Yale Psychiatry Grand Rounds: December 4, 2020

December 04, 2020

Information

Dr. Sidney J. Blatt Lecture: "Healing in a Social Context: The Importance of Clinician/Patient Relationship"

Bruce E. Wampold, PhD, ABPP, Emeritus Professor of Counseling Psychology, University of Wisconsin - Madison; Senior Researcher, Research Institute at Modum Bad Psychiatric Center, Vikersund, Norway; Chief Scientist, Theravue.com

ID5969

To CiteDCA Citation Guide

00:00One I'm ready to Sinha and Chief of the
00:03psychology section here in our Department,
00:05and I want to welcome you all to the third
00:08Sidney J Blad lecture today I've had the
00:10honor and privilege to follow Doctor Blad
00:13as psychology section chief and there
00:16have been some very big shoes to fill.
00:19In almost his 50 years here at Yale,
00:23he grew our psychology section from 2
00:26faculty members 50 more than 50 years ago.
00:30Now to over 100 full-time faculty,
00:33more than 200 voluntary psychologists,
00:35and we are now among, I think,
00:38the largest psychology section at
00:41any medical school in the country,
00:43contributing really in a very diverse way
00:47to our wonderful psychiatry Department.
00:50Sid had a very special warm and
00:52wise approach to leading us.
00:55I know how hard it is to emulate that
00:57he has touched and helped so many
01:00of us in building our careers and
01:03helping us flourish and to really
01:05propagate our discipline.
01:06And for that we are eternally grateful
01:09for those of you who did not know him,
01:12you will hear briefly about his
01:15special abilities and qualities
01:16and what we miss so much.
01:18Even today.
01:19Most of all,
01:20I'm very appreciative of the black family
01:22for establishing this lectureship.
01:24This is allowed.
01:25USTA celebrates its contributions
01:27each year to recognize them,
01:29learn from them here from great speakers
01:31each year and two most importantly
01:34help us sort of recognize their
01:37importance and incorporate the work
01:39in our current and future endeavors.
01:41So with that,
01:43let me Calapan Doctor John Crystal are
01:46chair of the Department to say a few
01:49words and also to introduce David Black.
01:52John,
01:52yes,
01:53thank you so much. Let me just
01:56add my welcome to this lecture.
01:58This is a very special
02:00day for the Department.
02:01Every year in three years
02:03we've had just remarkable.
02:07Presentations and and communal
02:09discussions that have really elevated
02:11discourse in our Department as benefits.
02:14Since memory and today will be
02:17no exception, we're very pleased.
02:19Professor Wampold that
02:20you've joined us today.
02:22I also want to extend my thanks
02:24to David and Lisa Blatt,
02:26who are on the call and who will speak
02:30for creating this opportunity to come
02:33together and both remember sedan.
02:35Look to the future of of psychology.
02:37I just wanted to say a couple
02:40of words about Sid.
02:45He was he was really quite a remarkable
02:48figure this morning I was rereading
02:51notes from the farewell address of
02:54Fritz Redlich who was the chair
02:57of the Department of Psychiatry,
02:59who stepped down and who credits Sid
03:02particularly for building psychology
03:04within psychiatry back in 1967.
03:09Remarkably, Sid led the section
03:12of psychology for 40 years.
03:16So you have what? 35 more years to
03:21go rajita continue that legacy that
03:26say it's an unspeakable, unspeakable,
03:28let legacy and and we think of him,
03:32his asmodel teacher as a mentor.
03:35As an investigator,
03:37particularly for his work on the study of
03:40the nature and treatment of depression.
03:43And of course, husband,
03:45father, colleague, and friend.
03:48I first met said.
03:52Just a little over 40 years ago and
03:55my father, who was a psychoanalyst,
03:58suggested that I should look him up.
04:01When I came to Yale for medical school,
04:04and you know,
04:06I had no expectations of
04:08what would come of the
04:10discussion. And yet. From
04:12the first meeting, he was so incredibly
04:15open and kind that that I met with him.
04:18You know, many, many times over the
04:21succeeding years and had the opportunity
04:23to work with him more closely.
04:26When I became chair of the Department.
