other issues. OCD is an area where we need to do more research.

The claims about CBT being superior to other treatments are not founded.
Another area where we thought CBT was the most effective treatment is panic disorder. But now Barbara Milrod and others have dynamic therapy for panic, and it’s just as effective. Social anxiety is another area. If you read the clinical trials carefully, there isn’t convincing evidence that one particular treatment is more effective. CBT folks have done some amazingly good research and have helped the field immeasurably. I don’t want to discount that, but the claims about CBT being superior to other treatments are not founded.
GA: Those claims are far and wide, deeply rooted. Given that, among the bona fide treatments, they’re all equally effective, then the medical model is not superior either, correct?
BW: Yes. In Western culture, we’re so indoctrinated by the medical model that we ignore the social factors that make psychotherapy particularly effective. Humans are evolved as social animals, and we’re influenced through verbal means. How many of us learn not to stick our fingers in electric sockets because of classical conditioning? Our parents didn’t put our fingers into the socket to learn by experience, or put their fingers in there and have us watch them writhe on the floor in pain. All the parent had to do is say, “that’s dangerous.” We have evolved in such a way that significant others have tremendous influence on us through social means. Psychotherapy very effectively does just that.

A skilled therapist makes a big difference no matter the orientation.
The medical model can have some unfortunate consequences. It leads us to think that a “cure” can come through specific “interventions,” that if a therapist follows some kind of protocol, they will have good outcomes. That’s a myth. A skilled therapist makes a big difference no matter the orientation.
GA: Which is good news, right? People are going to be happy to hear we make a difference.
BW:

Therapists Deteriorate Over Time

Yes, but it comes with responsibility. Let’s ensure that our outcomes are commendable, that they meet benchmarks, and that they improve. We just did a study where we looked at therapists over almost 20 years of practice, and the therapists did not improve. In fact, they deteriorated a bit.
GA: Sobering.
BW: It is. But it’s not surprising when you think about it. What other profession do you go into a room, do your work in privacy, aren’t really allowed to talk about it because it’s confidential, and don’t get any feedback about how you’re doing. How can we expect to get better? Would we go to hear a musician who only performed and never practiced? Do you think world class tennis players just play Wimbledon and the U.S. Open and Australian Open? No, they practice hours a day on particular skills. So becoming a better therapist takes a lot of deliberate practice.
GA: Can you talk a little bit about the therapist factors that make us better or worse that we could be working on—be it in consultation groups or in feedback informed therapy.
BW: For many years I said the fundamental unanswered question in psychotherapy was, “What characterizes an effective therapist? What do they do?” And we didn’t know. But we’re starting to get good scientific evidence about what effective therapists do, so I’ll run through it.
GA: Please do!
BW: Effective therapists are able to form a working alliance—a collaborative working relationship—with a range of patients. The motivated patients with solid attachment histories who easily form an alliance with you—those aren’t the ones that challenge us. The ones that challenge us have poor attachment styles, do not have social networks, they alienate people in their lives, they have borderline features, they’re interpersonally aggressive, they tell us we’re no good. A really effective therapist is able to form a relatively good collaborative working relationship with those types of patients. The therapist effect is larger for more severely disturbed patients, which makes sense.

Effective therapists are also verbally fluent, they can describe the disorder as well as their treatment rationale.
GA: They get the buy-in from the client.
BW: Yes, they’re persuasive as well as verbally fluent, so when they explain things, they do it in two or three sentences and it’s coherent. I have my students practice explaining what they’re going to do in therapy. It’s difficult to do and you have to practice until you can do it in three or four sentence.

An effective therapist can read the emotional state of clients even when they’re trying to hide it. And we know the patients hide what they’re feeling. It isn’t intentional; it’s part of their struggle in life. They suppress anger or they’re not allowed to express sadness. A good therapist can understand and respond to the patient affect. Good therapists also can modulate their own affect.
Can you be expressive and activated when you have a really depressed patient who just kind of sits there?
Can you be expressive and activated when you have a really depressed patient who just kind of sits there? Affect is really contagious. We know that from basic science.

On the other hand, if we have an extremely anxious patient, can we be relaxed and calm? Modulating our own affect takes some practice as well. Are we warm, understanding, and caring? You may think all therapists are warm, understanding, and caring, but it takes work. I had a student whose patient didn’t bathe, so it reeked when the patient came in. What would your facial expression be?
GA: It would be hard not to feel some disgust.
BW: Exactly. We had to practice not displaying disgust. Being warm and empathic is easy with some patients, but really hard with others.
GA: Do people lose faith when they realize that the medical model, that any model really, isn’t the X factor in therapy? Do they just throw in the towel?
BW: I wouldn’t say that. When therapists say, “My treatment is the best there is for X, Y and Z,” in a way I’m glad. I want people to believe in their treatment, as that is an element of effective therapy. But instead of thinking that treatment X is the most effective treatment, we should believe that treatment X as I deliver it to this particular patient is effective.

This is where the focus on outcomes is so helpful. Is this patient getting better? Are they reaching their goals? If so, you can have faith not in the treatment itself but in your use of the treatment with the patient who is getting better. If we’re rigidly attached to a treatment, that’s problematic. I dislike it when therapists say in the first session, “Here’s how I work. This is what we’re going to do here.” You haven’t even listened to the patient yet and understood how the patient wants to work.

You need to modify treatment for some patients, or you might have to abandon it and do something very different for particular patients. Flexibility is another characteristic of effective therapists. That doesn’t mean doing something different every week with them, which is confusing; we need to be consistent, but also flexible.
GA: Dogma gets in the way here, and you’ve shown that more fidelity to a treatment actually gives less positive outcomes.
BW:

The Sweet Spot

There’s a sweet spot. You don’t want to be so flexible that you lack coherence, as that is not effective either. We need to be kind of in that sweet spot where there’s consistency in what we’re doing so the patient feels like we’re working towards their goals with a logical treatment plan.

But there may be a crisis in a patient’s life or a dramatic event or they’re just resistant. One of the things I teach my trainees is to see the nonverbal signs of resistance—they’re not following through on activities or when we explain what we’re doing they look away. They don’t want to say, “No, that doesn’t make sense, you’ve got it wrong.” So we have to be really attuned to those signs and willing to explore them.
GA: Still, it seems like this contextual model kind of suggests that we don’t really need particular treatment models. That if we are naturally good at making alliances with all kinds of clients and verbally skilled, we don’t need to be steeped in a particular treatment model.
BW: Well that’s where coherence and clear articulation of a treatment plan come into play. You don’t have that without having some kind of approach. When we go to a doctor, we want to know what’s wrong with us and how we’re going to get better. CBT therapists are great at this. They incorporate psychoeducation into the treatment structure, so a coherent treatment plan is central to the work they do with clients.

Where CBT therapists can fall short if they don’t attend to it is the warm, empathic, understanding treatment expectation part of the contextual model.
If you administer CBT without warmth and understanding, it’s not going to be nearly as effective.
If you administer CBT without warmth and understanding, it’s not going to be nearly as effective. On the other side are the humanistic therapists who are often great at the warm, empathic part of therapy but don’t always have a coherent treatment structure. I think we all have to look at our practice and assess what we are really good at, what are the elements that seem to work well with our clients and then have a good hard look at the areas where we are falling short.
GA: Yes, for me it’s figuring out the fine line between non-directive and directionless.
BW: That a good way to put it.
GA: It sounds like we should all be multi-modal, integrative, competent in several modalities because different things are going to work with different clients. None of us should be one-trick ponies.

To what extent does this call upon us to be more educated and trained in multiple modalities? Training culture these days seems to be trending towards manualized therapies, those that have been shown to be effective with particular disorders, etc. How do you think students should be getting trained these days?
BW: That’s an interesting question. I’m a counseling psychologist, and in counseling psychology we usually start by teaching the basic interpersonal skills first. In clinical programs, they are more often these days teaching manualized treatment—CBT for panic disorder or exposure therapy for OCD. We need to integrate the basic humanistic skills that are necessary for effective treatments as well as learning treatment protocols.

I have no problem with treatment protocols. I think people should be relatively fluent in several. And we should recognize our limitations. If we’re psychodynamic and have a client who is more interested in doing CBT, or we think would be better served by a CBT therapist, we should refer them out.
We often have this belief that we can help everybody, but it’s really not true.
We often have this belief that we can help everybody, but it’s really not true.

Look at how many treatment failures there are for widely accepted medical practices. We’re not going to help every psychotherapy patient, and maybe some other therapists could do a better job with particular patients. Flexibility is called for not just within a particular therapist, but within the community of therapists.
GA: One of the elements of effective therapy you cited was being able to create a positive working alliance with a variety of patients, and difficult patients, so how do you balance that with knowing when to refer out?
BW: Well, the really effective therapists probably don’t refer out much because they’re pretty good at accommodating their treatment style to the particular patient. And we have to be careful about referrals because if it appears to the patient that they’re just being referred out because they’re difficult, that can be very wounding. I’ve heard of difficult patients saying, “I didn’t really get better, but this therapist stuck with me, and that was really helpful to me.”

Some disorders are going to take maintenance therapy to keep people out of the hospital and functioning. So even though they’re not going to approach what we would call “normal” functioning, it’s still an appropriate use of therapy. The medical model doesn’t really support this kind of treatment though. It’s looking for a specific outcome in a limited amount of time.

