Child Study Center Grand Rounds 11.03.2020

March 29, 2021

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Beyond Assessment Developing Online Therapeutic Assessment Resources

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00:00Frameworks and it's something
00:03very attractive to me.
00:06And I'll tell you guys,
00:08kind of a funny story.
00:09So Jim said a little bit
00:12about like my background.
00:13So what what was my iconic kind of
00:15teenage or adolescent rebellion?
00:17Where did I go?
00:19But I went to Jerusalem kind of link.
00:25Feedback then.
00:29See.
00:33Max before you continue.
00:34If I could ask everyone to mute
00:36themselves or rose me if
00:38you could just mute and Max.
00:39Just be sure to unmute yourself.
00:49Go ahead, Mike.
00:52Yes, sorry, so I was saying,
00:55yeah my my kind of young adult
00:58rebellion was heading to Jerusalem
01:00and kind of perhaps returning to
01:03a little bit of the heritage,
01:05religious heritage and identity
01:07which my my parents have had,
01:10and grandparents even had thrown off,
01:12and I immerse myself within religious world.
01:17I'm very interested in mental health
01:20and how was practiced within Jerusalem
01:23and I ended up actually having an
01:27early position at a mental hospital
01:30in Jerusalem where I was given so
01:34fascinatingly complicated character
01:35who is Ultra Orthodox Jew but who was
01:40inked in Nazi tattoos and had had an
01:44amazing renamed himself after SS figures.
01:47Anyway, it's a complicated story.
01:49It complicated clinical dynamic,
01:50but I found using narrative I began
01:53to open up our relationship and
01:56this inspiration actually is what
01:57brought me back and brought me back
01:59to the US into Graduate School
02:01trying to understand story,
02:03trying to understand the dynamics,
02:05and even we might say the structure of story.
02:08Anne Anne.
02:12Sorry this quote from Hannah Rent I
02:15thought was compelling and in many
02:18ways summed up my list drive this.
02:20This appeal towards story she writes
02:23storytelling reveals meaning without
02:25committing the error of defining it.
02:27And I think it's true and yet.
02:31Unfortunately, stories both inspire us
02:33and they have the power of dividing US
02:36stories or something that it's very hard
02:39not to be swayed by or even believe in.
02:42And I think it's something we see now.
02:44We see how our nation is divided.
02:46Jim, very Inspirationally brought
02:48forward the awareness that today is
02:50Election Day that we have a lot of
02:53power in our hands and we have power
02:55to kind of shift this narrative there
02:57to even maybe rewrite this narrative.
02:59But nevertheless,
02:59narratives have a lot of power,
03:01and they have a lot of power.
03:06Even though we know that their story,
03:08it's hard for us not to believe in them
03:11and to lose our ability to interpret them.
03:18So how can we understand stories?
03:21How can we look within story to appreciate,
03:24sorry appreciate the narrative arc.
03:2822 to leverage the beauty of creativity
03:31to reauthor to use these frameworks,
03:34which narrative psychology has offered us?
03:40But not be trapped within. Dogmatic stances
03:50so I proposed and this is kind of been the
03:53lion share of my research is looking at
03:57two different aspects of narrative looking
04:01at linguistic information and story.
04:04Looking at content versus form and this
04:07is a kind of a classical dichotomy.
04:10And when I say content, I mean.
04:15Kind of the crude linguistic information,
04:18not crude as to be disparaging,
04:20but but kind of but words and
04:23semantics in form.
04:24I mean as in narrative structure.
04:29And this is the work which brought
04:32me to Dartmouth and to the VA where
04:36I've been working with using.
04:38Semantic analysis,
04:39natural language processing,
04:41parts of machine learning,
04:43and artificial intelligence to look at
04:47ways that we can evaluate suicide risk.
04:51So within the VA.
04:54There is like many large health systems.
04:57There is a pretty sophisticated
04:59electronic medical records system.
05:01And so for every clinical consultation,
05:05veterans are.
05:08Parents records are kept and.
05:12And in many individuals have
05:14huge backlogs of notes,
05:16so it's a question of what can be
05:19done with notes other than you know.
05:23Obviously clinicians reading them,
05:24which takes a lot of time.
05:27So a project which I launched with
05:30my colleagues is to look at notes,
05:33the semantics of notes for indicators of
05:37psychosocial risk variables for suicide.
05:39So as you guys may know,
05:42veteran suicide is a huge problem.
05:45There's been.
05:47Something like 20 daily suicide
05:49deaths of veterans in recent years,
05:51and so the VA's been really pushing
05:54and this this happened to be a project
05:57which which we stepped forward and,
05:59and we've had a lot of
06:02really intriguing results.
06:05So that was just some
06:08recent paper that we made.
06:11So in general it's really hard to
06:13predict suicide for a variety of reasons.
06:16People don't disclose it.
06:17A lot of variables aren't so effective.
06:21People aren't necessarily honest.
06:23There's stigma you can imagine,
06:25but the VA developed a pretty
06:28sophisticated model algorithm for
06:30predicting suicide and what we
06:32did in those are based on kind of
06:35standard demographic variables,
06:37healthcare usage variables.