04:30And so I mean,
04:32that's the kind of guy said was,
04:34which was you could you could easily
04:37find yourself both entrance band adopted
04:40in the context of getting to know him.
04:43Well. He was a very very
04:46special in generative person.
04:48It's my pleasure today to introduce
04:51another COP, not a policeman.
04:54Not a cop, but child of psychoanalysts.
04:58And in that is David Blatt,
05:01who I've also gotten to know in
05:04the context of of saying goodbye
05:08to said before and now and now,
05:11celebrating this this.
05:14Annual celebration,
05:16so it's my tremendous pleasure.
05:19If you're on the call, David.
05:22To introduce you to say a
05:24few words at this point.
05:28I saw Lisa. I don't know
05:30if I if David is on.
05:33You're muted David.
05:43He is still muted.
05:52Chris, could you unmute David?
05:56I don't see David's name
05:58on the list
05:59listed as Lisa Blatt. You are I'm OK.
06:03Yeah OK yes, sorry this. What happens
06:06when you use your wife's computer.
06:10So thank you so much.
06:12Both Doctor Sinha and Doctor
06:14Crystal for your kind words.
06:16Thank you to the Department of Psychiatry
06:18for hosting and thank you Doctor Wampole
06:21for presenting today at this lectureship.
06:23My dad would have thought these
06:26to be fairly remarkable times.
06:28He would have had.
06:29I'm sure in private and certainly with
06:32his family some very choice words
06:35for our current political leaders,
06:37but I think he would have been most alarmed.
06:41Yeah, publicly by the rise in
06:43anxiety and depression and mental
06:45illness in our society,
06:47and I think he would have been most
06:50interested in the ways in which
06:52individuals have managed to pursue
06:55relationships over new mediums like this.
06:57And through old methods like sitting
07:00on porches and walking with friends.
07:02So thank you.
07:03Thank you all of you for coming to
07:06this socially distance lecture and
07:08continuing the connections and interactions.
07:11That my dad enjoyed so much.
07:13Thank you.
07:15Thank you so much David.
07:18Let me ask Doctor K Long to say a
07:22few words about said as a mentor,
07:26friend, scientist and an colleague.
07:30Yes, thank you.
07:32It's my happy task to say a
07:35few words about Sid Blatt,
07:37whose memory we're honoring today,
07:40said, was my teacher, mentor, and friend.
07:42More than 30 years in 1986,
07:45I moved from Texas with my young
07:48family to spend one year in New
07:51Haven in the predoctoral psychology
07:53training program that said lead.
07:56I never returned to Texas as I planned and
07:59Sid had a lot to do with that decision.
08:02Sid was a professor in the Yale
08:04Psychiatry Department as we've heard for
08:06almost 50 years for more than 50 years.
08:08Actually, most of that time,
08:09as the chief of the psychology section.
08:12He was a leading personality
08:15theorist or prolific researcher,
08:17a gifted psychoanalytic clinician.
08:19A master in the almost lost art of
08:24psychodynamic, psychological testing,
08:26a revered teacher and mentor.
08:29Sid was a true Renaissance man whose
08:32work was marked not just by the highest
08:35achievements in each of these areas,
08:37but also by his unique ability to
08:41integrate these interests seamlessly.
08:43Since life work of theoretical clinical,
08:46an empirical contributions began with
08:48a simple but profound observation.
08:51During his analytic training,
08:53he saw that the two patients he was
08:56treating had similar symptoms of depression.
08:59But each was occupied with
09:02different concerns.
09:03Said saw that his patients worries
09:06coalesced around two distinct
09:08but interrelated poles.
09:09What he termed self definition
09:12and relatedness.
09:14It was a mark of his brilliance
09:16that from this observation he
09:18developed groundbreaking theories
09:20of normal and abnormal development
09:23and personality organization and
09:25extensive body of empirical research.
09:28Including the development of widely
09:30used scientific measures and theories
09:32and techniques of therapeutic change,
09:35but this particular genius,
09:36the ability to see the big ideas in
09:39a simple observation extended beyond
09:42his theoretical and empirical work.
09:45Into his unique ability to find
09:48and nurture the talents in his
09:51many students and colleagues.
09:53If we measure Sid's achievements
09:54in terms of the volume and
09:57quality of his scholarly output.