In the United States we’re paid by the health delivery system, which is advantageous for therapists because they’re getting paid, and advantageous for patients because there was a time when only the rich could pay out-of-pocket for therapy. Those without resources simply couldn’t afford psychotherapy and now it is available to many more people, which is a great thing. But there are some unfortunate consequences of being forced into this medical model. Limitations on sessions is probably the one that impacts therapists and clients the most.
GA: This isn’t going to change overnight. It’s deeply embedded in our culture. But in order to change the culture, we need a positive vision for the alternative. What would that look like? I think the contextual model has the potential to really change the system because not only is it scientific, it’s more scientific than the medical model.
BW: That’s a fundamental question we have to address.
We know psychotherapy is remarkably effective. It helps many people. It’s as effective as medication, and longer lasting. But we have to influence policy makers.
Many of us are working hard to influence policy, and the way to do that in my view is to present the evidence. I’ve dedicated my career to providing the evidence for the humane delivery of mental health services. We know psychotherapy is effective. It’s remarkably effective. It helps many people. It’s as effective as medication, and longer lasting. But we have to influence policy makers. There are places where we’re making progress, and there are places where it’s frustrating as hell.
GA: I bet.
BW: But we also have to be making progress as therapists. We have a responsibility to provide effective services.
GA: It’s disheartening to hear that we aren’t getting better over the course of our own professional lives.
BW:

Coming Out of Isolation

We don’t, but as we learn more through research about what makes therapists effective, we can begin to incorporate what we learn into our training and professional development. I’m involved in a start-up company, TheraVue that’s dedicated to online skill building for psychotherapists. I think technology can play an important role in making not just therapy, but consultation and training more accessible to people.
GA: That’s hopeful to hear. So many people want to be in consultation groups, but it’s much harder to make happen than you would think.
BW: This is an isolating profession. We’re sitting one-on-one or sometimes with couples or families, but essentially we’re doing our work in isolation. We have to have that peer support to help us both fight the isolation and to get better, but it’s difficult. We work six, eight hours a day with patients and at the end of the day, we don’t want to drive somewhere for a peer consultation. We want to get home to our families and friends.
GA: So given that there are these challenges, how do we get more therapists to make consultation a regular part of the practice?
BW: Psychotherapy is not the road to riches. I think most of us are in this field because we’re dedicated to helping people, so I think there’s an intrinsic motivation to get better. I don’t think there’s going to be resistance when people really understand what it takes to be a better therapist. In fact, there’s going to be eagerness to improve if it’s built-in in a way that makes it accommodating. I think it’s absurd that we don’t give CE units for actual efforts to improve other than going to workshops and doing online courses. I’m a licensed psychologist, so I do them, and some of them are really good, but is this helping me become a more effective therapist? Tomorrow are my patients going to be getting better therapy than they got before I went to this workshop? So the training and accreditation processes need to support the activities that actually help therapists get better.
GA: So we know that workshops and online courses and reading books isn’t enough. We recently did an interview with Tony Rousmaniere on deliberate practice, although we haven’t published this yet. It’s a concept he learned from Scott Miller that involves literally practicing—like tennis players do between games—the skills of therapy outside of the therapy office. Videotaping ourselves, practicing how we talk, having mentors watch our work, trying to eliminate things that aren’t helping clients—weird idiosyncrasies we wouldn’t necessarily pick up without an outside observer. Are these the kinds of practices you are talking about?
BW:

Good Therapists Are Humble

Yes, exactly. You can’t just reflect and think about your practice, just do process notes or whatever. It’s important to do those things, and certainly one of the characteristics of effective therapists is professional humility. Good therapists, the ones that get better outcomes, are the ones who say, “I’m not sure I’m helping patients. I need to get better.” But Daryl Chow and Scott Miller did a study that revealed that people who work outside of their practice to get better actually have better outcomes.

Good therapists, the ones that get better outcomes, are the ones who say, “I’m not sure I’m helping patients. I need to get better.”
The skills I’ve talked about, you have to do them over and over again with feedback from somebody. This is what we’re doing with practicum students now. Often students will go, “I’m an advanced student now; these are basic skills you’re teaching.” No, we all need to practice these things. By the end, they often say, “this was the best practice class I’ve ever had because we actually practiced the skills we use in therapy.”
GA: So we can improve our skills through practice, get unambiguous feedback from someone we respect and hopefully challenge our own confirmation bias that we’re the best therapist ever, by cultivating some humility.

Still, if the motivation to get better was intrinsic, don’t you think more therapists would be doing these things? Sell us a little more on it if you don’t mind. Like, how much am I going to improve if I implement these new strategies?
BW: That’s a great question. In my presentations I use the example of baseball. The difference between a 300 hitter and a 275 hitter is not very much. In fact, if you watch the poor hitter for two weeks, they may have more hits than the 300 hitter. But if you look over the career, the 300 hitter helps his team immensely more.

A small improvement by each therapist would have a tremendous impact and benefit to patients.
An incremental improvement doesn’t have to be dramatic, but it has a tremendous impact on the number of patients who benefit from psychotherapy. I can give you the facts and figures because I love math and statistics, but a small improvement by each therapist would have a tremendous impact and benefit to patients. It’s quite remarkable.
GA: So that’s our call to action as a profession.
BW: Yes.
GA: We know what we need to do, the gains are there for the taking, and we need to keep pushing on policy to support those efforts. None of us are going to get rich doing it, but it’s hopeful that we can really make a difference as we improve and grow.
BW: I think it is hopeful. We have the strategies and the technology for continual improvement as therapists. Let’s get better. Let’s work at it. Let’s support each other. And let’s measure outcomes so that we know how we’re doing.
GA: That’s a whole other piece we hadn’t talked about: measuring outcomes.
BW: Yes, it’s very important. What the research seems to show is that at least for cases at risk for deterioration, feedback may improve outcomes. But it’s pretty clear that just getting feedback—this patient is improving; this patient is not—doesn’t help the therapist become more skilled.

But it is important to know if you’re actually helping patients, if you’re gradually improving over time. Look and see what types of patients you’re having difficulty with.
GA: Routinely.
BW: Yes, and I would add that, in my experience, and I think the research supports this, discussing the feedback with patients is helpful. What it communicates to the patient is that you are improving and that their feedback actually matters to you. But it also makes it clear that the focus is on, “Are you getting better?” I want to know that continually. We should all be discussing with our patients how therapy is going and how we can change to more readily support their goals. That’s a tremendously powerful message when we discuss that with patients. If we’re not meeting the goals, what can we do differently? Some would call that client-informed, but all therapists are client-informed. To a large degree, we should all be discussing with our patients how therapy is going and how we can change to more readily support their goals.
GA: There’s also an indirect benefit in that it communicates care in a new way to the client, bringing them in on monitoring outcome.
BW: It’s not indirect. It’s direct. In the contextual model, we don’t minimize these things as indirect. This is deliberate.
GA: The meat and potatoes.
BW: Absolutely. The focus on patient progress is central to what we do.
GA: So we have a call to action for clinicians, one for policy makers, what about for psychotherapy researchers?
BW:
My plea to all researchers would be, if you’re going to do a clinical trial, please include a quality of life measure because I want to see that your treatment actually has a significant benefit to patients in the quality of their life.
My plea to all researchers would be, if you’re going to do a clinical trial, please include a quality of life measure because I want to see that your treatment actually has a significant benefit to patients in the quality of their life. That’s why they come to treatment. I don’t want to just see targeted symptoms are reduced and therefore your model is best for a particular disorder.
GA: Any final words of wisdom you’d like to leave our readers from your years in the industry?
BW: I would say to therapists—to all of us—let’s work to get better, to continually improve over the course of our careers. It will benefit patients. It will benefit us. Our satisfaction with our work will improve as well. At this point in my career, I want to do whatever I can to help therapists do that.
GA: I am so grateful for the work you do, and I want everyone to go out and read your work so that we can all become better therapists.
BW: Thank you, Greg, it’s been such a pleasure talking to you.

Straight Life Cycle/Queer Life

Posted on by Psychotherapy.net Team

It's Time

“It’s time,” my husband emailed me, along with details for an adoption orientation. We were thirty-seven. We both had careers we loved—he a lawyer, me a therapist. We had achieved some creative goals–writing, acting, cake decorating–and let go of many more. We had each lost parents way too soon. And we were not getting any younger. This was obviously the right time to have a kid, I said to myself, right?

And then I met Miles, a client whose life would collide with mine, rousing us both to rethink the concept of time.

He contacted me just as I reached the finish line of promoting a book—a period of time I have heard others describe as “the calm after the calm,” i.e., when the book release is less life-changing than the author anticipates. My book was about modern weddings, including reflections on my own wedding, and so I found myself talking a great deal in interviews about my very “normal”-sounding stages of development, along the lines of those created by psychoanalyst, Erik Erikson—e.g., First comes love, Then comes marriage…. As my husband and I had begun the adoption process, people wondered if my next book would naturally be about modern adoption. And while my exterior may have shone with a normative veneer, on the inside I felt entirely queer: off the track of social expectations.

For one thing, I missed my parental figures. I missed my father and mother-in-law, who died when I was twenty-two and thirty-one. I missed my mother who had just moved to a senior facility, halfway across the country (Erikson didn’t warn me about any of that). And while I was passionate about raising a child, gone were the illusions of moving through time as a normal-looking family with a normal set of parents (now grandparents) sagely guiding my spouse and me to the next normal milestone.