06:38So what we did is we look we developed
06:42a big data set of veterans that
06:45died by suicide matched with those
06:48that didn't die by suicide on.
06:51Using the VA's current algorithm
06:54such that every person
06:59had equal suicide risk and then we
07:02looked at their notes to decipher
07:05if we could untangle any linguistic.
07:08Variables which might give us
07:12additional predictive clarity.
07:14And what we found.
07:17Some we did something kind of interesting.
07:19Here. We also matched such that every person.
07:23Every patient that died we matched
07:25controls with patients at the
07:28same psychotherapist, so we had.
07:32Something like 218 veterans
07:33that died by suicide and more
07:36than 1000 veterans that did not,
07:39but that were each share the same
07:41psychotherapist and we ran this through
07:44a variety of machine learning prompts,
07:47and we found actually 8% improvement in
07:50predictive accuracy and very interesting Lee.
07:52We found a subtlety which was that as
07:55opposed to a lot of like demographic
07:58variables which don't particularly
08:00change overtime, we found that.
08:02Using linguistic variables
08:04derived linguistic variables,
08:05we could detect a lot of subtlety,
08:08and changing overtime who was dying
08:12when and fascinatingly we found
08:15actually that that relative to when
08:18people were diagnosed and started care.
08:22The those that died sooner rather than
08:27later corresponded very closely in
08:30terms of Maslow's hierarchy of needs.
08:34It was kind of a surprising find,
08:37but it also makes sense,
08:40and so this is just just pointing
08:43to the subtlety of of information
08:45we were able to derive.
08:48Just out of this,
08:49unknown,
08:50otherwise not very used linguistic data.
08:54And this is a project now,
08:56which we're now expanding on and
08:58actually doing a much larger sample of
09:01all veterans as opposed to just ones
09:03who were receiving mental health care.
09:05So this is something we're replicating
09:08now within the whole VA system.
09:11So so now that was kind of
09:131 important project for me.
09:17And in that, so that was again
09:20talking about about content.
09:21I want to now transition
09:23a little bit in top form,
09:25so talking again about how
09:27do we understand creativity,
09:28not just in terms of semantics
09:30but also form structure.
09:35So one of the most basic understandings
09:39of creativity is that there's.
09:42Going back to Aristotle,
09:44is there is a beginning,
09:46middle and end with in all story.
09:49There's kind of hallmarks structure.
09:53And in many ways we can look
09:56into that structure too.
10:01To develop a more pronounced understanding
10:04about about narrative arc right,
10:06and what we typically see is
10:10that there's a conflict in the
10:13beginning and resolution at the end,
10:16and between there's some
10:19type of transformation.
10:21And and I called it here conflict resolution.
10:24And because in many ways what a story
10:28does it, there's an incipient stress,
10:30which in the end is resolved.
10:37So. One way of measuring these
10:41transformations is by looking at other
10:44kind of fields of transformation.
10:47How do we evaluate transformations?
10:50So one model which has been impactful
10:53for me and how I conceptualize this,
10:57is using via Piaget the idea of the scale.
11:03Of the foot, the two trades scale.
11:07And looking at ways that
11:09we can conceptualize,
11:11shifting from conflict to resolution
11:13and and so there's a couple of
11:16important transformations which
11:17many of you guys, I assume no.
11:23One is reciprocity and others
11:25negation and others correlation.
11:27So the way I'm conceptualizing
11:29these is reciprocity,
11:31as adding a weight to the
11:33other side of the scale, right?
11:36There's the the the action of
11:38identity is the initial stress.
11:41Reciprocity is placing a
11:42weight on the other side.
11:45Negation is removing the initial weight in.
11:48Correlation is shifting the fulcrum.
11:51And these as kind of mechanistic
11:55changes represent ways in which.
11:58We can conceptualize and will
12:00utilize in terms of looking a
12:03little bit more finely at the acts
12:05of what happens in plot and air.
12:11And this is this kind of push tours
12:15understanding of conflict in the Den.
12:18The transformations of
12:21conflict is work which.
12:24Which actually my father really
12:26started while a clinician in New
12:29Haven and a researcher there,
12:32he developed a model called conflict
12:35analysis training and this is
12:37essentially looking at how can we
12:40evaluate patterns of conflict through
12:43samples of narrative and creativity.
12:46And this is something that
12:48I've been working on in terms
12:50of in my own doctoral work.
12:52And then after that,
12:54in terms of using this framework to
12:56develop a self guided online assessment,
12:59an intervention and recognizing that
13:01creativity is a pretty accessible.
13:05Tool that people that is not only
13:07cathartic but it also has a certain.
13:12Potential for diagnostic information.
13:13So we've I've developed this as a
13:16self guided online implementation.
13:18When because it's online and self guided,
13:21it's low, low cost and very accessible
13:24and it combines an array of tasks
13:27which will get into in just a moment.
13:31So so conflict analysis?
13:33What does it include includes?
