Beyond Best Practice

How Mental Health Services Can Be Better

Birgit Valla, David S. Prescott

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429614606
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

Written by practitioners for practitioners, this empirically-grounded book offers clinicians of all backgrounds a guide to incorporating feedback and self-development strategies that will dramatically enhance their therapeutic abilities. Building on the foundation of Feedback-Informed Treatment (FIT), Beyond Best Practice explores the benefits of practicing therapy using in-the-moment client feedback, with an emphasis on ongoing, typically solitary, deliberate practice.

Chapters describe the real-world journey of an established master therapist and her agency, examining each element of FIT in detail through her eyes. Her journey is illustrated through discussions with prominent researchers, authors, former clients, as well as informative experiences outside of psychotherapy. Rich case examples of success, failure and "failing successfully" are also woven throughout, with a focus on the practical applications and skills needed to become an excellent and effective therapist and agency.

What becomes clear through the many narratives is that we can improve our services by studying the obvious and subtle forms of feedback that are available to us at all times. Beyond Best Practice emphasizes what each practitioner can do to become more effective, one client at a time. It will be essential reading for all mental health practitioners and agencies working at the front lines of medical care.

1

How effective are we really?

In all affairs, it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted.

Bertrand Russell

One afternoon in late August 1999, I received a phone call from the Department of Psychology at the Norwegian University of Science and Technology (NTNU). The semester was already a few days underway when it turned out that a place had opened up in the psychology programme. The woman on the phone informed me that I was the next person on the waiting list. I was thus offered a place in the programme. Delighted about the news, I called relatives in Trondheim to help me find a place to live, packed the essentials, and a few days later turned up as the last candidate for my first day in the psychology programme I had been longing to attend. And I loved being a psychology student. I attended lectures faithfully, enjoyed studying in the reading room, and got involved in student government. I devoured psychology theories in huge gulps. This was exciting material.

The last part of the programme also included supervised professional training. We would now have actual clients to test our skills. As a part of my practical training with children, I worked with a young boy accompanied by his mother. I read up on different therapeutic approaches for children and tried to follow the most appropriate method to the best of my abilities. With a supervisor and three fellow students monitoring everything I did from behind a one-way mirror, I was certain that the therapy was carried out in the best possible way. After every session, we discussed the therapy in a tutorial. I received good feedback on my relationship with the boy and everything of interest that emerged in our sessions. His statements were analysed in light of the issue in question along with my interventions as a therapist. The boy’s mother sometimes attended the sessions, while on other occasions she sat in the waiting room. The therapy was carried out as prescribed, the boy and his mother seemed satisfied, and eventually we approached the final session. As a conclusion to the therapy, I had a session with the mother to sum up and ask her about how she had experienced the contact. It was now early summer, so my supervisor and two of my fellow students were away on holiday. However, I did not consider this to be a problem; up to that point I had had many sessions with the mother and boy and felt relatively secure about our relationship. Only one fellow student remained to sit behind the mirror and give me feedback afterwards.

The mother arrived for our appointment and on this occasion had brought along her live-in partner, whom I had not met before. She seemed a bit uncomfortable and I asked her how she thought the therapy had been. She replied that it hadn’t been in any sense as she’d expected. On the contrary, she was quite disappointed with all of it, and did not think it had helped very much with the boy’s problems. She’d had completely different expectations for the help they would receive and described what she had envisioned. It turned out that she had very clear ideas. I listened to her feedback, resisted the need to defend myself, and hoped that I demonstrated understanding for her experience. We then ended the session and said our goodbyes. Demoralized, I went to join the one fellow student who had witnessed the entire episode to collect myself. “You could not have received such negative feedback in a better way,” she said in consolation, trying to restore my confidence.

Over the years since then, I have often thought that I would like to be able to thank the mother. To this day, I appreciate her giving me excellent feedback at such an early stage in my career on what I was doing that was ineffective. In many ways, it has shaped me as a psychologist.

In both my university education and later, when taking part in different courses and specialized studies, there was little focus on integrating the ideas of the client with the therapist’s knowledge when it came to determining what should be done in therapy. The phrase “client participation” has of course been used frequently, but the opinions of the client have come second or as an afterthought to what the therapist believes to be best – if one even remembers to ask. Ever since I was a student, I have been interested in understanding how I can find the best way to work with a given client, with a basis in my expertise as a therapist. I have discovered that the process that I was taught to use for determining this contains serious drawbacks, and I have therefore searched for another way to determine how to help people who are struggling with psychological problems. In 2010, I wrote an article about how clients should play a leading role in determining the design of their own treatment (Valla, 2010). Since that time, I have developed these ideas further, and I believe that the process by which we determine what we will do to help people should be quite different from the traditional practice, which is also established in structures and legislation within the field of mental health care. For many people, my thoughts are probably not new. When you read this book you might discover that you are already working this way.

