Archive for March, 2009

I picked Memphis

March 27, 2009

So I am obviously not going to win my office pool. I never would have dreamed Memphis would give up 100 points with the defense I saw them play earlier this year. I knew they were a risky pick to go allthe way though.

I correctly picked UConn, Pitt, and Villanova to win.  I love to see Duke lose, though I really respect their coach.

But I am not a total Big East guy, I am picking Oklahoma to beat Syracuse.

Gonzaga over North Carolina. I hate their coach for being so two- faced in Kansas.

Louisville will win.

I also am picking Kansas to top Michigan State.


Please share your picks in the comment section.


What works with childhood trauma survivors?

March 25, 2009

Barry Duncan responds to the question in italics below:

You said: She says that the research on this population clearly establishes that you must do some type of therapy that is sensory in nature (for example, Theraplay®), not just verbal or cognitive therapy because for so many of these children the abuse occurred early in life, at pre-verbal stages, and so that is how the abuse memories are stored.  I do not have specific research studies to cite at this moment; although I’m sure I could easily get my hands on some.  I’m guessing Scott & Barry as well as the other trainers have been asked this question before and are familiar w/ the research in this area as well to respond.  So, she says that because this is well-established in the literature, the first part of her job is to educate the clients and family on the fact that this is the specific type of treatment that they need.  She does not agree that there would need to be a negotiation with the client & family about what type of therapy would help; because they may not be aware of the research.  She sees that part of her job is to make sure that they understand that this is the type of therapy that the child needs and hopefully they are accepting of that. 

I hear this kind of stuff all the time. “But what you’re saying doesn’t apply to (fill in the blank). This approach (fill in the blank) is vital for this population and is well established in the literature.”

What people tend to confuse here is efficacy and differential efficacy. Efficacy over sham or no treatment or over treatment as usual that is not an equal or fair contest is not the same as efficacy over another therapy approach delivered in a similar fashion by therapists who believe in what they are doing. The dodo verdict rules.  I try to answer the question as respectfully as I can but this is rough terrain when someone really believes an approach is better.  They can almost never cite a study so it’s more of a belief, but I don’t rub their noses in that. No point there especially if I want them to consider what I am saying.  So here is what I would say:

“Sounds like you have really found an approach that resonates with you and is helpful for the folks you work with. I am not familiar with that literature but I respectfully disagree that the approach has demonstrated its superiority over another treatment model.  It may be very well established in the literature, but that brings us to the distinction between efficacy over sham or no treatment and differential efficacy over other approaches…”

The second part of your friend’s comments are far more troubling. No approach should ever trump client values and preferences. If you look at APA’s definition of evidence based practice:

Definition:  Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (American Psychologist, May 2006).


l  Clinical decisions should be made in collaboration with the patient, based on the best clinically relevant evidence, and with consideration for the probable costs, benefits, and available resources and options

l  Psychological services are most effective when responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences.

l  The application of research evidence to a given patient always involves probabilistic inferences.  Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential.


So the one way or the highway application doesn’t make sense to anyone. The alliance implications are also troubling. What does she do if families don’t accept her prescription? What if they do accept it but don’t benefit?


then Dave Elliot chimes in: I really resonate with what Russ and Barry have said.  Just a couple thoughts. 

In my work with trauma survivors there is a great deal of mistrust.  This mistrust is founded not just on the traumatic experiences, but also on betrayals in their efforts to find support and validation.  The Killer D’s come to mind or the “False Memory” fiasco of the mid 1990’s and its lingering impact.  Therapists can be very protective of these clients.  I think we should be careful in questioning the allegiance of therapists with their theory.   Our intention of wanting to bring more information on therapy effectiveness can seem like, ‘you don’t know what you are talking about.  I have the best theory.’   This attitude turns people away.  We have to be careful not to create a ‘Tyranny of Science’.  (Now, don’t get me wrong.  I am a believer that measuring outcomes and following the clients direction in a boon for trauma survivors and those who help them.  Hell, I wrote a computer program that is grounded in the science.  Still, there is a prevailing oppression that uses !
science as its primary tool. )

What works best for me is the positive attitude of folks like on this list.  We need heroes who are steeped in the science and use that wisdom to advocate for client welfare.  I love to see how people bring a respect for therapy balanced with a challenge to improve our ability to help.  I remember Jim Walt said something like, “I think it’s great that you’re doing this, but how do you know it’s working?”  I did a double take.  The words could seem belittling, but Jim said it in his curious respectful way.  I couldn’t help letting the challenge in.  I’m so glad I did because now I challenge myself with that question in every session.