13:36And in inventory,
13:38which gets into conflict,
13:40resolving pattern identification,
13:41questionnaires, metaphor,
13:42tasks which are self report
13:45and narrative drawing exercises
13:47and then the feedback profile,
13:49the feedback profile,
13:51it's essentially extracts information
13:53from the earlier two components and it
13:57presents this information back to the
14:00user in an interactive way such that
14:03we can breakdown story from just again.
14:06Just being a narrative
14:08expression too instead being a.
14:12And resource to push for for deeper
14:15understanding and self understanding.
14:22So just to give you a little bit
14:25of a sample of what are these
14:28items from the from our inventory
14:31looking at things along the the
14:35axis of dominance and submissiveness
14:37and antagonism and cooperation.
14:39Trying to help frame ways that which
14:42will in turn used to interpret
14:45the creativity and the creative
14:48samples subsequently.
14:49And so this is a self report.
14:53Again in these, try to.
14:57Utilizes a Wellness framework
14:59rather than an illness framework.
15:02Anne, Secondly,
15:03the next component or the metaphor
15:06task and these are tasks which
15:09asked people to creatively.
15:13Related stories in the Indies are guided
15:17stories an and they mix in terms of
15:21thinking about developmental and family
15:24conflicts to more creative spontaneous.
15:28Prompts and unlike traditional projectives.
15:33We are not asking anybody
15:35to interpret something,
15:36but rather giving them a canvas
15:39to create something afresh in and
15:42then interpret it themselves.
15:44And then Lastly,
15:46this feedback profile is what I
15:48mentioned before this organizes
15:50all of the content and this is
15:52something which provides then
15:54inability for people to continue
15:57to reflect on it's interactive,
15:59and then it also can be automatically
16:01emailed to clinicians or to work
16:04for the user to keep themselves.
16:09So these are just a couple of
16:12papers we've been doing utilizing
16:14this conflict analysis in a
16:16bunch of in a bunch of clinical
16:20contexts and Community context we
16:23published recently a implementation
16:25with a community sample online.
16:27We also did a case review,
16:30kind of in detail,
16:32looking over how is it utilized
16:34and we also did a psychology
16:38implementation with cancer patients.
16:40Kind of stepping in for providing
16:42additional therapeutic resource
16:43for an underserved population.
16:49A recent study which we just completed
16:52was actually at the VA in White
16:54River Junction where we compared
16:56utilizing this conflict analysis.
16:58Creativity based intervention with
17:00mindfulness intervention and we found,
17:02although it was a very small sample
17:05which was in our recruitment,
17:07got curtailed because the unit
17:09was closed because of covid.
17:11But we found still even with a
17:14different group only of five and
17:17six people we found significant.
17:19Therapeutic differences and
17:22reasonably large effect sizes
17:25for the conflict Analysis Group.
17:29And we also found that clinicians
17:32were really able easily to to
17:36access this information and.
17:38And we found that it would lead
17:41to pronounce sense of treatment,
17:43motivation and engagement.
17:47So I just wanted to give you a little bit
17:50of a sense of what this might look like.
17:52This was one of one of our VA patients,
17:55and again, this was an online context.
17:57It was not actually working
17:58with any clinician on this.
17:59This is all done himself.
18:02And so this is somebody who
18:05is a 59 year old black man.
18:07He was a marine.
18:10He was receiving substance abuse care.
18:13He was in an inpatient substance.
18:16Monthlong substance recovery unit,
18:18and he also had a anxiety disorder
18:22diagnosis and what we what we found
18:25in doing this intervention was.
18:31That he had a very elevated, dominant,
18:35cooperative stands, and we found that.
18:39This this elevated dominance also
18:42led to a pronounced sense of anxiety,
18:45and that anxiety he dealt with by drinking.
18:51And the stories, and we'll deal
18:53with those just for a little bit.
18:57Go into some of his.
19:02Evolution and how did he?
19:03How did he respond to early conflicts?
19:06And how did those impact is later
19:08conflicts later, identity ancient.
19:10So this is a story that he wrote
19:13about and this is just kind of
19:15a synopsis, but I'll read it.
19:20So this was a prompt. Was asking about
19:22a conflict Xual childhood memory,
19:24and he wrote about how I was crossing the
19:26street following someone I looked up to,
19:28I got hit by a car just
19:30before it reached the curve.
19:32I had a broken right leg and
19:34hip and fractured left leg.
19:36It was all my fault because I
19:38was following someone else.
19:39I didn't have confidence.
19:40I looked up to some other guy I
19:42shouldn't have looked up to him.
19:44I shouldn't have run across.
19:45I learned not to hesitate.
19:46I learned that you got to take your shot.
19:50I realized that I need to be more direct,
19:52not just try to do things to please people.
19:56In this message of individualism and
19:58the need to be strong, the need.
20:00To be differentiated, they need to be.
20:04Very kind of classically male.
20:09R is a role which which
20:12runs throughout his story,
20:13but I want to jump towards to
20:16the end to the final prompt,
20:19which was a short story metaphor.
20:24In which he goes into a little bit of.
20:29Which projects a very different
20:31story but with very similar themes.
20:34So this is a memory that he shares me.
20:3759 year old male nervous
20:39about being underwater,
20:41my boss 30 or 38 year old female.