In fact, my parenting fantasies went well beyond taking home a delicious little baby to make us three. My mind flashed forward eighteen years to having a happy healthy young adult we could visit, share a meal with, hear stories about college, or simply sit on the couch and watch a good movie with. I could think of nothing more rewarding between parent and child than that. What I wouldn’t give to have such a moment with my dad today! I longed for the past and for the future.

Miles knew none of this, and only perceived what was available to him about me in the present. He had read about my book and thought I could offer guidance on his impending nuptials with his male fiancé. He was excited about his wedding but could not envision the next step, repeatedly thinking to himself, “Then comes….what?”

Miles came from an educated and accomplished family: his mother was a respected trial attorney and his father a fancy judge. Miles himself went to an Ivy League college and law school, and then he clerked for—you guessed it—a fancy judge. Meritocracy had served him well, shuttling him smoothly from one life milestone to the next. He did hit one detour along the way, though, when he came out as gay. This was challenging for him, as his parents accepted but rarely acknowledged his sexual orientation. For Miles, righting the course after this detour demanded ever higher levels of personal achievement. In addition to his robust CV as a lawyer-to-be, Miles spoke three languages, played the saxophone at jazz clubs, and showed his artwork in galleries. All of this, unbelievably, before he turned thirty.

And then Miles’ mother died unexpectedly. She had always said she couldn’t wait to sit and talk with him before his first big trial. “This was a when, not an if,” Miles said, mournfully describing this expectation.

Insult compounded injury when Miles learned that the civil rights law job of his dreams, which he had landed soon after his mother’s death and which he had worked toward for years, did not pay enough to cover his law school loans. And despite his impressive education, law firms were not interested in hiring a lawyer several years out with no private-sector experience. In order to pay the bills he had to take a non-legal job doing work that to him (and his father) seemed mediocre. Miles had lost his identity. He had been knocked to the sidelines of social expectations where for the first time in his life he was forced to watch other people, including his fiancé—a successful photographer—pass him by.

He did have one crucial milestone left, marriage, but by then even this felt uncertain. “Though he was in love with his partner and eagerly looked forward to their wedding day, he simply couldn’t picture the day after.” The day the milestone had passed. “Then comes what?” His experiences with law school, and coming out, and losing his mother—a littering of unmet expectations—had at this point left him with little hope for the future.

First Comes Marriage

Then Miles got married. The wedding was gorgeous and meaningful. I know this because he showed me pictures during one of our sessions, kneeling next to my chair and swiping his phone with a child’s glee. I absorbed each image like a proud parent. In that moment we were two peers, two married gay men in our thirties, and at the same time we were father (or mother) and son.

And therapeutically I wondered, just as Miles often asked himself, “then comes…what?”

The dark after the dawn came. Week after week Miles seemed more and more lost, stuck, and depressed in our sessions. “I just don’t know what to do,” he would say, repeating a pattern of always seeming to have the answers until he didn’t. In this state of dread he desperately hoped I would have an answer. I didn’t but desperately wished that I did.

For example, I could have taken a page from my own life and asked him if he thought about raising kids. But to bring up family planning would disguise me in the mask of Erik Erikson, the confident, arbiter of “normal”—albeit the gay version—while I squirmed in my own queer ambivalence about “stages of life” underneath.

Given Miles’ experiences of achievement and loss (as well as my own), I felt strongly that if I suggested any tangible solution existed for him at all, I would only conjure false hope. I did not want to set him up for disappointment yet again: to cross yet another finish line only to be denied another trophy.

But it was hard for me to sit with his despair. “I felt like a fraud, like I had failed to be the accomplished, gay married therapist who had it all figured out—in other words, the therapist I imagined he wanted me to be.” Were we both failures? Both lost outside of time, aimlessly floating in space?

At the beginning of one session, both of us hopeless and forlorn, I was sure he would tell me that he was done. That therapy was a waste of time.

Miles’s father had been staying with him for the previous week, and this made him feel worse than usual. “Why?” he wondered aloud. Was it because his father polished off all the leftover booze from the wedding? That he failed to show much interest in Miles or his husband during the visit? That the only question he asked was if Miles had checked in with any of the law firms that had rejected him in case they might reconsider? Was it all of the above?

As usual, I felt like I was coming up short. Miles wanted me to tell him what he should do, and I didn’t know, so I did what therapists do at such times and reflected his feelings back to him. This only made him feel worse and ask again, “What should I do?”

Caught

The feelings of failure and loss in the room were suffocating. I found my mind casting about desperately for air. I thought of the next ream of adoption papers my husband and I still had to fill out—ugh—and then I thought of something more fun. My fantasy of the future, the simple weekend visit with my grownup kid, and how nice that would be.

“What are you thinking about?” Miles asked.

Oops. He caught me. Daydreaming is not on the list of expectations for a therapist. I felt a rush of embarrassment. But I also realized there was nothing I could do but be in the moment.

As I inhaled (deeply and pensively), I began to realize how on topic my daydream actually was—which is often the case for therapists in moments like this, as it turns out. I remembered how lovely it was to sit and look at pictures with Miles, and thought how sad it was that his father had overlooked that opportunity during his visit.

“I was thinking that your father could have told you how lucky he is to be alive and to have you. How happy he is that you’ve made an interesting and loving life for yourself, and how rewarding it is just to sit and visit with you, right now.”

“Yes,” Miles said. He began to tear up. “He could have said that.”

We shared a momentary smile and sat in silence. The past and the future, the lost and the longed for, were all commingling, awake and alive in the present.

Tony Rousmaniere on Deliberate Practice for Psychotherapists

Posted on by rezendevknowfully.com

The Other 50%

Victor Yalom: Tony, congratulations on your new book, Deliberate Practice for Psychotherapists: A Guide to Improving Clinical Effectiveness. We’ll get to the deliberate practice part later, and find out what that means, but let’s start with clinical effectiveness, which we as therapists all certainly strive for. You’re very candid and self-revealing in this book, which I think is admirable. And it seems the thing that got you started on your quest towards improving your own clinical effectiveness was the realization early on in your training that you were only helping 50% of your clients. Can you tell us about that?
Tony Rousmaniere: When I initially started training at my first practicum, I was working with high school students and I had a number of the clients respond very quickly. They had a range of different goals and whether it was anxiety, or feeling depressed, or wanting to do better at school, and they showed what is called in the research literature, “rapid gains.”
VY: That’s always nice when that happens. It makes you feel like you know what you’re doing, or you’re doing something helpful.
TR: I went into the field feeling like I could be good at this. I’m good with people, so I was optimistic, and the initial response from clients gave me a lot of optimism. But as time went on,
I gradually realized to my disappointment that a fair amount of my clients were not improving.
I gradually realized to my disappointment that a fair amount of my clients were not improving. And when I started to try to assess overall how many that was, it was about 50%. I call that “my other 50%.” There’s some of them who responded a little, and then just plateaued. There’s some of them who deteriorated—they actually got worse during treatment—and then there are also a fair amount, at least a quarter of them, who just dropped out.
VY: Dropouts are certainly a big problem for almost all therapists. I certainly recall, especially early in my career, I had a file of dropouts that came once or twice, and it was a pretty thick file.
TR: Yeah. It’s something we don’t always like to talk about but it is pretty universal across therapists.
VY: So you took the initiative to take a frank look at this, and what did you find?
TR: Well, I spent a number of years throughout my training trying to figure out what was going wrong and then how could I improve. Specifically, how could I reach the 50% of clients that I wasn’t helping effectively? And I started going back to the traditional method of clinical supervision. I was doing the same clinical supervision that pretty much every graduate student does, where they’re meeting weekly with their supervisor for an hour or two individually, and then also with a group.


I’d often feel like I was getting better, and I was learning the theory better, so I could write better papers about psychotherapy, or I could talk in more sophisticated ways about psychotherapy, but the percentage of my clients actually improving stayed the same.
I was very fortunate that throughout my training I had really good supervisors. I know that’s not always the case, but every year of my graduate training I had supervisors who were very open, very collaborative, very encouraging. They had really good advice and understood psychotherapy theory and technique well, but I found that though I was getting all of this great advice from them and my peers in group supervision, my effectiveness was not actually improving.

I’d often feel like I was getting better, and I was learning the theory better, so I could write better papers about psychotherapy, or I could talk in more sophisticated ways about psychotherapy, but the percentage of my clients actually improving stayed the same.
VY: It sounds like one thing you did was actually track your data, which is something most of us don’t do. We rely more on the second form of feedback you described: Do we feel good about what we’re doing? Can we talk about it intelligently? Do our peers seem to respect us? But that’s not really what we’re in the field for.
TR: Our whole field suffers from a lack of outcome data at the individual therapist level. We have lots of data from randomized clinical trials which show you how therapists do in these tightly controlled circumstances. And we have some data from research collaboratives where they’ll track a large group of therapists over time. But pretty much no therapist individually tracks their own outcome data, or reports it to the public. So nobody really knows how effective they or other therapists are. We know how well we can talk about therapy, or how well we can write about therapy, or how well we can theorize about therapy, but imagine if you could never see a basketball player play, you could only hear them talk about how well they played. Or you could never hear a violinist perform, you could only hear them talk about it.