Gotchya Day

March 23, 2009

Today marks the anniversary of the day we finally got Josie in China. Reena’s family blog does a little review of the last year.

An important warning

March 21, 2009

If the majority of Americans come to accept the caricatures of business (being crafted by liberal politicians) as true, then America is closer to the end of its life as a global leader, as a champion of markets and individualism.


From The Anchoress

Obama steps in it

March 20, 2009

UPDATED (scroll down)

This makes me feel ashamed. I don’t like Obama but he is my President after all. I tend to feel angry with the mainstream media for not reporting this stuff (NPR thought the Leno interview was newsworthy, yet they didn’t mention Obama’s gaffe this morning), but I actually can understand the impulse to wish this would just disappear.   I still hear the enduring faith of Obama supporters and I figured that maybe at least that positivity serves a purpose. But now I have even lost that consolation. The comment reveals something about him  that is ugly and undeveloped. He is not just a rookie, not just an arrogant rookie, but a dangerously arrogant rookie. The arrogant don’t learn from mistakes, and that is dangerous for us.

Here is what he said:

Towards the end of his approximately 40-minute appearance, the president talked about how he’s gotten better at bowling and has been practicing in the White House bowling alley.

He bowled a 129, the president said.

“That’s very good, Mr. President,” Leno said sarcastically.

It’s “like the Special Olympics or something,” the president said.

When asked about the remark, the White House had no comment.

I don’t expect an apology. He may even try to spin this in his favor like he spun his association with Reverend Wright in his famous race speech during the election.


So he did apologize. But there is something insincere in that apology. He said through his spokesperson that he took inspiration from the athletes in Special Olympics. If that were really true, and Special Olympics had touched his heart at some point, he would have had a natural brake and avoided such a comment. So I don’t believe him. I don’t fault him for not being inspired by the Special Olympics. I have never been involved with them either and though at an intellectual level I can say it is inspiring, it hasn’t touched my heart. As a therapist I have been impacted at a heart level by the courage  and resourcefulness of mentally challenged clients, so that has helped me devel0p some sensitivity. I think he is being disingenuous with his claim of inspiration. In other words – he’s lying to cover up his foible.  

He ought to have just owned up to his own ignorance and perhaps commited to rectifying it somehow.

I think this might end up being a blessing in disguise for the handicapped and Special Olympics and get people to reevaluate their attitudes.   

Journal of American Medicine vs. British Medical Journal

March 19, 2009

Who needs Hollywood for some juicy scandal? Check it out – from the heroicagencies listserve at :

Study 15 is certainly stirring up a storm amongst various groups watching
Big Pharma.  A couple of others that are hot at present include a scandal
involving JAMA.  The journal published a study comparing problem-solving
therapy; an antidepressant (Lexapro); and a placebo for treating stroke
patients with depression.  Now a couple of teachers from a small university
wrote a letter, that was published in the British Medical Journal, pointing
out that the JAMA article had failed to point out that the talk-therapy did
as well as the anti-depressant. And not only that the lead author had
financial ties to the drug company. When a Wall Street Journal writer
followed up on the story a deputy editor of JAMA told the
Wall Street
Journal writer
that the principal writer of the letter to the BMJ was “a
nobody and a nothing”.  According to the letter writer himself, he says he
got a call from the JAMA deputy editor saying “Who do you think you are?
You are banned from JAMA for life.  You will be sorry.  Your school will be
sorry.  Your students will be sorry.”   You can read the story here:

And that’s not all – more on this scandalous study from the Washington Post.

The saga of Study 15 has become a case study in how drug companies can control the publicly available research about their products, along with other practices that recently have prompted hand-wringing at universities and scientific journals, remonstrations by medical groups about conflicts of interest, and threats of exposure by trial lawyers and congressional watchdogs.