20:44Good boss experience runs the show.
20:48What happened going sailing with the
20:50crew from the restaurant where I worked
20:52the morning was calm and I was a little
20:54nervous because I can't swim and it's
20:55my first time in a sailboat ever.
20:57It turned out to be OK after I
20:59got over my fear of the water,
21:01I learned how to sail and guide the boat.
21:03We went out as far as we could
21:05before turning around.
21:05I had been in a boating accident
21:07when I was younger,
21:08so I don't joke around on the water.
21:10I learned the dangers of how to stay
21:12out of the way of the mass so as not
21:14to be knocked into the water and the
21:16proper technique of docking itself.
21:18Change is understanding.
21:19This shouldn't be afraid of the water.
21:21Be more willing to take the backseat,
21:23evaluate the situation,
21:24more realized that there are multiple paths.
21:26Multiple alternatives,
21:27yes,
21:27I'm afraid of trying new things
21:29like being in rehab.
21:30I've never been in rehab before.
21:31It's like coming in from the rain.
21:33It's not easy to get out of what
21:35I know and try something new.
21:37I'm still working on that.
21:39I can go from zero to 100 quick,
21:41but I'm working on ways to find a medium.
21:44I want to deal with it,
21:45not when it gets to 50 when it gets to 25.
21:49I don't want it to get to 20.
21:50I don't want it to feel that it
21:52needs to resort to violence.
21:53Violence is the last resort of a weak man.
21:56So within this quick kind of
21:59synopsis we can chart.
22:04The evolution of from his childhood
22:09role of being very quick too.
22:13To go it alone will not hesitate that
22:16you've got to take your shot that you
22:19have to be more direct to instead coming
22:22and being a little bit more able to.
22:27To be OK with being scared,
22:29being OK, being vulnerable,
22:31recognizing that it's OK, not having
22:33to get angry or resort to violence.
22:36And again this,
22:38just we just want to reiterate.
22:40Maybe it wasn't clear enough, you know.
22:43Again, this is an intervention with
22:45somebody before really starting it's
22:48designed before commencing psychotherapy,
22:50so this is kind of a resource to prepare
22:53both the individual and the clinician.
22:57For being able to be have an understanding
22:59of who this client is and where this
23:02client might go in their opinion,
23:04or how we can direct therapy to
23:07offer this person the best resource.
23:10And in writing about what? Anne.
23:17What his kind of reviewing part of the
23:19conclusion of the intervention offered this,
23:21this this patient,
23:22an opportunity to reflect on the exercises.
23:24And he wrote there all about me.
23:27The first is being more determined,
23:28the 2nd about love, the 3rd about anger.
23:31The 4th is about getting over fear.
23:33We just looked at the 1st and
23:35therefore I can be a caring person.
23:37But I need to learn to be patient.
23:40I used to be like I don't like when people
23:43get too close to me or walk up next to me.
23:47I would get up in their face.
23:48I don't let anybody invade my space,
23:50but I don't need to retaliate.
23:52I can remove myself from the situation,
23:54see there are other ways
23:55of responding to a threat.
23:56I was responding out of anger.
23:58I was fooling myself. I can create walls.
24:00Every wall has a gate.
24:01Let people in and out.
24:03If they're keeping everything out,
24:04nothing is getting in.
24:05You can't get anywhere or lose
24:07anything if you don't give,
24:08you can't receive.
24:10So going back to what I was talking
24:12about before about dominance
24:14versus submissiveness here,
24:15we see somebody who has again elevated
24:18dominance and need for leadership
24:20and need for controlling this.
24:23But that creates an obstacle for him.
24:25A boundary for him.
24:27Such that he can receive.
24:33And through this process.
24:36He learns just I'm going to just
24:39quickly read through a couple little
24:40bit more of what he what he wrote.
24:45He learned that he wants to be more
24:46aware of emotions to go slower instead
24:48of running and running out of gas.
24:50Once they have trust,
24:52be slower to speak and better at listening.
24:55In reviewing the program overall,
24:57he wrote it was eye opening and definitely
24:59motivated me to be more objective.
25:00The whole thing about this is one of
25:02his metaphors was about perspective.
25:04The dog can be out and about.
25:06The deer can't do that.
25:07I need to be honest with myself
25:09and not be afraid of rejections.
25:10I need to have no hidden agendas.
25:12It's like crossing the street.
25:14I need to be direct and cross cross it.
25:16It's like when you meet women
25:17when a man is drinking,
25:19his courage is built up.
25:20He can talk to any women when
25:22he isn't drinking.
25:23He will never speak to the woman he wants.
25:26Drinking I can talk for real
25:27if you don't approach her,
25:28you might let the woman of
25:31your dreams walk away.
25:33Rejection would be the same,
25:34but you're better off trying.
25:35I need to see the rejection
25:37is going to be rejection.
25:38I shouldn't be afraid.
25:39Sometimes I can't see the
25:40forest from the trees.
25:41I need to learn to be honest
25:43and learn to take rejection,
25:45not hide their dear.
25:46Didn't ever want to be seen.