There are good reasons for starting to think differently within the field of mental health care. The first chapter addresses this book’s point of departure: therapy works, but perhaps not as well as we would like to believe. There is clearly room for improvement.

Therapy works

The experience from my studies stands in stark contrast to the experiences of my childhood. I come from a small town in Nordland county, Norway, with a population of around 400. Just before the Second World War, my grandfather built the house where I grew up, a large villa in the timely style of functionalism. My mother was born and raised in Oslo, but as a recently licensed psychologist, she moved to Northern Norway to get away from the academic community and learn how to “talk to the people in the countryside”, as she put it. There she met my father and they moved into my grandfather’s big house.

When I was a little girl, my mother’s private practice was in the basement. She viewed this as being practical, because in this way she was always at home and close to her children, even though she was busy with her clients. There weren’t many psychologists in these parts and for that reason people travelled from far and wide to see my mother. I never really understood what they were doing behind the soundproof door to what we called the treatment room, but I knew it was supposed to help people who were not feeling well. Sometimes they brought along their children and then I would play with them while their mothers were talking to my mother. These people seemed to get better, because I noticed that they thanked my mother and were pleased about the contact they had with her. Since she died, I have met people who have expressed to me how much the help she gave them has meant to them. I have, in other words, grown up with a belief that therapy works.

My childhood experiences were wholly correct. That therapy is often effective has been scientifically proven. Viewed from a historical perspective, it has been important to demonstrate that psychotherapy actually works. In the 1950s and 1960s, the research scientist Hans Eysenck claimed in a number of articles that psychotherapy is not effective and that it could even be harmful (Eysenck, 1957, 1966). Eysenck defined psychotherapy as psychodynamic and eclectic approaches, but behavioural therapy, of which he was an adherent, was something different. In the years following the publication of Eysenck’s claims, two fronts emerged: one advocated behavioural therapeutic approaches, while research scientists like Saul Rosenzweig (1936), Allen Bergin (1978), and Lester Luborsky (1954; Luborsky, Singer, & Luborsky, 1975) defended more traditional psychotherapy.

It wasn’t until 1977 that Mary Lee Smith and Gene Glass intervened with an alternative method for examining the effect of psychotherapy, specifically meta-analysis. As a research strategy, instead of carrying out new research on new subjects, meta-analysis entails analysing the results of previous studies. Smith and Glass’s (1977) first article, “Meta-analysis of psychotherapy outcome studies”, was groundbreaking research that drew attention from all over the world. They found that psychotherapy was extremely effective as a treatment approach, and the debate was dramatically changed. Today their study is considered to be one of “40 studies that changed psychology” and remains one of the most frequently cited studies within psychology. Since Smith and Glass’s first study, a large number of other studies have shown that psychotherapy is an effective form of treatment. This is now a well-established finding. Meta-analysis has determined that psychotherapy has an effect size of 0.8 (Wampold, 2001), which means that 80% of those who complete treatment experience more improvement than those who do not receive treatment. This is considered an extremely large effect size, and we have good reason to pat ourselves on the back when it comes to psychotherapy as a treatment approach. But what does that mean, really? I will return to this later.

Another means of assessing the impact of psychotherapy is through something called “numbers needed to treat” (NNT), which refers to how many people must be treated to achieve an effect. For psychotherapy this is the number 3. In other words, you must treat three people in order to be able to say that the mental health of one person has improved. This perhaps does not sound very promising, but let us look at other treatment forms that many people view as being very effective. For the flu vaccine, the number is 12. For the treatment of acute asthma, it is 9. The number for aspirin as a heart attack prevention measure is 176. I can also add that lice shampoo as a treatment for children with head lice is very effective. The number is two.

Some history of psychology and psychological problems

Let’s take a quick look back in time. We introduced this book by stating that psychotherapy can be effective. It is the prevailing method for helping people with psychological problems, but psychotherapy has also evolved in keeping with the way in which we understand psychological problems. The process of psychotherapy can entail a variety of approaches and as a treatment form is far from uniform. The evolution of psychotherapy and the understanding of psychological problems must be viewed in the context of the development of the field of psychology and in light of the greater culture and society.

Volda University College professor Tor Johan Ekeland knows a lot about the history of psychology. I have been reading his articles ever since my student days, and his critical perspective on the profession has been inspiring. After reading his most recent article in the Journal of the Norwegian Psychological Association (Ekeland, 2012), I decided to call him for an in-depth chat. What interests me in particular is his description of the two cultures of psychology. In a classic essay from 1959, the scientist C.P. Snow (2001) addressed the relation between the cultures of the natural sciences and the humanities. The sciences have the ambition of being able to explain behaviour with an eye towards prediction and control. The humanities’ ambition is understanding, in other words investigating how we interpret the world around us.

I asked Ekeland how these two cultures have impacted psychology.