Helping clients talk about their psychotherapy with their therapist

March 19, 2009

Another great post from the heroicagencies listserve by Dr. Barry Duncan:

Let me first deal with the precipitous drop in ORS score.  The first order of business is getting the client’s explanation of what has happened. Is the drop related to the reason for service—a deterioration—or is it the pothole phenomenon or where some recent event or perhaps even the events of the day are holding sway over the client’s rating? If it is a deterioration, then this is a red flag for sure, and signals the necessity to have a heart to heart about what needs to happen different to quickly turn things around.  

But a pothole effect warrants different action. The pothole metaphor goes like this: The client hit a pot hole on the way to the session and got a flat tire. It was raining cats and dogs, and the client’s nice clothes were soaked and soiled. Then the client was in such a hurry that radar caught them, and so on.  You get the idea. The pothole effect is where the events of the day overly influence the client’s response on the ORS rather than how the week has gone in general as related to the reasons for therapy. If the client reports it is a pothole, then ask him or her to redo the ORS looking at the week in general, and related to the reasons that served as the impetus for therapy. If the event or events are important to the client and seem to trump the original reasons for therapy, then of course, go with it. Just reconnect the issues at hand to the open spaces on the ORS. Just be cautious and alert to the problem of turning everyday life events, the ups and downs of being a human being, into therapy issues—don’t stir the cauldron.

Sometimes client scores, even when connected to the client’s experience of the problems to be worked on in therapy, go up and down over time. These graphs depict a zigzag pattern. It’s okay, it’s not so unusual. Do your best to keep the measure as the accurate representation of the client’s described experience and reasons for therapy. Of primary interest is whether there is an upward or downward trend in the pattern, which leads back to the basic question that the ORS addresses:  Are things getting better or not? If the zigzag progression of the ORS plots depicts an overall change from the intake score, then you are on the right track. Conversely, if the fluctuations reflect no change at its lowest point, then the implementation of the strategies of when things are not changing are warranted.

So if it is not a pothole, your client still has an upward progression (from 11 to 15) but still warrants caution

Now the SRS: I believe the drop in the SRS scores in session three tell the tale.  Not only is it a very low score but it is a significant drop from the previous two sessions. Something is amiss.  First some general comments:

If a client scores less than a total of 36, or less than 9cms on any dimension on the SRS, there is a potential problem that should be discussed. There are really only two choices. Either the SRS is good or it’s not. And your actions are equally simple: Either you thank the client for the feedback, and invite them to share any future concerns—letting them know it’s the best favor they could do for you; or you thank the client for the feedback, and explore why their ratings are a bit lower so that you can try to fit what they are asking for. A high rating is a good thing but difficult to interpret. A lower rating is cause for celebration.

Traditionally, clients have given their evaluation of the alliance with their feet—they walk out and don’t come back. Clients, however, will let us know on the SRS long before they will confront us directly or bolt. That is what the SRS offers us. People will mark the scales a little lower when they might never say anything. But it still takes more than a bit of work to create the conditions that allow clients to be candid with us. Indeed, the disparity in power between therapist and client, combined with any socioeconomic, ethnic, or racial differences, can make it difficult for our clients to tell us we’re on the wrong track. When was the last time you told your physician, “Listen, you’re making a big mistake with me”?

It’s okay for the client to go slow with the SRS. Remain open and keep encouraging the client to let you know if there’s anything else you can do. Don’t be expecting specific feedback or grand revelations, although they do happen from time to time. Usually the feedback is somewhat vague and general. Remember it is hard, for nearly all of us, to give interpersonal feedback, especially critical, so any feedback is a godsend and is communicating something. Just try to get at what it is. Is there anything else I could have done differently, something I should have done more of or less of, some question or topic I should have asked but I didn’t?

It sounds like with your client that you did indeed thank and explore. But when the score is that low and a drop from before, it might take a bit more time and effort to shed some light on what is going on. For me, I just try to hang in there a bit longer, commiserate with how hard it is to talk about the relationship, and transparently share my concerns about drop out or null outcome. It’s a lot like hanging out with client’s distress. When we learn to embrace, understand, and appreciate it instead of thinking we have to change it, a lot more connection occurs. But I first start with appreciating the feedback:

Therapist: Thanks so much for your feedback. I really appreciate your help here and you are doing me a huge favor to let me know that things could be better because you are giving me an opportunity to do something different for next time.  A lot of times people will mark the SRS a bit lower long before they will say anything about what needs to happen differently. Any thoughts about what that could be?