Imagine if you could never see a basketball player play, you could only hear them talk about how well they played.
This is a real problem in our field. Imagine learning to paint, but you’re never able to show your paintings to anyone. You would just describe them to someone and say, “In this painting I used a lot of green. It might have been too much. Do you think I should have used less?”
VY: When I produced my first video, and then got in the business of producing training videos, what I used to say is, imagine a dental student going to a lecture about dentistry, or about a certain technique like doing fillings, and then going off to perform the filling in a private room, and then meeting with a supervisor a week later to discuss what they did. Would you risk getting a filling from such a person? That’s the problem we’re dealing with. And that was one of the things that motivated me to start producing videos of expert therapists doing therapy.

So you were aware of this problem and used the traditional tools available for developing skills as a therapist: clinical supervision, reading, talking with colleagues.
TR: Going to workshops.
VY: But you still found that your client outcome data wasn’t getting better. How did you track your client outcome data?
TR: I was using one of the simpler outcome measures called the “Outcome Ratings Scale” that as well developed by Scott Miller and Barry Duncan and others, and is part of what’s called “Feedback Informed Treatment.” It’s very accessible—it’s free and can be downloaded from their websites. It lets therapists over time track how well each client is doing, and then if they get enough data, let’s say 30 to 50 clients, they can look at how well are they doing as a therapist overall.
VY: Once you got your data, what did you do then?
TR:

Deliberate Practice

Honestly, I just started casting about, trying everything I could get my hands on. I went to lots of different workshops, read lots of different books and got supervision from different people. I was in a supervision group with you, as you well know, where we actually used some of the methods of deliberate practice, though we didn’t call them that. In retrospect, I can see that they were, and we can talk about that later on.

But there’s one supervisor in particular I found, Jonathan Frederickson, who was trained as a classical musician, and as a musician he used the method of deliberate practice. He integrated deliberate practice into his supervision and I found that working with him, using those methods, that it really improved my effectiveness more directly.
VY: Can you define what deliberate practice is and where it came from?
TR: Sure. Did you ever learn a musical instrument?
VY: Depends what you mean by learn, but I tried. And achieved a very low level of mastery with a few instruments.
TR: What instruments?
VY: Piano. Clarinet. Banjo. Harmonica.
TR: So imagine you went to your piano teacher and you said, “I want to be really good at piano. In fact, I want to be a professional pianist. But I just don’t have time to practice. I’m hoping you can assign me some books so I can get better. We’ll meet once a week, and then in a few years I’d like to have some performances.” What do you think your piano instructor would say?
VY: If I could say that with a straight face, I’m sure I’d be laughed out of the room.
TR: Exactly. As part of learning piano you did deliberate practice. Did you ever learn a sport in school or college?
VY: Sure. I played tennis and I’m engaged in some deliberate practice of tennis these days. I have a weekly lesson and am playing during the week and trying to get better, but it’s very difficult.
TR: Well, imagine you went to your tennis coach and said, “I want to play tennis at a professional level, but I just don’t have time to practice. I mean, who has time for that? So let’s meet once a week. Give me some books I can read and I’ll make it work.” They would, again, laugh you out of the room, right?

Most people have experience with deliberate practice, they just do it in other fields. Many fields use deliberate practice as a core part of training—not just to be a professional, but to achieve basic competence, to achieve moderate expertise, and then to achieve full expertise.
VY: So what does that mean in a psychotherapy practice?
TR: Deliberate practice is a term invented by K. Anders Ericsson and colleagues in the early ‘90s. They were trying to figure out how experts achieved their expertise across a broad range of fields—musicians, athletes, chess masters, pilots, you name it—and they isolated only one variable that predicted expertise: solitary deliberate practice.

Deliberate practice is based on five principles. The first is observing your own work. So in psychotherapy that would be watching videotapes of your own work, or having an expert observe your work.

Second is getting expert feedback on the work. So that’s supervision or consultation.

The third is setting small incremental learning goals just beyond our ability. In tennis, that is turning your wrist a little to the left, or in piano it would be just working on this one note.
In psychotherapy, we talk about broad things like trying to improve the working alliance, but there are a hundred skills that fall under that broad umbrella.
In psychotherapy, we talk about broad things like trying to improve the working alliance, but there are a hundred skills that fall under that broad umbrella.

The fourth component is repetitive behavioral rehearsal of those specific skills. So when you’re playing tennis you’ve got the ball machine shooting balls at you and you’re just hitting the balls again and again and again. That’s your repetitive behavioral rehearsal. It lets you move the skills that you’re learning into behavioral memory, procedural memory, so that they can begin to happen automatically, which frees up your mind to think about more complicated parts of the game.

The fifth component of deliberate practice is continually assessing performance. That’s something we do subjectively in psychotherapy, but there’s a lot of research to show that our subjective assessments of client outcome are not terribly accurate.
VY: One thing you say in your book, which I find quite refreshing, is, “I am not a master clinician. I am not a master therapist.” Why did you write that?
TR: Well, I wanted to be very clear. This is not a book by an expert therapist and this wasn’t me imparting my wisdom about my therapy techniques. I am a beginner. I am relatively new to the field. However, I am obsessed with becoming a more effective therapist. I might not ever become an expert therapist. I might not ever become a master therapist. That’s okay. As long as I keep getting better, I feel really good about that. So I really wanted to frame this book from the very beginning as one about just trying to improve.
VY: How did you start learning about deliberate practice and then implementing it for yourself?
TR: Well, I should say that I actually found out about deliberate practice when I interviewed Scott Miller for Psychotherapy.net. In that interview, Scott Miller talked about deliberate practice for psychotherapists, and it was the first time I had ever heard of it. So he should get credit. He is the first psychologist to consider this for our field and he worked on this from the ground up.

My supervisor at the time only would supervise therapists who videotaped their work. He said the reason was that there’s so much nonverbal communication going on. A lot of it is totally unconscious. Unless we can see what’s happening in therapy, as well as hear it, we just don’t really know what’s going on. And as I showed him videotapes of my work, there were multiple instances where the transcript of the session looked like good therapy. It read like good therapy. But the nonverbal communication showed that the client wasn’t progressing at all.
VY: You give several examples of that in your book. Can you give us one now?
TR:
I found that I had a bunch of clients who were basically complying with me. They were pretending to go along with therapy.
I found that I had a bunch of clients who were basically complying with me. They were pretending to go along with therapy. They would answer my questions. They would think about themselves, but they weren’t really struggling within themselves. They were appeasing me and kind of assuming, “If I give Tony what he wants, somehow magically I’m going to feel better.”

And I was going along with this. In fact, sometimes I was even cutting them off. I was talking over them. That’s another thing you can’t see in a transcript. Sometimes my tone of voice was very strong. Theirs was very meek. You can’t catch that in a transcript. Sometimes I would be sitting forward, with a lot of intention in my seat, and they would be sitting back kind of passively. In psychodynamic therapy, we call these “transference dynamics.” Each model of therapy has a different way of discussing the relational dynamics between the client and the therapist, but I found that by watching video I was able to identify all kinds of mistakes I didn’t realize I was making.
VY: It takes courage to look at yourself and have someone else observe you.
TR: Thank you, but it felt more like desperation than courage. I got into this field because I really wanted to help people, and I had a lot of clients that I really cared about. I really wanted to help them but I wasn’t. Sometimes they’d drop out and sometimes they’d deteriorate, and that really pained me.

I could give you another example. Role-plays are another great way of getting direct observation of your work and we would do role-plays in the consultation group you and I were in together. You observed while I was role-playing with one of the other group members that my voice was kind of forced.
VY: Yes.
TR: Do you remember?
VY: I do remember it, yeah.
TR:
My voice sounded like someone trying to be a therapist rather than just being a real person.
I was trying to be a therapist. And my voice sounded like someone trying to be a therapist rather than just being a real person.
VY: Right.
TR: That would have never shown up in a transcript. What you advised me to do is to work on this specific skill. We isolated the specific skill. You said, “Just try talking naturally, Tony. Just try saying whatever you’d say naturally.” And if you remember, it was hard. It took a lot of practice for me to do that. I don’t know if I ever told you this, but I went back after that group and I watched video after video of my clients and I practiced just talking naturally to my clients in the videos.
VY: You just sat by yourself and practiced saying the words aloud?
TR: Yeah.
VY: Wow. So that’s an example of solitary deliberate practice. You were just sitting by yourself with a video and practicing speaking.
TR: Exactly. In most other fields, the bulk of the training actually occurs during solitary deliberate practice. So a professional musician might get coaching a few hours a week, but then they’re spending 20 hours a week practicing on their own. The same with an athlete. Same with a master chess player. And that is something that we do not have in our field. We spend time reading about psychotherapy a lot. But we don’t spend time practicing skills ourselves, so the skills don’t move into procedural memory, and then we’re often left floundering in session.
VY: I remember that term procedural memory from graduate school, but I don’t remember what it is. Can you refresh our readers about what it means and why it’s important?
TR: When you ride a bike you are using procedural memory. When you drive a car you’re using procedural memory. It’s when your body just remembers automatically how to do something, because you’ve done it so many hours. It’s automatic. So you can think about other things while you’re driving—like how to get to your destination—because your body knows how to make turns and yield and stop at the light.