25:47He is in real danger.
25:48He needs to know that he can trust
25:50some people not be too anxious.
25:57So let me just step back for a second.
26:01So I just wanted to be clear.
26:06In terms of what we're doing here,
26:09so yeah, so this intervention
26:11pushes the envelope a little bit
26:14in terms of what the boundary
26:17between assessment and intervention
26:19and what we're trying to do is.
26:22Again, not not only utilized
26:24creativity for cathartic purposes,
26:26but unlock this kind of self reflection
26:29and insight part that can be accessed
26:32through it and towards that end we utilized.
26:36A framework for interpretation and also.
26:40A framework of technology to help
26:43make that part accessible.
26:44So what I was trying to show with that
26:47case study is how very simply this
26:49individual without any additional
26:51care started very openly and quickly
26:54addressing those relevant changes
26:56that he hopes to make in his life.
27:04So you know this. This relates.
27:07I don't mean to skip over other
27:09interventions and other models which
27:11are trying to do similar things.
27:14I assume many people are familiar with
27:17therapeutic assessment which is advanced
27:19by Steven Finn and his colleagues,
27:21which offers a very interesting
27:23model of using assessment as
27:25part of therapeutic intervention.
27:27But as opposed to what we're doing.
27:31Therapeutic assessment in it.
27:33In a typical sense,
27:35relies on a classical assessments and
27:38B like like the Ro Shack of MPI or
27:42something like that and B requires a
27:45lot of clinician time to breakdown and
27:48break open the assessment to include
27:51the person within the experience
27:53when we're trying to do is instead
27:57develop assessment resources which
27:58were in and of themselves therapeutic.
28:01Because of their ability to draw
28:05from creativity and narrative.
28:07Plus they have this additional feature
28:11of being insight oriented and being
28:14self guided and other comprable approaches.
28:18The CRT borski which which similarly
28:21tries to identify core patterns
28:25through narrative processes.
28:28The central difference between us and CRT is.
28:33CRTS model similarly
28:34requires clinicians efforts,
28:36but it's also fairly nuanced and a
28:39little bit complicated in terms of
28:42understanding what the roles are.
28:45Whereas here we're trying to use very
28:49simple roles in terms of dominance.
28:53And submissiveness and cooperation
28:55and antagonism.
28:57Recognizing that these are different
29:00problem solving models which are
29:03relatively straightforward and accessible.
29:07Another important related approach has
29:10been advanced by Pennebaker and Luke.
29:12Pennebaker has been at the forefront
29:16of utilizing narrative analysis
29:18and semantic analysis to drive in.
29:21At to kind of unlock text, and I think.
29:26Again,
29:26going going back to what I was
29:30saying before about form content
29:32versus form pennebaker's work is
29:35primarily on the content level.
29:38And less under under form level and
29:40but I do think it's very important
29:43and all of these work are very
29:45relevant and have been central to
29:47kind of the development of of the
29:50work that we're doing and which
29:52brings us up to our next steps.
29:54So one thing which which will
29:56be doing in terms of in terms of
29:59the predictive analytic piece.
30:00Is that we're working now with
30:03a much larger via database,
30:05and in the past we had something
30:08like 250 veterans that died by
30:11suicide and we looked at matched
30:13controls of about 1000.
30:15Now we're looking about.
30:19Something like 18,000 veterans
30:21that have died by suicide and
30:23matched controls of again.
30:27Again 5 to one.
30:29So we're looking at a pretty big
30:32number and we're looking at identifying
30:35psychosocial risk variables within the text.
30:38We're also preparing a larger
30:41implementation of conflict analysis
30:44intervention as a pre therapy intervention.
30:47Seeing to what extent using this
30:51approach increases treatment
30:53motivation within a large sample of
30:57veterans before starting therapy.
31:00And the final aspect which we are pushing
31:03for is the integration of these two things.
31:07Bridging content and form.
31:09And this is kind of refining.
31:13Use of conflict analysis.
31:16To not only be looking at.
31:22Not only looking at form but
31:25also looking at content,
31:27so bringing in natural language,
31:29processing an artificial
31:30intelligence to to be able to
31:33extract more detailed feedback,
31:35more sensitive awareness about
31:36the way that words are being used,
31:40and share that information back
31:42to patients in real time so as to
31:45strengthen their their ability of
31:47gaining personal information and
31:49insight and self understanding
31:51through the process.
31:53As well as providing this information
31:55in real time to clinicians to help
31:58boost the efficacy of therapeutic care.
32:03So just kind of in summary.
32:09What? What we're trying to do is is first.
32:15Inventing Wellness based
32:16mental health resources.
32:18Stepping outside of typical
32:20diagnostic frameworks to instead be
32:22able to relate to the person in the
32:26person's own vocabulary utilizing
32:28narrative forces utilizing narrative.
32:30Resources recognizing that it works
32:33really well an it in and people enjoy
32:37it and but also pushing beyond it.
32:41Beyond just catharsis 2, instead look
32:45structurally and what is negative 2?
32:50Leveraging narrative and creativity
32:51to provide accessible, meaningful,
32:53and culturally informed care
32:54and this cultural informed care
32:56part is an important point.