09:59The more than 200. 20 published articles.
10:01The 17 books, one on art history no less.
10:05The result is extraordinary,
10:07but if we look at the exponential effect
10:11of his impact on generations of scholars,
10:14many of whom have become who have become
10:18leading figures in the field themselves,
10:20his contributions are truly remarkable.
10:24In Peter Fonagy's words,
10:25Sid was the talent scout of the
10:27psychoanalytic academic world.
10:29He had a rare,
10:30an life changing ability to
10:32see not just who you were,
10:34but who you had the potential to become.
10:38He could be demanding intimidating even,
10:41but he was always kind.
10:44Over the years, every time I met was said.
10:47I would find myself taking a mental inventory
10:50of what I've done since we last met.
10:53I'd evaluate myself through
10:54his eyes and worry whether I
10:56had enough to show for myself.
10:58But our actual encounters
11:00were never like that.
11:02They were filled with warmth and
11:05interest in each other's families.
11:07I came to realize that I held him in my
11:10mind as a prod Tord
11:11aspirations and achievements.
11:13And I count myself lucky to be one
11:15of a great many psychologists,
11:18psychiatrists and psychoanalysts
11:19around the world who can
11:21say with deep appreciation.
11:22That's it's confidence in me and
11:25his interest in me changed the
11:27course of my career and my life.
11:33Thank you K. Let me ask Doctor Matthew
11:38Steinfeldt now to please introduce our
11:41speaker for today Doctor Bruce Wampold.
11:45Thank you Doctor Sinha so I have the great
11:49honor to introduce our speaker this morning.
11:51Doctor Bruce Wampold is emeritus professor
11:54and previously the Patricia L Wallet
11:56professor of counseling Psychology
11:57at University of Wisconsin, Madison.
12:00He is a senior researcher at the Research
12:03Institute Institute at Modem Bad
12:05Psychiatric Center in Vickerson, Norway,
12:07and chief scientist at tharavu.com,
12:09an online platform dedicated to helping
12:12psychotherapists develop and maintain
12:13therapeutic capacities and skills.
12:15Doctor Wampold received his BA in
12:18mathematics from the University of
12:20Washington Masters in Educational
12:21Psychology from the University of Hawaii
12:24and his PhD in counseling psychology
12:26from the University of California,
12:29Santa Barbara.
12:30His research has sought to understand
12:32psychotherapy from empirical, historical,
12:34anthropological perspectives.
12:35This work is summarized in his book
12:38The Great Psychotherapy Debate.
12:39The evidence for what makes
12:41psychotherapy work published in 2013,
12:43now in second edition,
12:45and which has been cited
12:47almost 5000 times since then.
12:49Doctor Wampold is a fellow of the
12:53American Psychological Association
12:54in Divisions twelve,
12:551729 and 45,
12:57a diplomat in counseling psychology
12:59of the American Board of
13:01Professional Psychology. The recipient
13:03of the 2007 Distinguished Professional
13:05Contributions to Applied Research Award
13:07from the American Psychological Association
13:102015 Distinguished Research Career
13:11Award from the
13:13Society for Psychotherapy Research. And
13:16an honorary doctor in the
13:17social Sciences. Ordered from
13:19Stockholm University.
13:21Doctor Wampold's work is especially
13:23relevant now. During this time,
13:24when fundamentalisms of all kind pervade
13:27everything from political
13:28discourse to ideological
13:29partisanship. His research orients us
13:31beyond the often constructed fault
13:33lines in our own fields to the deeper
13:36humanistic realities that undergird
13:37effective psychotherapy across modality in
13:39context in which have
13:41the potential to mitigate
13:42the truly staggering
13:43costs of human suffering,
13:45that all too often go unaddressed.
13:47His research is an ongoing
13:49invitation for all of us to think
13:51together about where our skills,
13:53models of the mind and brain and
13:56clinical commitments converge,
13:57and how these intersections
13:58can illuminate the way forward
14:00in the service of others.
14:02Please join me in
14:03welcoming Doctor Bruce Wampold.
14:06Well, thank you very much
14:08for the introduction.
14:08I have to say it's a great honor to.
14:12Give a lecture in.
14:15A lecture name for Sidney Black.