Client: “Well, it was actually a really good conversation, maybe I didn’t fill the measure out right, I think it just looks lower, but really it felt the same as session 1 and 2”.

Therapist: Okay. Well a couple of things concern me here, and please bear with me because I know this is hard to talk about this stuff. In fact, people don’t usually talk about the relationship at all so this is a lot of new ground. First is the drop in score, when SRS scores drop like that, clients are generally at a big risk for not coming back, especially combined with your drop in ORS score. So if you have any ideas about what I can do to prevent that, I would greatly appreciate it. The last think I want is that you would leave here without benefiting, without getting what you wanted from this process. Do you think it might help if we went through the SRS items one by one? Would you be willing to give it a try?

So essentially, my only thought is that you stay with it longer, allowing silence and uncomfortableness to linger, showing your appreciation for the difficulty of the conversation and for any feedback you might get. Given her drop in ORS score, you might consider calling her.



Barry Duncan, Psy.D.
Institute for the Study of Therapeutic Change;;
954.721.2981; 561.239.3640

The dangers of presupposing someone is in denial

March 12, 2009

I belong to a listserve composed of psychotherapists who are interested in the development, understanding and promotion of client directed outcome informed therapy (CDOI).  It is called the heroicagencies listserve, and I plan to share excerpts of listserve posts occasionally on Diddly becuase they are often really well written and interesting. You can learn more by going to   CDOI is not a model of therapy, such as cognitive behavioral therapy, but an approach that attempts to priviledge the therapy client’s voice by systematically collecting information each session from clients about their how well they are doing , and how they well they think the session went. We use brief scales to do this. The Outcome Rating Scale (ORS) measures how well they are doing. Scores range from 0-40, and scores below 25 indicate clinical levels of distress. In other words, scores above 25 indicate that the client is not going to show the same benefit from therapy as clients below 25 will show. They are actually at a higher  risk of deterioration. We hold 25 to be ‘the clinical cutoff’.

So do what do we do when someone shows up for therapy and scores 25 or above? Do we therapists call it ‘denial’?  Barry Duncan wrote a great post on the subject that appears below:

This is a great discussion about clients coming in over the cutoff—many valid points of few. But let me throw in a word of caution regarding people getting “more real” as time goes on. With folks who score over 25, caution is warranted about any approach that focuses on matters other that the issues at hand. Why? People who come in over the clinical cutoff are, on average, at a higher risk of deterioration. Think about it. What do we often do with folks who think they are doing well? We put on our Wicked Witch costume, suddenly growing warts and a humongous nose, and we stir the cauldron. Laughing devilishly as we are stirring the steaming brew with large strokes, we shriek, “Oh you think things are going okay do you, we’ll see about that, my pretty!” So are they getting more real, or are they accommodating the therapist’s view that they must be doing worse than they are reporting? This is especially true with mandated folks. I am not saying it never happens. I am just saying that we should use caution and ask ourselves this question. Often people score high because they are truly not in distress. Someone else might be.

Here is I wrote about this issue recently:

Given that the first ORS provides the comparison point for all future work with the client, it is essential to get a good rating. This means striving to get the best, most accurate rating of the clients experience possible, a sincere appraisal of his or her life at that moment. I encourage a frank discussion of the issues involved, express my desire to be helpful, and hopefully get the idea across that therapy works best when the ORS accurately reflects how his or her life is going

I have had clients who rated way over the cutoff and then after a few minutes start telling me how badly their life is going. I then pick up the measure and express my confusion about their rating, which often leads to a different rating in the first session. For example, I saw Darrell, a referral from the DUI who rated himself a 36.8 on the ORS. This is not just doing good—this is doing DAMN good. Very, very few people score this high. But I took it in stride and merely commented on how well he was doing, especially considering his recent arrest. When I asked him how the referring PO would rate him, he told me he did not give a flying f..k about what his PO thought.