Now, that can be a double-edged sword. My wife points out quite frequently that my driving is not always so great. But it’s in procedural memory, so I do it automatically. We want to get the skills into procedural memory, but then we want to also keep refining them throughout time, or else we stay stuck at the same plateau.
VY: Getting back to deliberate practice, so the first step is observing your own work, and one way to do it is through video. Getting expert feedback is step two, and you were getting some feedback from your supervisor about your work via video. The next step is setting small incremental learning goals just beyond your abilities. How do you do that?
TR: Ideally that’s done by the supervisor. In the group supervision we were in, you identified my voice being forced, which was something I couldn’t hear in myself. You showed me how to improve that and then let me practice it. In the group, you gave me little tweaks here and there. Try a little of this, a little of that. And then I took it home to practice on my own with the solitary deliberate practice. Ideally we’re getting that kind of corrective feedback that focuses on specific incremental skills throughout our careers. That’s how you learn pretty much any other skill.
VY: In any other field you’re getting constant feedback. If you’re a lawyer, you’re observing your senior try a case and you’re sitting next to him and maybe you’re getting up and doing some things and they’re observing you. If you’re in plumbing, you’re an apprentice plumber, you’re going to watch a master, they’re going to watch you. We’re about the only field that I can think of where that doesn’t happen on a regular basis.
TR: I think we actually work in one of the most secret fields on the planet, though not intentionally so.
I think we actually work in one of the most secret fields on the planet.
I mean, obviously there’s confidentiality rules and that kind of thing, but even CIA agents in deep cover every few years get some kind of performance review. But I could go the next 30 years without ever having anyone give a meaningful look at my work. We’re required to do continuing education units, but that’s generally about cognitive learning, which is valuable for learning new laws or new theories, but a lot of research has shown that it doesn’t translate to improved skills or effectiveness with clients.
VY: You cite a lot of evidence in your book that even years of clinical experience don’t lead to improved performance.
TR:

The Audience Can Tell the Difference

Researchers have been looking into this for decades. There’s literally decades of research and they’re trying every which way to show that experience improves performance. But except for isolated cases here and there—for example, experienced clinicians can do better with severely psychotic clients—experience is not associated with improved performance.

I think this can be possibly explained by the fact that we do not as a field engage with ongoing deliberate practice. You could take a professional basketball player and if you tell them that they’re not allowed to practice anymore, and then ask them to play 10 years later, they’re not going to be as good.

My friend plays for the symphony in Washington, DC, and she practices two hours a day, six days a week. She’s at the very top of her field and she still practices. She’s getting close to retiring. She still practices. I asked her why she still practices and she said, “If I go a day without practicing, I can tell the difference. If I go two days without practicing, my peers can tell the difference. If I go three days without practicing, the audience can tell the difference.”
VY: The evidence is compelling, but it flies in the face of what we as clinicians think. Most of us feel a lot more confident ten or twenty years into our practice. We feel like we know so much more, not only from our clinical work, but from our life experience. We can empathize with a broader range of clients because we have a broader range of experiences ourselves. We’re not so anxious in session, worrying about how clients are going to think of us, and whether they are going to see how young and inexperienced we are. So it just feels like we are much better therapists. Yet you’re saying that the evidence does not bear that out.
TR: Well, the evidence shows that there’s a lot of variability. Some therapists do improve in time. But some get worse over time. And because we’re typically not tracking our outcome data from an empirical perspective, it’s hard for us to know. We have a lot of cognitive biases, not because we’re bad people, but because it’s the way our brains were built. So it’s risky to trust your own private perception of your work over time without ever getting feedback.

Unfortunately relying on our clients’ opinions is not entirely reliable either. There’s been many studies showing that clients will routinely not tell their therapists when they’re not doing well. In fact, Matt Blanchard and Barry Farber at Columbia University did a study of over 500 clients and found that 93% of them reported having lied to their therapist. Negative reactions to therapy was one of the most common topics they lied about, including pretending to find therapy effective, and not admitting wanting to end therapy.

Now, almost every client I have in my practice has been in multiple previous therapies that they found to be marginally effective or not effective at all. They probably did not tell their previous therapist this. I can tell you, I have a lot of dropouts. I’ve had an overall 25% dropout rate across my career.
Almost none of my clients tell me that I’m not helping them before they drop out. They just leave.
Almost none of my clients tell me that I’m not helping them before they drop out. They just leave. These are the clients we need feedback from the most. Clients who are like, “Oh, this is helping so much!” are not as helpful with their feedback.
VY: Are you still using the same forms to get feedback from your clients?
TR: I use a variety of forms—the session rating scale and some others. I’m always experimenting with different ways of getting feedback from clients and also from experts—but what I do most now is record all of my sessions through video and then get expert feedback on the sessions.
VY: And when you have dropouts, if you look back on those rating forms, do you see warnings signs?
TR: Yes. There often are, but not always. Many clients feel pressure to be nice to their therapist. Look, when I’m at a restaurant and I don’t really like the food, and they come around and ask me how’s the food, I don’t often say, “It’s kind of crappy.” I usually say, “Oh, it’s fine.”
VY: So let’s get back to the final two steps of deliberate practice: engaging in repetitive behavioral rehearsal and continuously assessing performance. How have you gone about doing that?
TR:

Jazzing it Up

So the first three steps we’ve covered are usually pretty easy for therapists to understand, but I often lose them when I talk about repetitive behavioral rehearsal. They’re like, “Psychotherapy is a relational art. Every session is different. Every relationship is unique. This isn’t just playing chess and moving pieces around. It’s not football or basketball where the net is always in the same place. Our clients change their goals every session. We work in an infinitely complex field. So, how can we repetitively practice behavioral skills?”

A metaphor I like to use is jazz. Jazz is the kind of music that utilizes improvisation as an inherent part of the craft. But jazz musicians don’t just sit down and start randomly doing whatever they want on their instruments. To become a jazz musician, you actually go through very rigorous training where you’re learning standardized ways of playing your instrument. You’re learning the same notes as everyone else. You’re learning the same theory as everyone else. You’re practicing the same way as everyone else. And when all those musical skills are moved into procedural memory, you’re then able to improvise with other performers.
VY: That’s why I never got too far with clarinet, because I wanted to improvise. I just wanted to be able to improvise like jazz, but I wasn’t willing to spend the hundreds or thousands of hours playing the scales.
TR: There’s been a lot of research that shows that slavishly adhering to psychotherapy models, kind of following them cookbook style, or doing exactly what’s in the manual with every client, actually leads to worse outcomes. So that doesn’t help either.

There’s a tricky balance where on one hand you know the skills, you’ve internalized the skills, you’ve practiced the skills. But then on the other hand, you’re very adaptable and reflexive to the client.
VY: I think what you’ve pointed out is not obvious to therapists at all, because we just don’t have that in our professional culture, in our training. As you said, so much of the focus is on theory, on reading books, on writing papers, on being able to sound intelligent in class or seminars or group supervision. What are the actual skills to practice?
TR: Many people assume that since they’ve gotten lots of face-to-face hours with clients that that should count as practice. To get a degree and get licensed, typically you have to have hundreds or thousands of hours with clients.

It only counts as practice if there isn’t a real client in front of you.
Something K. Anders Ericsson and the other researchers on expertise found was that it only counts as practice if there isn’t a real client or real engagement in front of you. So a basketball player playing a game doesn’t count as practice. A musician performing doesn’t count as practice. A chess player playing a match doesn’t count as practice. That’s all considered performance. And the reason is that during performance you can’t isolate a specific skill, and you can’t repeat it again and again and again while getting feedback.
VY: I see that in tennis. I’ve spent years trying to learn a top-spin backhand, and yet when I play matches, I’m worried about winning the point. I default to hitting a slice. I don’t do what I’ve learned.
TR: Well that takes us back to procedural memory. When we’re in moments of what we call emotional arousal, your brain immediately goes to procedural memory. That is why it’s important to practice these skills behaviorally and repeat them hundreds and hundreds of times until they’re moved into procedural memory—so you can perform them in those moments of emotional arousal.

In psychotherapy, we work in states of very high emotional arousal. We help clients who are suffering intensely. And we feel that suffering while we’re sitting with them. So we will go almost immediately into procedural memory.
VY: We don’t have a lot of experience or knowledge about how to practice skills that are fundamental in the psychotherapy enterprise. How did you figure this out since there wasn’t a manual for you?
TR: Most fields have taken hundreds of years to figure out models and methods for deliberate practice. I’m hoping that we can start this. Because there wasn’t already a model or method for doing it, I focused on what’s called “facilitative interpersonal behaviors.” These are behaviors that have been shown by research to be effective in therapy across a wide range of models. You can think of them as the basics of psychotherapy. Many of them have to do with attunement with the clients in session, components of the working alliance.