32:58One of the things that we found in this,
33:01in this resounds in the literature,
33:03which is that.
33:06Well as.
33:09You know classical DSM diagnostic criteria
33:11are normed and even normed on large
33:14samples samples that are not necessarily
33:17corresponding with everyone and,
33:19and this is similarly a problem
33:21with other assessment registers.
33:23So part of what we're doing is by allowing
33:26story into the assessment practice.
33:29We are allowing people to tell
33:31stories in their own words,
33:33so in this is something which
33:36we find corresponds and.
33:38Across kind of the gamut of cultural context.
33:43Lastly, we are furthering the
33:44ability not just to tell stories,
33:47but also to interpret stories to promote
33:49personal and cultural understanding.
33:51And again I began with this kind
33:54of dichotomy's of of how narrative.
33:57Although inspirational can lead
33:58us to get stuck,
34:00the meet us to belief lead us to.
34:05Reinforcing things in a dogmatic way and.
34:10I think that maybe the most important
34:13part of what we're doing here is.
34:16Trying to answer that critique by saying,
34:19well, actually we can understand narrative.
34:22We can break it down into structure.
34:25We can break it down using technology,
34:28but also breaking down using
34:30classical physics,
34:31physics and logic as I've tried to
34:35demonstrate with the the metaphor of
34:38scale to to look at transformations
34:41present within story and and therein.
34:44Be able to discern things in a in a,
34:49in a direct and pragmatic way.
34:52Bringing story into the fold as as
34:55as a credible diagnostic resource
34:57and something which can also move
35:01our treatment methods forward.
35:06So I. I can keep going,
35:09but I was thinking that maybe
35:11I would open up now it's about
35:141/4 to the hour and start.
35:16Maybe we can.
35:17We can talk a little bit more in
35:19detail and I would be happy to
35:21answer questions and go into go
35:23into things with a little more depth.
35:30That sounds great and Max.
35:31Do you want to just stop sharing so that
35:33yeah there we go Jim, go ahead. Well,
35:36thank you very much Max.
35:38It's always a pleasure to hear
35:40your presentation and I must say.
35:43Given the audience,
35:44the big question for many of us is.
35:48How young have you actually
35:51been able to sort of?
35:53Provide some opportunity like this to
35:56individuals who may not be veterans,
35:58but who are certainly struggling with some
36:00of the same issues you're talking about.
36:03And if you haven't gone down that road,
36:06what would need to happen?
36:08And how appropriate do you think it
36:11would be in terms of adolescents and
36:13even perhaps younger individuals I guess
36:16makes me think of the pictures that I had.
36:19Some of the individuals that
36:20were on the unit drawing for
36:22May and also talking about,
36:24but the whole issue about narrative.
36:27Strikes me as being very potentially
36:30important topic and I guess how
36:32useful with this tool be and how
36:35interested would you be in potentially
36:37finding a way to have this be
36:39something that could be used for a
36:42younger generation of individuals
36:43struggling with their mental health?
36:49Now you're muted, you're muted.
36:53OK, great, thank you for the
36:55question and it's nice to.
36:57To see your face again after being obstructed
37:01by a PowerPoint for the last while.
37:04It's a great question.
37:05We have done a couple of pilot
37:08implementations into school systems,
37:10both in an elementary
37:11school and in a high school.
37:13In both of those context,
37:15we refine some of the inventory
37:17questions on some of the interpretive
37:20guide questions so so I don't know
37:22if I've made this clear enough,
37:25but you know,
37:25a big part of it is helping the people
37:29interpret their own creativity.
37:31So, so in that fashion,
37:32we've had to refine some of the
37:35information to make it more accessible.
37:37In terms of self analysis but.
37:41We had fairly successful small
37:44implementations in schools.
37:46We worked with mental health group
37:49at a local high school and I think
37:53also because it was an we use like
37:57computers and iPads computer kids.
38:01In some way we're more proficient and it
38:04was easier to begin with than adults,
38:06and they enjoyed. To the art part a lot.
38:12So I think it was fairly productive
38:14and I think it was something that
38:16also because it was outside of kind
38:19of the classical diagnostic context.
38:21It was not really stigmatising
38:22and I think it was even fun.
38:24So I think those are pretty successful.
38:27I haven't published anything about it,
38:29but it was something I would
38:30look forward to
38:31doing again. Is there any plan
38:33in terms of moving forward in
38:35terms of being able to make this
38:38available more widely and I guess,
38:39especially with the revisions that
38:41you made for the younger. Participants
38:44I would love to.
38:45I guess I got a little scared off just
38:49by like implementation of IRB stuff
38:53within within with kids and schools and I.
38:57Working with veterans was complicated
38:59enough but but I would love to,
39:01and you know, perhaps there would be
39:03something which we could you know.
39:05I'm sure you guys have expertise with
39:07navigating those research concerns well.
39:09It's certainly gotten to
39:10be more of a challenge
39:12these days, but if you would be
39:14willing to share some of the
39:16material with Andreas and some
39:17of the other people on our team,
39:20I think we would have a great
39:22interest in looking at that,
39:23especially the revision revised
39:25versions that you've been using for the.