14:18I never had the opportunity to meet him,
14:22but clearly inspired by his brilliant work.
14:26To hear you talk about what he
14:29meant to you personally really
14:32brings another dimension to this.
14:36It's rare our field that somebody
14:39is so brilliant yet so engaged,
14:42so willing to mentor and
14:45bring forth new generations.
14:47You know long after we're done
14:50contributing to the scientific
14:52leadership scientific literature.
14:55It's the contributions of those people
14:58we mentored really carry the legacy,
15:01so it's just exciting to hear the
15:05personal stories of what Cindy meant too.
15:09Many of you so with that I'll start my talk.
15:15It's a little bit ironic.
15:18I'm talking about the importance of
15:21social relationships in a pandemic
15:23where we're socially isolated,
15:26but I think maybe it really
15:29emphasizes how important this is.
15:32I know here at the University was constant.
15:36The students are all clamored for.
15:40More technology and more distance learning,
15:43but with the potential pandemic
15:46is shown across education,
15:48is that the personal relationships
15:51are absolutely critical.
15:52People want to see and interact with their
15:57professors, their teachers and so on.
16:00So with that.
16:02I'm gonna share my slides.
16:09And please let me know that they are there.
16:16Everybody, yeah good thanks.
16:19OK thanks. So I'm just going to
16:25start with this notion that you know,
16:28humans are clearly characterized
16:31by very large and powerful brain.
16:34Why did that evolve?
16:36It's a very expensive organ that
16:39uses what 20% of our calories?
16:41And it weighs about 2% of our body weight,
16:45so the brain is very expensive Organism.
16:48But it evolved according to many.
16:51As you will know to manage
16:53social relationships.
16:54So here's just a graph of the size
16:57of the brain compared to the size
17:00of social networks in primates,
17:03and you can see there's a very.
17:06Strong positive relationship.
17:08The larger the social network.
17:12The larger the brain and the
17:14more capacity we need to manage
17:17those social relationships.
17:19So we have this remarkable.
17:24Organism organ that manage this
17:28these social relationship so
17:32wouldn't be surprising that.
17:35This was involved in healing as well,
17:37so two books that really.
17:41Summarize many important things about
17:44the social brains are the social
17:48which is a neuroscience book on.
17:51How we manage social relationships
17:53and connected which is based on the?
17:56The social contagion,
17:58the idea that what are friends are friends,
18:02friends, friends,
18:02think and do and believe affects
18:05what we think, do and believe.
18:11So let's talk about healing
18:13in a social relationship.
18:15Actually, ants do it.
18:17So this is quite unusual behavior,
18:20at least mystified scientists.
18:22For some some time.
18:24But when there's an Ant in
18:26the colony that's infected,
18:28it's interesting to know what they do.
18:32So if we were together,
18:34I could ask for for input from the
18:38audience about what they think they do.
18:41It might be that the other ants
18:45don't recognize that there's
18:48an Ant that's has a disease.
18:51Or it might be that the Ant
18:54become socially isolated.
18:56Kind of a quarantine,
18:57but what happens is the healthy
19:00ants take time in close physical
19:03proximity to the infected Ant,
19:05and this seems kind of counter
19:07intuitive why you would want
19:10to be in close proximity?
19:12Well,
19:12it turns out what happens is that
19:15physical proximity transmits a small
19:18amount of the pathogen to the healthy and.
19:21And the healthy Anthem develops
19:24an immune reaction and they
19:26call it social immunization.
19:28So it's a social healing practice.
19:31Bees do it as well,
19:33so if there's an infection in a beehive,
19:37the bees will phonetic Lee flap their wings,
19:41which raises the temperature of the hive,
19:44which in a way is a social fever.
19:48So it's interesting to
19:51see these social species.
19:53Healing and social ways.
19:58So vampire. Apps which are particularly
20:02social species don't do this.
20:05What they do is if there's an infection
20:09and they they do this experimentally
20:12as well as naturalistically
20:14the ants experience fatigue and
20:17lethargy and therefore reduce their
20:21social interaction with other
20:23particularly non kin conspecifics.
20:26So this is social quarantine.
20:29So we see.
20:34Ants or insects.
20:35I should say which are very social animals.