A lot of research shows again and again that the quality of the working alliance in therapy contributes ten times more to outcome than the model or anything else. Bruce Wampold has written a lot about this in his books. He calls it “the contextual model for psychotherapy,” where he focuses on facilitative interpersonal behaviors. An example of that would be tone of voice. I’ve noticed that if I’m not careful I can start speaking louder than my clients. I can talk over them. I can basically overpower them with my voice. This is sometimes due to my own anxiety that goes up in session due sometimes to what they’re presenting, or my own counter-transference.
VY: How do you work on that?
TR: I sit with my own videos, especially videos of clients that I find stir up my own anxiety, and I will practice talking to the video in a level voice. I want to be engaged.
VY: You’ll literally be watching a video and just practice speaking?
TR: Yes. If someone saw me doing that, they would think I was crazy. But think of it like a basketball player shooting, practicing free throws. They’ll just sit there doing it again and again and again, and they might do a hundred a day. So I’ll spend 15 minutes just practicing speaking to videos of clients who I find I have some anxiety with when in session with them.
VY: So you’re experimenting with different tones of voice, and kind of get that into your body, into your procedural memory.
TR: Yes. Another thing I’ll do is I’ll watch videos where there’s clients who are stalled, deteriorating, something’s not going well. I’ll watch the sessions with the volume off. And I will take notes about everything I see in terms of their body language. And as I watch that, I’ll also notice my own anxiety. Does my own anxiety go up or down based on their body language?
VY: Your anxiety in the session, or your anxiety as you’re—
TR: Watching the video.
VY: Your anxiety as you’re sitting there watching the video?
TR: Yeah. I found this very surprising at first, but just watching my own videos was incredibly mobilizing of my own anxiety, my own feelings, and my own defenses. Every therapist I’ve talked with who watches videos of their own work also finds it to be quite challenging emotionally.

It’s exposing ourselves to ourselves, and in a way that we normally aren’t. And that’s one of the reasons it’s difficult to videotape and then watch your own work. So if I can sit there watching the video and noticing the body language and noticing my own anxiety, those are two different skills I’m working on. If I can do enough of that so it moves to procedural memory when I’m sitting with the real clients in front of me, it’ll be that much easier to do those skills in the background, so I can focus on something else.
VY: And what impact did that have on your work? How did you know or notice that that was actually helping you?
TR: Well, one thing I noticed is that I have a butt-load of anxiety with a lot of my clients. And I was shocked to find out. At first I was incredibly embarrassed. I didn’t want to tell anyone. And then I realized that some people could tell anyways when I talked about it with them. And then I thought, keeping it secret is not going to help anyone.
One thing I noticed is that I have a butt-load of anxiety with a lot of my clients. And I was shocked to find out.
And then I realized most therapists have some degree of emotional reaction. I’m a psychodynamic therapist; we call this “counter-transference.” But I also found that there’s a certain level of anxiety that’s kind of universal working with all of my clients. So I don’t know if it’s individual counter-transference from a certain client, or it’s just me.

Some of it might be a sympathetic reaction to what the client is bringing up. Some of it is just my own material. Some of it is wanting to do a good job. And there’s just a certain level of anxiety always going up and down within me during a session. I’m still not really good at this, but I’ve gotten better at tracking that in the background during the session. I can use it psychodiagnostically. So if a client is talking about something that really bothers them, but they’re good at hiding it in their words or even nonverbals, I can often feel their anxiety within me. A sympathetic reaction to their anxiety within me. There’s a clue there.
VY: Using yourself as a tool.
TR: Exactly. When I talk about deliberate practice, people often assume I’m talking about CBT or behavioral therapy, but that’s not accurate. The most benefit I’ve gotten from the deliberate practice methods has been with the more dynamic interpersonal/intrapersonal aspects of therapy.
VY: What do you mean by that?
TR: The more subtle, intuitive sense of myself and the transference roles being played out between me and the client, what I feel pulled to do with the client, how that might be repeating old problematic patterns from the client’s life. How my own counter-transference might be getting stirred up, and I might be guiding the client towards or away from material in ways that are unhelpful. How I might be retreating.

I’ll give you another example. A supervisor once pointed out that I was being critical of a client. I was horrified by this. Horrified. My job is to be empathic, not critical. And if you read the transcript, I was not coming across as critical. In the transcript, I was coming across as very supportive. But he said, “Listen to your voice. It’s critical right here.” I was embarrassed to admit it, but I actually had a sharp edge in my voice. And that was due to my own counter-transference.
VY: Whether you use the term counter-transference or not, or whether you work with a model that has transference or counter-transference or intersubjectivity, or as an important part of a theoretical model, those things are happening anyway.
TR: Yes.
VY: There are feelings between client and therapist that you’re feeling drawn orcompel us to do compelled with certain thing with certain clientsclients to do certain things, whether you act on them or not, whether it’s to support them, whether it’s to tell them what to do. Whether you feel detached or bored. Or whether they pull on your anxiety in one way or the other. Those types of dynamics are always occurring, whether you’re paying attention to them or not.
TR: Many of us know this from reading the theory, but we haven’t practiced actually noticing it in the moment. We practice it with real clients, but that doesn’t count as practice. So, one of the ways that I have addressed this is I’ll sit and watch videos of clients where, again, they’re stalled or deteriorating. And I will just write down what do I feel pulled to do. Do I feel pulled to save them? To criticize them? To support them? Or what role do I kind of want to be in with them?

And over time, doing this again and again, and again, I’ve built my ability to observe that as it happens in session.
VY: So the final idea in deliberate practice is continuously assessing performance. Usually we think that most of our training belongs in graduate school or early in our careers, when we’re interns or psych assistants, accumulating our hours. But you believe that if we want to achieve our maximum proficiency, we should be like other professions and keep doing whatever is necessary to get to the top of our game.
TR: In pretty much every other profession, professionals have to engage in continual deliberate practice throughout their entire career. And if they don’t, they stall, and then gradually decrease in effectiveness.
VY: Let me just challenge you on that. If you’re a professional athlete or musician, yes, you’re going to spend hours a day practicing. Most other professions, I think, you don’t do that. If you’re a surgeon, you do surgery. If you’re a lawyer, you do legal work. You’re not setting aside time to actually practice being a lawyer or a surgeon.
TR:

Competency vs. Excellence

Surgeons actually do set aside time now, and they engage in repetitive behavioral simulations. For other fields, including psychotherapy, it is possible to stay at a level of competence without deliberate practice. So I believe most therapists are competent. In fact, by the end of graduate training, most therapists are competent. Overall, the outcome data for psychotherapy is pretty good. It compares favorably to medicine in many ways. Our deterioration rate of 5 to 10% is actually not horrible. The rate of complications or side effects is very low. The rate of legal problems, people suing us, is relatively low. Overall, we perform a competent service, right? And you can stay an absolutely competent therapist your entire career without using deliberate practice.

Now if you’re an accountant, you might not need to get better. Being competent might be totally fine for your livelihood. Or if you’re a lawyer, being competent might be totally fine for your livelihood. And I’ve met musicians who don’t engage in deliberate practice. They’ve found a level of competence which works for them and they’re totally happy with that. That’s totally fine. For me, it’s not satisfying. It wasn’t satisfying. And it still isn’t satisfying. But that doesn’t mean that it has to be appropriate for everyone.
VY:
You can stay an absolutely competent therapist your entire career without using deliberate practice.
I know that for several years your wife got a job at the University of Fairbanks and you were up there with a lot of darkness. And you used that time productively by learning about deliberate practice and some of these exercises you’ve just described. For therapists that are reading this and are intrigued, and do have that desire to up their game, in addition to reading your book—which is wonderful and well-written and also very funny at times—what would you advise them to do in terms of utilizing these principles?
TR: I’d recommend a few things. One is record your work. Video is really the most effective way of doing that. Using video for consultation supervision is now becoming more and more recommended across the field, and I have advice in the book about how to start videotaping your work. I want to emphasize that this is especially true for psychodynamic therapists, who are traditionally the most resistant to reporting their work.
VY: A lot of therapists worry that their clients will be put off by that.
TR: There’s been a bunch of research on this, and they’ve found that clients in general don’t mind. The client wants to get better. That’s really what the client is thinking about. I don’t mandate recording video for all my clients. I always ask them and it’s always optional and 10 or 20 percent say they don’t want to do it. I don’t argue with them about it.
VY: So you think it’s the therapists who are more uncomfortable about it?
TR: The research shows that, absolutely. Mark Hilsenroth, a psychodynamic researcher, and colleagues did a study recently where they gave the clients questionnaires about using video, and most of the clients were like, “fine, no problem.” They just want to feel better. When I go to the doctor, I’m like “do whatever you got to do.” I want to feel better. That’s what I’m thinking about. However, they also gave the questionnaires to therapists, and they found that when the therapist was uncomfortable with video, the clients were more likely to be uncomfortable with video.

I almost got fired from one of my first supervision jobs because other supervisors were uncomfortable with me using video. Therapists can be very uncomfortable with it, which I find to be quite ironic. Because the clients don’t seem to mind much.
VY: How do you introduce it to clients?
TR: I’m very upfront with the client. I say, “ I’m a human being, I make mistakes like everyone else. And if we record the session, and I can look at the videos later, or show them to experts for consultation, I have a much higher chance of spotting my mistakes. And then we can address them and then I can help you more.”
VY: It makes so much sense. And as you say it now, I recall early in my career, maybe in my internship when we audio recorded our sessions, the idea that I might make mistakes, or that I was getting supervision or consultation, filled me with a lot of anxiety. I think that’s more reflective of the state of anxiety that many beginning therapists feel. And as you mature you realize you’re not perfect, that you don’t help everyone, that there’s always more to learn. Certainly a maxim in psychotherapy is that there is no end to what clients can learn about themselves. There’s certainly no end to what therapists can learn about themselves, including how to be a better therapist.
TR: I’ve found through watching years of my own tapes that if I work with a client for two or three sessions, I’ve already made a mistake. Honestly, I probably made a mistake in the first session, which sometimes can take two or three sessions for me to see. So if I’m not seeing my own mistakes by the third session, it means I’m missing something. And I’m okay with that.
I don’t think being an expert means never making mistakes.
I don’t think being an expert means never making mistakes. It means knowing how to spot your mistakes and correct for them in a timely way.
VY: All right. So you’d encourage therapists first to start video recording their sessions. And then what?
TR: To get expert feedback from someone that they trust. It’s got to be someone you feel good about it. A good supervisor is able to get under your skin. You were able to notice something in my voice. And that’s personal, that’s intimate. And it was okay because I trusted you. We had a good relationship. Without a relationship like that, it’s going to be hard to get the necessary feedback. Ideally it’s a long-term relationship. A lot of our trainings are these one-off weekends or series of two or three weekends, where you’re getting a big knowledge dump, but no one is looking at your work. You’re not getting individualized feedback. And then you’re not getting ongoing long-term feedback. But that’s what’s necessary for the skills to improve.
VY: I think that may be changing. Some of the approaches that we’ve just been making videos of—motivational interviewing and emotionally-focused couples therapy— actually have a lot of that integrated into their ongoing training, where you have to submit samples of your work and get feedback on it. But what you’re saying makes a lot of sense.