39:27For the student.
39:30For the high schools.
39:32I love you.
39:36Max of first of all, thank you for for.
39:40Really wonderful and and very
39:42provocative in the good way.
39:44Thought provoking presentation.
39:45I really, really enjoyed it.
39:47I guess a comment and a question that
39:49the comment is that in some ways you are
39:52bringing our past and our future together.
39:55You know, I was thinking that you know,
39:58thinking back to little Hans and two.
40:00Fried going all that you know,
40:03we could do even further back,
40:05but story has been central to
40:08psychiatry into psychotherapy and I
40:10think that as a pendulum between.
40:12Between the biological and the non
40:14biological psychiatry has fought out.
40:15We probably given up a lot on this
40:17story so it is wonderful to see this
40:20and other efforts to bring story back
40:22because I think that so many of us went
40:25into this field because we love stories.
40:27So I think that's really terrific.
40:28At the same time you're taking
40:30us into the future with all this
40:32big data AI data management.
40:34I don't know if Pam Hoffman is around,
40:36but she is our local.
40:38Expert in AI applied to the EMR.
40:40So you're bringing all of those things
40:42together and I think that's that's terrific.
40:45You know the VARB is scary,
40:47I think with kids it's less scary,
40:50so I think it's you know the other thing
40:52going to our past we have been looking at
40:56drawings it's Jim mentioned telling stories,
40:58hearing stories.
41:00Linda,
41:01our chair at enough she is on but you
41:03know we have a big effort with Scholastic
41:06and with others to really explode.
41:08The storytelling power of child psychiatry.
41:11So I don't know.
41:12That was a question.
41:13It was like a admiring comment
41:15and anything you want to.
41:18I I admire that and I think that's
41:21something which I think both yeah,
41:23and in particular you know your your group.
41:26It has held, you know,
41:27I think that for myself I I didn't
41:30have the luxury of, you know,
41:32like clinical training or research
41:34training in a space where that
41:36was too much of an option.
41:38And so it kind of existed on the fringe and
41:41therefore is kind of an inspirational space.
41:44But yes, you know I.
41:46I feel like story can absolutely be used.
41:49But you know, with the caveat
41:51that we can also get lost in it,
41:53and that's something which you know,
41:55which I which I fear and that you know,
41:58that's something which politically you know.
41:59Again, it's Election Day.
42:01It's something that like it's so we see
42:04in our in our media we see in our society
42:06people that take stories literally.
42:08Ann, and so you know it's part of
42:11the challenge is if we're going
42:12to step into this game which
42:14which I suggest that we do,
42:16we need to be prepared to,
42:17you know it's rules well.
42:20Linda is here and she she's
42:22she's going to say something.
42:24Let me just add before that that the
42:27other connection you started telling
42:28us about your connection with Israel.
42:30And I cannot but think back to the
42:33suicide autopsy studies that were
42:35done by our colleagues in Israel,
42:37including Donald Cohen years
42:38ago published in the archives.
42:40So I think that you are also
42:42following that kind of scholarship.
42:44You know 30-40 years later
42:46with AI and whatnot. But Linda.
42:48No, thank you.
42:49I'm axing I too,
42:51just this was really,
42:52really lovely and thank you
42:54for bringing bringing story
42:55into the center is under is
42:57mentioned and would love
42:59to talk with you more.
43:00We have a really deep
43:02collaboration with our Scholastic
43:04colleagues who think about
43:05story as promoting child development
43:07as promoting children's resilience
43:08even in difficult times. So we
43:10love to love to think with you more about
43:13that, introduce you to our scholastic
43:16colleagues if you'd like to be wonderful.
43:19I think there's the real opportunity there.
43:22I mean it, it really is something that
43:24we should fully take advantage of.
43:27I would be honored, yeah?
43:31Going to flock to. Thank
43:34you. I think also there's this
43:37resurgent interest certainly in myself,
43:39but so many of our trainees,
43:41medical students,
43:42young residents on in qualitative studies,
43:44and I think that it's a field of psychiatry
43:47in general and shelter in particular.
43:50We have not nearly paid
43:52enough attention to this,
43:53and I have to thank Jim for pointing
43:56me in that direction later today.
43:58Jim, I'm actually right before their
44:01return start coming in were colleague
44:03and really one of our heroes and.
44:06Qualitative Teresa Betancourt
44:07will be presenting her work on
44:10refugees and something here in
44:12Africa today at 5:00 o'clock.
44:15At 434 thirty please join us.
44:19So if you just look online,
44:21it's one of the events that's coming
44:23up and Teresa is this amazing
44:25person who has been, you know,
44:26taking stories and really trying to
44:28interpret them from these colleagues.
44:30But Interestingly,
44:30her presentation this afternoon
44:32and she is a good friend is going
44:34to be focused on the work that
44:36she's been doing with the refugee
44:38population in the Boston area.
44:41It will be fascinating for all
44:42of us to participate in that
44:44and wonderful colleague, and
44:45I think also to make the point
44:47for those of you who may not know
44:49much about qualitative and Max
44:51brought us in squarely into it.