20:40Healing in the social way.
20:43So one of the questions in this
20:46social healing is how the infected?
20:49Insect. Signals to the other.
20:54Insects that it's six.
20:56So to answer this question,
20:59will actually turn to humans and
21:02the facial expression of pain,
21:04so we know when we experience pain.
21:08We make this facial expression
21:10of pain and it turns out
21:13that this is cross cultural.
21:15Not all facial expressions of emotion
21:18or cross cultural but pain is,
21:21so it evolved evolutionist.
21:23Think about 10,000 years ago.
21:26And the purpose is to communicate
21:29to other humans that we need help.
21:32So there are theories that many of the
21:36symptoms we express when we're ICS.
21:39Sick is really a way to signal that
21:42we need assistance from others.
21:49All human societies have had
21:52social healing practices,
21:54so the earliest civilizations
21:56all had designated healers and
21:59designated healing practices.
22:01Of course they differed OK,
22:05so the Incas and Aztecs.
22:09Indigenous Americans had very
22:13different healing practices in
22:15the ancient Greeks, for instance,
22:18but what was in common is the
22:21designated healer and culturally
22:23accepted healing practices.
22:25So this idea of healing in a
22:28social context as a lot of basis,
22:32not just in humans,
22:34but in other social species.
22:37So what are the components of
22:40healing so we can breakdown healing
22:43into these various components?
22:46So there's a natural effect,
22:49so this is the ability to heal and
22:52resist disease without any intervention.
22:58So this is a slide from a
23:03presentation made in a class,
23:06so we're exposed to pathogens all the time.
23:10We experience traumas an we heal
23:15without any intervention course.
23:18The coronavirus is an exception
23:20to this ability to heal naturally,
23:24but we have barriers in immune system,
23:27blood, coagulations and so forth to fight
23:30disease and to heal without invention,
23:33so that's the natural effect
23:36we have specific effect.
23:38This is Western medicine.
23:39This is the effects due to the intervention
23:43that remediates the pathophysiology,
23:45surgery or or medicines and so forth.
23:50So the specific effect is a considers
23:53the patient a passive recipient if they
23:57receive the surgery or take the medication,
24:01and so the effect is do not to the
24:05active engagement of the patient,
24:09but to the specific ingredients
24:11of the intervention.
24:16And of course we use placebo
24:19controlled studies to be able to
24:22identify this specific effect.
24:24Then we also have contextual effects.
24:27These are due to the psychosocial
24:31factors healing rituals, symbols.
24:33These involve a conscious patient
24:36making meaning of the experience
24:40of the healing practice.
24:42Of course it's too lot to our
24:48expectations for benefits.
24:50It also can be due to condition,
24:52defect or vicarious learning so.
24:55You know, I'm really talking
24:56about placebo effects here.
24:58To a large extent.
25:02But there's also as part
25:04of the contextual effect.
25:06An effect due to the relationship
25:07between the healer and the patient,
25:09and this is what I will talk about today.
25:13So let's just look at a graph to
25:16show these different effects.
25:19So here's a naturally improving condition.
25:22Maybe it's a laceration of some kind.
25:28Person presents for the
25:30patient presents to a.
25:32Clinic and there's a suture placed
25:34so there is a specific effect.
25:38There's an intervention.
25:39There's a natural effect
25:41because these wounds were going
25:44to heal naturally anyway,
25:46but there's also a contextual effect,
25:49and these three combined really
25:52characterize. Healing.
25:55So if you think of an acute appendicitis
25:58and I use this example to show how
26:02these work together so the patient
26:04presents with abdominal pain, OK,
26:07but there's also fair discouragement,
26:09it may be happening in a very
26:12critical time in a person's life.
26:15Starting a new employment,
26:17and they're going to be absent from work.
26:20There's relationships that are
26:22going to be difficult because of it,
26:25so there's a psychological.
26:28Aspect of this as well,
26:30there's communication with the
26:32clinician which the clinician describes.
26:35The diagnosis with the treatment plan
26:38will be, but the clinician also gives
26:41assurance that this is treatable,
26:44that there won't be any lasting effect,
26:47shows warmth,
26:49understanding and so forth.
26:51Then and after and Ectomy is performed.