Research shows that most therapists think they’re well above average, which statistically is impossible. How do we then go about choosing a supervisor, a consultant, who is good?
TR: This is tricky because I don’t know any supervisor who tracks their outcome data or reports it to people who are approaching them for supervision. At this point all we can really go off of is our gut sense, and occasionally we can watch videos of our supervisor’s work. I found you because I met you and had a good feeling about you. And then as we did supervision together I found it was helpful. But ideally we’ll have a more empirically rigorous way of assessing that in the future.
VY: I tell therapy clients to meet with a therapist a few times. If it doesn’t feel helpful, you may want to discuss with them what feels good, what doesn’t feel good, and see if they’re open and receptive to hearing that. If they’re not, or the therapy doesn’t feel helpful, try someone else. It’s too important not to.

So get a coach, supervisor, a consultant. And then what?
TR:

Track Your Outcomes!

Another thing I recommend doing is tracking your own outcomes, and then using some kind of empirical measure to do that. The outcome ratings scale is a great measure to use. It’s free. It’s easy to use. There are dozens of other measures available. There’s the Outcome Questionnaire. There’s the Behavioral Health Measure. There’s measures made for different settings, like universities, or working with children. And accumulate your own outcome data over time. And over years you’ll start to get a picture of how effective your practice is.

One of the reasons I started doing this is I had a supervisor look at my work and she thought I was doing horrible work. In fact, she said, “You want to kill your clients.” I was shocked. I knew I had made mistakes but I didn’t think I was that bad. But I didn’t have any data; it was just one opinion versus another. This is one of the reasons I doubled down on collecting my outcome data. After a year I had enough outcome data to look at my practice and see that overall I was helping the majority of my clients.

I definitely still have dropouts and deteriorations, but it helped my self-assessment be more level. Before then, there were some weeks I felt like Superman. I felt like everyone was getting better. And then some weeks where it seemed like everyone was getting worse. Of course, neither was ever true.
VY: But we certainly have days like that. If you’re in private practice and you have a few dropouts, or a few no-shows, it’s hard not to feel like something is wrong with you. So getting long-term outcome data is kind of a buffer for that.
TR: I found that my outcomes at my private practice in San Francisco were pretty good. The outcomes at the university counseling center in Alaska were not as good.
The outcome data never looks all good. And it never looks all bad.
Maybe that was due to the setting, the clients, maybe it was due to the darkness. Maybe it was because I was on the edge of being depressed because I was in the middle of Alaska. I mean, it could have been any number of things. Back here in Seattle, the outcome data is looking a little better. But importantly the outcome data never looks all good. And it never looks all bad.
VY: So it’s not so bad that you think you should hang up your shingle. And it’s not so good that you think, “I nailed this. I can coast.”
TR: Yes. Correct.
VY: So people start recording their sessions, getting a consultant in a long-term relationship, but the rubber meets the road with deliberate practice. What would you recommend to help people get over the initial hurdle, because I imagine it’s a big hurdle to actually sit down and do some of these solo exercises that you recommend.
TR:

“It’s the thing I look forward to least in my day”

It is a big hurdle. It’s the thing I look forward to the least in my day. It’s the thing I put off the first in my day. I would rather go to the gym, pay my taxes. In the recent election I was making get out the vote phone calls, which is a very stressful thing to do, and I found that I would do that before my deliberate practice. So it is very, very stressful. And unfortunately in our field it’s not recognized. It’s not rewarded. You’re not compensated for it. Your clients don’t know you’re doing it. Your peers don’t know you’re doing it, or don’t care. A licensure that never asks, or doesn’t care if you do it.
VY: Your spouse may prefer that you go wash the dishes, rather than sit and talk to yourself on video.
TR: Exactly. And to add to that burden is the fact that there are not immediate payoffs. They call deliberate practice short-term effort for long-term gain. So here’s what I do: I think of the therapists who are really, really good who I want to be like. And I know from talking with them that they got that good by engaging in hundreds or thousands of hours of watching their own videos. I’m not smarter than them. I’m not more talented than them. If I ever want to be that good, I’m going to have to put in that time.

The same way that if I wanted to be a really good basketball player, or a really good anything else. It might not make me as good as they are, but it will definitely move me in that direction. I have a reminder that pops up on my computer every day that says, “How good do you want to be in five years?” Now, if that day I don’t really care how good I am in five years, I won’t do it. And that might be fine. I might feel like I’m good enough, and that’s totally fine. But as of today, I still want to be that much better in five years.
VY: Well, I admire what you’re doing. And I’m gratified that I was able to impart some wisdom that was useful to you. It’s lovely to have this conversation and to have been able to read your book and have the tables turned and to be able to learn some very valuable things from you, Tony.
TR: Oh, thank you. To be interviewed by you for your website, it’s a great honor.
VY: I would encourage anyone who finds these ideas interesting to go out and grab your book and read it. Although it is chock full of research citations to back up what you’re saying, it’s not just idle theory. It’s also chock full of funny stories, humorous anecdotes, and I guess I’d like to just leave our audience with one of them. Can you tell the story about the job at the university?
TR:

Professional Identity Politics

Sure. My wife was applying for a job at a university in the West that really wanted to hire her. It was a very small town, and it was full of therapists, so I didn’t think I could just start a private practice there. She’s a wildlife biologist and the ecology department at that university that wanted to hire her were trying to arrange what’s called a “spousal hire,” which is something traditionally done in academic circles when they want to hire a person and there’s a spouse. They call it the “two body problem.” So they went to the university counseling center and they said, “We will give you money, we will pay for the salary if you hire Tony for three years. Part-time. Just so we can get his wife. We don’t care about Tony, but we want his wife, and Tony comes with the wife.” In other words they could have had me as a part-time therapist for three years for free.

We’re more like religions than any kind of public healthcare service.
They asked me to submit videos of my work as part of the application process and I thought, “This is great. I’ve been videotaping my work for years now.” So I sent in some videos and went in for the interview and they were horrified by my work. The style of therapy that I do is short-term psychodynamic psychotherapy. It’s a bit more active and engaged and I work actively with the client’s feelings and defenses. They were doing a more traditional long-term, reflective approach of psychodynamic therapy. When we were watching the video they kept asking, “Do you think this is appropriate for the client?” I kept saying to them, “Why don’t we look at the client outcome data. Why don’t we look at how the client responded?”

It’s like we were having two different conversations. They weren’t really concerned with how the client was responding. They were concerned with the model of therapy I was using. It made me realize that we’re more like religion than any kind of public healthcare service.
VY: You wrote in your book that they weren’t interested in your outcome data any more than a church would want to see how many meals a Buddhist monk had provided to the poor!
TR: Exactly. If we don’t collect our outcome data, if we don’t look at our work, we get unmoored from the outcomes, and we get stuck in professional identity politics where have all these debates about obscure theory because we don’t have actual outcome data to look at. They actually liked me as a person. They said, “You’re such a nice guy. It’s a shame it’s not going to work out.” But they didn’t accept me, and so we couldn’t move there, she didn’t take the job.
VY: The interesting thing is you were both in the general rubric of psychodynamic therapy where oftentimes the clashes are most intense.
TR: Yes.
VY: I had a college roommate who was a Leninist and he would go to some Communist convention. Probably less than a very, very small percentage of the population consider themselves Communist. And instead of coming back with a Kumbaya feeling, he would come back and report to me the big clashes between the Stalinists and the Leninists.

And even now with this emphasis on evidence-based treatments, or so-called evidence-based treatments, there’s a clash often between modalities, not taking into account that the data finds that modalities and theories do not explain outcome.
TR: If anyone ever talks to you about evidence-based treatment, ask them whose evidence. If it’s someone else’s evidence, it is not correlated with your personal outcomes as a therapist. There’s been study after study after study showing that though the models are proven very effective in clinical trials, when taught to therapists they don’t improve the outcomes of individual therapists.
Until evidence means our individual evidence, we’re not really doing evidence-based therapy.
Until evidence means our individual evidence, we’re not really doing evidence-based therapy. We’re working from someone else’s evidence.
VY: Well thank you so much for taking the time to share your journey and your expertise with our readers. Even though you humbly claim not to be an expert therapist, you certainly have accumulated a great deal of expertise on how to become an expert or master therapist.
TR: Yeah, I am learning a lot about how to become one. And thank you for having me. It’s been wonderful.