Psychology includes both these cultures, that is what makes the discipline unwieldy. The foundation of our discipline contains a knowledge-based opposition that is the source of a lot of conflict, and the research communities have not succeeded in handling this opposition. The dominant culture in the research communities has varied. In the early 1970s, psychology was defined as a social science, and at universities psychology has often been categorized as belonging to the social sciences. But in some places psychology is situated in the faculty of medicine and there it has greater prestige.

I asked Ekeland whether one of the cultures has a higher status than the other. “Yes, obviously,” he said, “and there is no doubt that it is the natural science culture that has constituted the basis for psychology’s development and identity.” According to Ekeland, the result of this has been that a lot of research in psychology is about individuals, but little about people; a lot about behaviour, but little about actions; a lot about emotional states, but little about subjectivity; a lot about cognition, but little about meaning; a lot about responses and reactions, but little about intentions and human beings’ self-determination.

I asked him what has influenced the orientation of psychology’s evolution. Ekeland mentioned social changes that have taken place outside of psychology but that nonetheless influence it.

Psychology has always been a weak discipline from a purely scientific standpoint, given the strong oppositions between the two cultures it has struggled with. It has, therefore, been easily influenced by fluctuations in society at large. In the 1970s, psychology emerged as a social science in opposition to what it had been previously when physics and behavioural psychology dominated. Then came the computer revolution, and the cognitive perspective acquired broad prominence. Now it is the revolution of the brain that prevails. We have acquired new technology to study the brain and this gives us new opportunities for understanding the human being. Over the course of these decades, society has become more and more individualistic and individual-orientated, and the perspective on the interaction between the individual and society has been undermined. And psychology follows suit.

Ekeland also explained that psychiatry has played a critical role in determining how psychologists carry out their work. In the 1970s, a scathing critique of psychiatry emerged, primarily targeting the institutional psychiatry that prevailed in the 1950s and 1960s. This resulted in a dismantling of the institutions, and it was believed that it would also lead to a curtailment of the medical understanding. However, that did not come to pass. Psychiatry began a reorientation. Its identity had previously been in the institutions and was now concerned about rebuilding confidence. It was thus a matter of reinforcing the scientific foundation and returning to the natural sciences. This found expression through a power struggle in the American Psychiatric Association, which culminated in a revision of the American system for diagnosis (American Psychiatric Association, 1980), entailing a return to a fundamentally biological model. There was a simultaneous increase in the number of diagnoses.

“Diagnoses have been of great importance for the discipline of psychiatry,” Ekeland stated,

and they have changed. After WWII, the diagnoses within psychiatry had a low status for professional reasons. It was psychodynamic thought that prevailed, and problems were interpreted as an expression of something having to do with a person’s life history and context. A diagnosis was not interesting in terms of understanding the problem. The thinking was more in keeping with the culture of the humanities. In the 1970s and 1980s, this was turned around. The diagnosis manual and its adherents acquired great power and influence with respect to how the field developed in the years to come. It turned out to be much simpler to sell individual diagnostics than contextual perspectives.

Ekeland was concerned about the fact that it is the medical model that predominates within the mental health care services.

This is a part of the culture of the natural sciences, and researchers and professionals are interested in developing knowledge about treatment that can tell us if one applies a specific method to a defined problem, one will achieve a given outcome. The diagnoses are used as a basis for determining the type of treatment to be offered and they are based on a cause and effect connection. The public authorities impose strict requirements for professional practice and documentation and professionals are to use methods based on research findings. The concept of evidence has become the prevailing stamp of quality within service provision, and it is a matter of determining “what” works, so the professions employ the correct psychotherapeutic knowledge. The problem with this approach to mental health care is that such a stable connection does not exist in psychotherapy. In the relevant research, there is little support for the diagnoses in and of themselves. Diagnosing is supposed to help us clarify and provide a better understanding of the problem, but this is contingent upon the diagnostics being valid; in other words, that diagnostics can establish the existence of illnesses and predict which treatment is the best. While somatic illnesses can for the most part be demonstrated objectively, psychiatric diagnoses are constructions; they refer to social data (thoughts, feelings, and behaviour) and are based on a consensus within the discipline about what it means to be sick or healthy. The diagnosis in itself only offers a weak indication of what the treatment should be, quite simply because it does not say anything about the patient as a person and subject. One can put it like this: In this field, one cannot treat illnesses the way one understands this in a somatic sense, one can only treat “sick” people. In short, this is precisely wh...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword by Scott D. Miller: Coming back from the dead
• Preface by David S. Prescott
• Preface by Birgit Valla
• Acknowledgements by Birgit Valla
• 1. How effective are we really?
• 2. Knowledge
• 3. Feedback
• 4. After feedback comes practice
• 5. Improving as a therapist
• 6. Improving the organization
• 7. Listen!
• 8. Beyond best practice
• Epilogue by Birgit Valla
• Epilogue by David S. Prescott
• References
• Index