26:54So this is a specific effect of surgery.
26:57But then there's also a natural
27:00healing of the wound.
27:02So here we have kind of the natural,
27:06specific and contextual effects working
27:09conjointly for the patients benefit.
27:14And of course, the same occurs for
27:18naturally deteriorating conditions,
27:20so without intervention,
27:22the patient would deteriorate quickly.
27:25Think of Parkinson's disease, for instance.
27:28Here the specific effect reduces
27:31the rate of deterioration and the
27:34contextual effect further reduces that.
27:38So even though the patient's
27:40deteriorating there is a specific effect.
27:44Anna contextual effect that occur.
27:51So let's talk about the relationship then,
27:54which is the focus here today.
27:56So the relationship is that face to face
28:00meeting between the healer and the patient.
28:04And there's two components,
28:06or at least we think and,
28:09and much of the literature
28:11talks about two components.
28:13There's the cognitive component
28:15we provide as healers information,
28:17so the surgeon explains what's
28:20involved with an appendectomy and and
28:24what the prognosis is and what the.
28:27Healing experience will involve,
28:29so that's information.
28:30But then there's an emotional
28:32component as well.
28:34That's the warmth,
28:35caring and understanding,
28:37so we want to look today
28:39at those two components.
28:44So we're going to look at the
28:47research to see is there a
28:49relationship effect and to do this,
28:52I'm going to review relatively quickly
28:55'cause we don't have too much time.
28:58The research in the area of placebos
29:00in which there's quite a bit of
29:03research because it's very easy to
29:05manipulate the relationship variables,
29:08will also look at the relationships of
29:10facts in medicine and in psychotherapy.
29:16And then finally, at the end I'll talk
29:20a little bit about some hypothesis
29:23about how relationship is healing for
29:26me as a psychologist, not enough just
29:30to say relationship is important.
29:32We want to know what are the mechanisms by
29:37which relationship exerts healing effect so.
29:41Let's start with disables and I call
29:45it the amazing influence of the mind.
29:48And I could say nothing works better.
29:52Now I didn't hear anybody laughing,
29:55and if I were there in person,
29:58it might be that. Nobody got it either.
30:02'cause I'm not a natural comedian,
30:04but it is a play on words.
30:08Evil works better,
30:10so we know placebo effects.
30:13Work for pain irritable bowel syndrome,
30:16which we will talk some today.
30:20Depression, we know.
30:21Large placebo effects for anti
30:24depressant medication anxiety
30:26fitness is an interesting one.
30:28We won't talk about today taste
30:31even Parkinson's disease,
30:33which surprising to many as
30:36well as athletic performance.
30:39So very quickly,
30:40pain is the the model is most often
30:45used to examine placebo effects.
30:48We know that if somebody is
30:51experiencing acute or chronic pain
30:54or even experimentally induced pain,
30:58that giving a pill and and telling the
31:02participant that this will relieve pain,
31:06relieve's pain, subjective reports of pain.
31:10Are affected by receipt and and
31:14involvement in placebo procedures
31:17or medications,
31:19but there is also a physiological effect.
31:25So when somebody experiencing pain
31:29and receives a placebo analgesic,
31:33the brain releases opioids so
31:37there's a natural opioid.
31:40That affects the pain.
31:44So also interesting is that
31:48awareness of receiving.
31:51You know analgesics has an
31:54effect on the experience of pain.
31:57So studies that Fabrizio
32:00Benedetti doesn't in Italy.
32:03Postoperative patients received
32:06morphine through a machine.
32:09And their Ivy.
32:13Under 2 conditions,
32:14one in which there.
32:16Uh,
32:17where they're getting the morphine so the
32:20the clinician comes to the room and says
32:23you're now receiving a dose of morphine?
32:26Doesn't administer the morphine
32:28because it's given through the machine,
32:31but just informs the patient they're
32:33going to receive the dose of morphine.
32:37The heart of awareness condition.
32:40The same dose of morphine is
32:42administered by the machine,
32:44but there's no clinician.
32:47Present so in the awareness condition
32:52where the clinicians present much greater
32:56subjective report of reduced pain.
33:00There is reduced time to requesting
33:04additional doses compared to getting the
33:07same dose of morphine out of awareness.