Note: Tony’s latest article, "What Your Therapist Doesn’t Know," has been been published in The Atlantic.

Why Every Therapist Should Read Dr. Robert Firestone’s New Book “Overcoming the Destructive Inner Voice: True Stories of Therapy and Transformation”

Posted on by Psychotherapy.net Team

Some people collect stamps, others baseball memorabilia. I prefer psychotherapy and treatment related books. It would be an understatement to say some select works have had a profound influence on my career.

As I type this blog, I have a vintage 1925 hard back copy of John B. Watson's Behaviorism sitting to the side of my monitor. In its day the work commanded a hefty price tag of $3.00 and tied for the most expensive tome in W.W. Norton & Company, Inc. "Lectures-in-Print" psychology series. Today, a signed copy—mine isn't, darn—will fetch $1000.00 on eBay. The book shows its relative age by sporting two small and quite primitive paper covers glued to the hardback surface of the text.

A few feet away is yet another one of my prized possessions: Andy Salter's classic Conditioned Reflex Therapy. Salter, often cited as the true father of behavior therapy and assertiveness training, could write as well as he could practice psychotherapy, and that's saying a lot.

A cursory glance to my left reveals several volumes from Lewis R. Wolberg's time-honored The Technique of Psychotherapy set. These books not only serve as a premier source of psychotherapeutic information, but weighing in at approximately 6 lb. per book, can easily substitute as a set of dumbbells for your next set of bicep curls if you happen to be away from the gym.

But the important thing is the impact that books of this ilk have on you as a helper. A case in point. When I purchased a copy of Jay Haley's Uncommon Psychiatric Techniques of Milton H. Erickson, M.D., I stayed up the entire night reading it. I thought I would never have a psychotherapeutic literary experience of this magnitude ever again. I mean history never repeats itself and they don't write psychotherapy books like they used to . . . or do they?

Frankly, after reading the Haley work, for the first time in my career my thirst for psychotherapeutic tomes was beginning to wane. I went through an extended period where nothing caught my fancy.

Then came the dawn. Enter Robert W. Firestone's 2016 book Overcoming the Destructive Inner Voice: True Stories of Therapy and Transformation. As I delved into the first chapter I unconsciously found myself giving my college class in theories a little extra time for a break so I could sneak back to my office and peruse a few more pages in Dr. Firestone's work.

Keep in mind that Firestone is no Johnny-come-lately to the psychotherapeutic arena. He began his clinical psychology practice in 1957 (not a misprint). Just to put that in perspective it was the year auto manufacturers put fins on cars making them look more like rocket planes, the Frisbee was released, and Elvis purchased a mansion in Memphis and named it Graceland. So much for the theory that experts who write psychotherapy books don't have any real-world experience.

In a sense I have both known and respected Dr. Firestone's work for an extended period of time. As a former program director of a suicide prevention center, and later a book author on the subject, I showed Dr. Firestone's award winning 1985 video The Inner Voice in Suicide to countless helpers and graduate students. It was simply a cut above everything else I could find on the topic. This book shares unique insights from the movie.

So what makes this book different and dare I say it, special? A lot of things.

First, the book is not sterile or antiseptic. Dr. Firestone is very familiar with the reader, often sharing his own innermost thoughts, feelings, reactions, and on occasion an off-color word. Most books of this genre portray the therapist as devoid of reactions, as if he or she is a blank slate or perhaps a computer performing the interventions. Not so in this case. The author comes across as a real person.
Moreover, his anecdotes go well beyond the traditional psychotherapy office with tales including friends, relatives, and colleagues.

It is difficult, if not impossible, to remain emotionless when Dr. Firestone recounts his friendship and first-hand experience (i.e., he was there) of the death of the famed psychiatrist R.D. Laing. He also shares his up-close-and-personal experience with noted psychiatrist John N. Rosen, who pioneered direct analysis which utilized psychoanalytic principles to take on the problem of schizophrenia. This creative approach contradicted the establishment's view that psychosis was a biochemical or strictly a medical problem and thus could not be treated by psychotherapy. Firestone gives us a truly unique perspective of the psychiatric facilities of yesteryear and helps us answer the question of whether Dr. Rosen was a genius or a madman.

If you are searching for another cookie cutter book that says do x,y, and z to cure your clients, this is decidedly not the book for you. And don't let the title fool you. Just because the term "inner voice" is emphasized, this is definitely not just another book on CBT. Far from it! In my estimation, the inner voice is a lot more intricate than conventional cognitive therapies. It is as if Dr. Firestone tweaked cognitive therapy, infused a healthy dose of existentialism, and added a dab of psychoanalysis in all the right places.

In a nutshell, your inner voice is composed of critical remarks from your mother or father, or significant others. These thoughts can eventually morph into your own negative thoughts. Thus, you might say to yourself: "You are so stupid. Only an idiot would do that. Who would want to date you. Nobody!"
Not that as a therapist you would have any personal problems, but just in case you know a colleague who does, Firestone rounds out the book with an appendix aptly titled "How To Incorporate Voice Therapy Into Your Life." Translation: Therapists as well as their clients can harbor some painfully destructive inner voices or parental attitudes he terms the anti-self.

I'm not going to spoil it for you by telling you everything, but I will go on record as saying that his work might just be the cure for the common psychotherapy book. It's definitely a keeper. Or to use a play on words from an advertisement released in the early years of Dr. Firestone's career: The name that's known is Firestone, where the psychotherapeutic rubber meets the road.

Why Clients Choose Online Therapy

Posted on by Psychotherapy.net Team

When I think about why clients choose online therapy, the first intuitive answer that comes to mind is about convenience: the comfort of being in your own office or home, no travel necessary, the time saved, and the possibility to have sessions during a work trip or a holiday.

For many of my clients online therapy was the only practical option. For example, I have worked with refugees or expats unable to find a therapist speaking their language within reachable distance. I have other clients who are constantly on the move, and don’t stay in one place long enough to engage in a stable therapeutic relationship (their peripatetic existence may indeed be a topic to explore in the therapy). I also work with women from some very conservative parts of the Middle East, for whom a therapist outside their country is the only way they are willing to open up and explore their religious beliefs, or their experience of oppression, without the risk of being judged or possibly persecuted.

In other, less dramatic cases, online therapy becomes the best choice for certain deeper psychological reasons. One such underlying reason is shame.

A feeling of extreme shame, of not being enough, freezes us, and makes reaching out for therapy nearly impossible. When the potential support is just one click away, and there is no physical exposure involved, we can take that step more easily. There is always the option to keep the camera off, which already reveals a lot to the online therapist.

Tim, a policeman from Ireland, had always suffered from shyness. He had grown up in a narcissistic family, which had left him with a deep sense of not being good enough. His father openly referred to him as a “failure” and the “biggest disappointment of his life.” He had sought traditional face-to-face therapy before, whilst struggling with drinking and depression, but hadn’t trusted the therapist enough to open up and expose himself to his potential judgment. He felt that his parents never really saw him, and any close emotional or physical contact seemed unbearable for him. Bound by shame, he had retreated into loneliness, which was his only safe space.

In the early sessions he would talk “at” me, and seek little input. His camera would easily get wobbly, focusing on a far corner of the room, avoiding his face: it seemed to enact his hidden desire to flee.

Later on, we explored the deeper reasons for his choice of online therapy with a foreign therapist. Tim reckoned that he felt safer this way: the distance between us and the differences in our cultural backgrounds made him feel more relaxed, allowing him to grade his exposure.

Another case, which comes up often with expats, is their tendency to develop extreme self-reliance.

As for Lucy, a Canadian aid worker based in Rwanda, she felt disillusioned by traditional face-to-face therapy. She had never been able to trust any of her therapists. All her previous attempts to get some support had only confirmed her belief that she could only “make it on her own.” This time, in the middle of an extremely unsafe environment, rigged with the weight of huge responsibilities, added to loneliness, she decided to give it another try and reach out to an online therapist.

At times, Lucy’s extreme self-reliance and difficulty in trusting others made our work challenging for both of us. But she gave it a chance. Letting a face on her screen slowly become a person, she allowed our therapeutic relationship to develop. She eventually learned how to trust again and receive external support. Paradoxically, a virtual online therapist facilitates the development of trust, especially when it seems nearly impossible. Turning potential obstacles into advantages is one of the creative challenges of online therapy.

In the same way as our clients do, therapists may display the avoidant attachment style and be uncomfortable with too much intimacy. Carl Rogers admitted that the intimacy he was able to develop with his clients in the therapy room "without risking too much of his person" compensated for his inability to take such risks in his personal life. I guess he would have become a keen online therapist…

The requirement for therapists to have an experience of personal therapy is an important one. I argue that any therapist offering his services online should go for an online therapy himself, experiencing the process “from the other side of the screen.”

My own personal therapy online helped me enormously to offer a better service to my online clients. The sensitivity and generosity of my “virtual” therapist also has continuously guided my work.

My choice for online therapy must have been influenced by my own displacement, and I often recognize in my clients who have left their country of origin, a familiar self-reliance.

Therapy is also about letting somebody else give you a hand.

Giving people who experience shame or extreme self-reliance the option of a seemingly easier way into therapy is not a trick; it is a gift to those who may otherwise never take the hand that is there to help them work on improving their lives.