44:52But one of the real strengths
44:54of it is that sample sizes do
44:56not need to be gargantuan.
44:58You know, we go into is and I don't know,
45:00Max if you want to talk about
45:02that because you talked about the
45:04large samples that you're doing,
45:06but maybe I'll let you
45:07comment on that, right?
45:08Well, it's yeah, I think you know it's it's.
45:11Playful right now. How we have now.
45:14The introduction of these
45:17fairly sophisticated machine
45:19learning technologies that make.
45:21That transformed the idea of
45:23qualitative research because we
45:24can start playing with things in a
45:27new depth and looking very closely.
45:29Also with with big data.
45:32And so able to kind of allow things
45:35to emerge out of data in a classical,
45:38qualitative way,
45:38but in a much bigger sample.
45:40Again, I'm not.
45:41I'm not like a true blue
45:43qualitative researcher,
45:44so I don't mean to step on anybody's toes.
45:48But but it does feel like
45:49right now we have we're at an
45:51interesting moment where we can
45:53have a certain confluence method.
45:59And I also think that there's an
46:02interesting luxury that we have right now,
46:04which is that utilizing these methods,
46:06we can also give resources back to
46:09patients so we can give feedback.
46:11And I think that feedback, interactivity.
46:15You know can facilitate new types of
46:19connection that therapeutically we
46:21have an imperative to take advantage.
46:26So I guess there was one other thought.
46:28I guess I've been participating to the degree
46:31that I can with the Geneva Peace Week,
46:33which is actually this
46:34current week that we're in.
46:36And it's interesting too.
46:37I'm part of the early Childhood
46:39Peace Consortium and the whole
46:41issue about youth leaders,
46:42but one of the points you made very early
46:44on Max with something that I thought
46:47we would just come back and touch on.
46:49And it's interesting to think about doing
46:51these interviews with individuals who are,
46:53you know, veterans,
46:54and so on and so forth.
46:56But I guess there's a part of me
46:58that would be fascinated to have
47:00the same kind of interviews done
47:02with some of our government leaders.
47:04Yes, some individuals who actually
47:06are leading the way in terms of how
47:08they perceive themselves relative
47:09to the others and and just for us
47:12to potentially have fed knowledge
47:14available to us.
47:14But we need to make a bigger
47:17change in this world.
47:18And sadly I think many of the
47:20people that are sort of politically
47:22leading the way are leading us
47:25sadly and it has a lot to do.
47:27I'm sure with their early child
47:28development and sort of where they can,
47:31but we need to make a difference and I'm
47:33not sure if you've actually had any.
47:36Policy makers or government officials
47:38take any of the information that
47:41any of the sort of tools you have,
47:44but I'd be fascinated if you had.
47:46I haven't, but I did have,
47:49and I had a final slide,
47:51which I kind of backed out from showing,
47:54which looked at some of the Twitter
47:57postings of Biden versus Trump.
47:59And looking how how clearly we can see,
48:02you know you might call them
48:04qualitative differences.
48:05Or you might.
48:06Call them psychological differences.
48:08You know, without what I would call relation,
48:10modality differences,
48:11power differences.
48:12Would you mind that Jim will second
48:14the vote? Could you send? Could
48:16you share that slide? I mean I can,
48:18but I can. You know better.
48:20We just talk about. I don't mean
48:22to like drift into the, you know.
48:28You know it's it's a time of
48:30heightened emotion anyway,
48:31you know, but but the point is that,
48:33but certainly you know these patterns
48:34are are we don't need this crap.
48:36We don't need to be experts in AI.
48:39To see you know fairly new on
48:42psychological differences between
48:43you know these candidates,
48:45how they present themselves,
48:47how they use words,
48:48how they conceptualize self versus other.
48:51Perfect answer, perfect answer
48:53for the nuanced is the right word.
48:56Either we have not. We don't
48:59need totally overt and scary.
49:03So Jim, do you want to close us off
49:06with a final thank you and a word of Wisdom
49:08as we head into the rest of the day?
49:13Well, I would just say thank you very
49:15much and I guess it makes me think of
49:17the work that we've been doing with
49:19the Israelis and Palestinians and
49:21trying to bring them together with the.
49:23And actually I was just on the
49:25phone yesterday with Ernesto
49:26Caffo and Foundation Child,
49:27but there's so much more work that
49:29we need to do around this globe
49:31and thank you for leading the
49:33way in some really creative ways.
49:35Max, I appreciate it.
49:37Thank thank you very much and it's
49:39it's been an honor to talk them to
49:42share and thanks for making time.
49:44Sorry the mechanism of sharing information
49:45over zoom is still a little clunky,
49:48but we're trying to find our way.
49:50Well, we were all in the
49:52same world right now and.
49:54I guess I will look forward to seeing
49:57everybody next week with James
49:58Swain and I'll be hopefully be.
50:00Be able to share some interesting
50:02realities about James's life, too.
50:04I was at his marriage,
50:05and certainly we've known him for many years.
50:09So thank you all and thank you.
50:12Well, alright take care.