33:10So this is our first hint.
33:13The relationship makes a difference,
33:15so the presence and the information
33:19provided by the clinician has an effect on.
33:24The experience of pain.
33:27So let's look at some studies on the
33:30effects of relationship and placebo,
33:33and this is a study done at
33:37the Harvard placebo.
33:39Unit up Ted Cap Chuck directs,
33:41so this is a study of irritable
33:45bowel syndrome,
33:46which we know is a prevalent
33:49disorder in primary care.
33:51It can be very distant and
33:54disabling for patients.
33:56So we know also that IBS
33:59is placebo responsive,
34:01and in this study the placebo
34:04is acupuncture placebo,
34:06so the patients think they're
34:08getting acupuncture.
34:09But the needle doesn't
34:12actually Pierce the skin.
34:14So technically it's a placebo,
34:17not true acupuncture.
34:18So there were three conditions.
34:21There's treatment as usual,
34:23so the IBS patient sees
34:26their physician as usual.
34:28But receives no.
34:32Acupuncture in the limited interaction.
34:37The acupuncture is a very matter of fact
34:41so says to the patient your doctor ordered.
34:44Acupuncture acupuncture is
34:46effective for the treatment of IBS.
34:49Here's what I will do,
34:52so it's a very matter of fact.
34:55Limited interaction in the third condition.
34:59Is the augmented interaction what they call
35:04the prototypic healthy interaction here the.
35:08Acupuncture feels warm, empathic,
35:11caring didn't provide any intervention.
35:14No mention of coping skills, but.
35:17You know, called the patient by name.
35:20Had good eye contact.
35:24Sympathized with the with the
35:27difficulties that IBS causes for my.
35:30So in terms of how comes.
35:37The augmented condition
35:38for global improvement.
35:40Adequate relief symptom severity,
35:43and particularly quality of life.
35:46Was significantly greater than the
35:49placebo limited interaction condition,
35:52which was also. Significantly
35:55greater than treatment as usual,
35:58so the placebo had an effect, but the.
36:03Relationship with a warm,
36:05caring practitioner.
36:08Augmented that effect.
36:10So here it's pretty clear another study of.
36:16Treatment for low back pain.
36:22This inferential current therapy in both
36:25the placebo condition and the variant
36:28the warm enhanced condition augmented
36:31the outcomes compared to the condition
36:34without that warm caring relationship.
36:37So another example, both of pasivo effect,
36:41but a placebo like effect,
36:43because even for the treatment condition,
36:47giving it in the presence.
36:50Have a clinician who's.
36:53Warm and caring. Is greater.
36:57So a final study in the placebo
37:00area is a very clever one that's
37:04done by Alia Crum at Stanford.
37:07Colleagues, so in this study.
37:13Undergraduates at Stanford were invited
37:15to participate in a medical study.
37:17Now there was no medical study,
37:20but what they told the participants was
37:22before we can enroll you in the study,
37:25we have to give you a physical
37:28so each of the participants.
37:32Came for the physical typical
37:34you know vital signs.
37:39Heart rate and so forth.
37:42But they also told the patients we
37:45have to screen you for allergies.
37:48And they. Prick the skin.
37:53Many of us have had. Allergy tests,
37:58but they pricked the skin with histamine,
38:01so everybody had an allergic
38:04reaction or reaction.
38:05And the outcome here was the size
38:09of the wheel. That a Kurd So what?
38:14Transpired was they said, well,
38:17I'm sorry you had allergic reaction.
38:20You're disqualified from the study,
38:22but we have some cream that will
38:26reduce the size of the reaction well.
38:29This was actually placebo cream,
38:32so it had no specific ingredients.
38:35No anti histamines,
38:36and they looked at how fast
38:39the wheel decreased in size.
38:42Now they did this with both.
38:45High and low competent physician
38:48and a higher low warmth physician,
38:51so they experimentally manipulated
38:53both competence and warmth.
38:55I'll tell you a little bit
38:59about how they did this.
39:03So in the high warmth condition,
39:05the physician asked the patient's name,
39:08made eye contact, smiled, sat,
39:11closed or warm posters on the wall.
39:14So this is this is kind of the
39:18prototypic warm and caring physician.