After a while of talking about things he lightened up with me when he figured out that I was on his side. He told me that his girlfriend kicked him out and that he had been sleeping in his truck. After commiserating a while, I asked him to help me understand how his life could be so hard while his ORS looked like he just won the lotto and spent a week in Hawaii with Angelina Jolie. He laughed and told me that he was pissed off in the beginning and rated the ORS without thinking much about it. I asked Darrell if he would do it again because it would help us keep track of our work together and make sure he was getting where he wanted to go. And he did. His score was 18.3. And when he decided to quit drinking, his partner joined him in therapy.  Sometimes you have to work at that first ORS—to build a culture of feedback and secure a good rating that reflects what is going on in the client’s life. It is worth the effort.

But please take the client at face value unless you have evidence, from them, to the contrary. Err on the side of believing that there is a good reason for the client to rate it as they did. All you have to do is explore the client’s experience—ask them—to figure out the context for the score. Consider Yvonne, an 18 year old woman in a CD unit that specialized in working with homeless young women. Yvonne consistently scored the ORS above 30 while also detailing problems in her family and struggles with finding a job. This was perplexing to the staff (she couldn’t be doing that well) so they asked me to do a consult. Once again Yvonne scored high, a 34.6, and once again conversation quickly drifted to problems she was having with her mother. After hearing her out and exploring the concerns she had in her relationship with her mother, I asked Yvonne about her ORS score (warning: reader discretion is advised—frank and explicit material…):

Barry: Yvonne, as I mentioned earlier, your score on the ORS was very high indicating that you are doing very well, and that’s great. But I was wondering how that fit with the conversation we just had, which seems like you have been hurting quite a bit about your relationship with your mother—and you scored high on that scale as well. Can you help me make sense of it? 

Yvonne: Sure, and that’s what they don’t get around here, that I could be doing so well given everything that has happened to me in my life, addicted to crack, living on the streets, being a whore, and all. But you see, my life is great now compared to where it was. I am straight for the first time in 6 years. Just 4 months ago I was blowing every swinging dick I could for crack. I lived in the most disgusting of circumstances, f..ked the most vile creatures on earth, and didn’t care about anything—mostly myself! But look at me now—I have a chance, I have a chance for a different life. And I have a chance to address the shit with my mom. .

Barry: Thanks Yvonne for helping me understand this. It makes complete sense to me now. It’s like you are saying that you always have to know what you are comparing it to. And for you, now, even with problems in your life, compared to what it was, is, essentially no comparison!

Yvonne: You got that right!

Transparency is the rule. Just ask clients for help if it doesn’t make sense to you. It usually makes sense to them. And even if it doesn’t make sense to you, take it at face value.    (END POST)



Warren Buffet and Jim Cramer stick their fingers down their throat and barf up the cool aid

March 11, 2009

I stole that post title from TMR (see blogroll) Warren Buffet’s overt support of Obama definitely gave me pause. I wondered what I was missing. Apparently he was missing something. If he can admit it, can you?

the media has paid almost no attention to the fact that one of Barack Obama’s most visible capitalist supporters has begun attacking him publicly. Why might that be?

And another  big finance fella hurling up the cool aid – Jim Cramer from

 I am proud to have voted for the Obama who I thought understood the need to get us on the right path, and create jobs and wealth before taxing it and making moves that hurt job creation — certainly ones that will outweigh the meager number of jobs he’s creating.

So I will fight the fight against that agenda. I will stand up for what I believe and for what I have always believed: Every person has a right to be rich in this country and I want to help them get there. And when they get there, if times are good, we can have them give back or pay higher taxes. Until they get there, I don’t want them shackled or scared or paralyzed. That’s what I see now.

Follow their lead – get your finger in your throat now! Let’s hope it hasn’t gotten too far into your system and already poisoned you.

I hope you all puke!

A different kind a pack rat

March 10, 2009

I heard a great quote from someone today:

” I am like a pack rat with my memories and feelings. I hold onto them until I can’t even move anymore and then I go nuts.”

Great insight. I have observed this phenomenon, but never heard it expressed so well.

I don’t see it encouragement to express everything you feel, but rather a warning about the wasted energy and time required to keep feelings and memories going. You have to keep focusing on yourself to hold on like that . 

Take a break from yourself. 

 Go to the window.

Look out.

Open it.

Fresh air.


Go out there and experience dealing with one feeling at a time.

Leave your pack rat ways behind.

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