39:21The opposite was.
39:23Just the same, just the same,
39:27just the opposite,
39:28so didn't use the patients name.
39:32Minimal eye contact.
39:33Use more of a stern tone.
39:37Very, very instrumental in their language.
39:40Sat relatively.
39:42Distance from the.
39:44Participant and there were
39:45no posters on the wall.
39:47OK, so that's high and low warmth,
39:51high and low competence in
39:53the competent condition.
39:54The physician use the clear,
39:56confident tone,
39:57didn't make any mistakes in the process.
40:00Teachers the room was well organized,
40:03you get a kick out of the low competence.
40:07So here the physician wasn't quite.
40:11Well started again,
40:12couldn't quite explain exactly
40:14what was going to happen.
40:17Made mistakes and procedures,
40:18put the blood pressure cuff on incorrectly.
40:22Had to start again.
40:24There was a meske messy desk.
40:27Couldn't find the stethoscope 'cause it's.
40:30Hidden underneath the chart,
40:32so try to induce this idea of
40:36high low competence so it's
40:39an interesting experiment,
40:41and again this is a physiological
40:44reaction to histamine,
40:46and the outcome is how fast did
40:49the wheel decrease in size over
40:52the course after the placebo anti
40:55histamine cream was administered.
40:58So here are the results.
41:01And in the. Hi warmth.
41:06Hi competent condition.
41:09The size of the wheel became
41:12much smaller overtime,
41:14so here's a physiological
41:17reaction affected by placebo,
41:19but augmented by both warm
41:22incompetence the the high warmth,
41:25low competence, and low competence.
41:28High warmth were in immediate outcomes,
41:32but again,
41:33both warmth and competence
41:36seems to make a difference.
41:39So the placebo studies
41:42show that relationship.
41:45Makes the difference in healing.
41:49Here psychiatrist effects in
41:51psychopharmacology and this is study that.
41:57Professor Black was well aware of and
42:00wrote some follow up studies for this.
42:05In the medication arms it was
42:09antidepressant medication versus
42:11placebo's. The typical double blind.
42:17Set up. So here the psychiatrist
42:21met with the patients 30 minutes
42:24in weekly clinical management.
42:30In the study,
42:313% of the effect is due to treatment,
42:34so this is the specific effect.
42:37Depressant medication more effective than
42:40placebo effect sounds relatively small,
42:42but that's the typical separation it is,
42:45you know, between antidepressant
42:47medication and placebo pills.
42:49How much of the variability in
42:51outcome was due to the psychiatrist
42:53giving the antidepressant medication?
42:56So here it's 9%.
42:58If I work there with you,
43:00I could jump up and down 'cause
43:03this is pretty exciting.
43:05The psychiatrist blind to whether
43:07they're giving the medication.
43:09Or the placebo?
43:12Accounted for about 9%.
43:14Of the alcohol and it turns out that the
43:18best psychiatrist got better outcomes,
43:21giving the placebo than the
43:23poor psychiatrist got giving.
43:25With the anti depressants.
43:27So the advice might buy be.
43:31But if you're depressed,
43:33go to a psychiatrist,
43:35get a good psych and effective
43:38psychiatrist and get a placebo.
43:40So it turns out more of the variability
43:44in outcome is to the psychiatrist
43:47administering another placebo.
43:49And remember,
43:50this is 30 minutes of clinical management.
43:54Per week
43:57so there aren't any.
44:01Have meta analysis of relationship
44:04effects in placebo administration,
44:07but it does turn out that in this
44:13meta analysis of placebo response.
44:18Two orourke response pain.
44:20I didn't say this very well.
44:23Response to placebos for pain.
44:25The number of face to face visits
44:29in the trial was related to the
44:32size of the placebo response.
44:35So the more visits,
44:37more face to face,
44:39visits of the patient,
44:41the greater the placebo effect.
44:44So it looks like for placebos relationship.
44:48Is absolutely critical.
44:52In medicine you know we have hundreds
44:55of thousands of clinical trials of
44:59various medications and procedures.
45:01Very few studies randomized studies
45:05that have manipulated relationship.
45:07But enough to do this meta analysis again.
45:11John Kelly and colleagues at the
45:14Harvard Center for Placebo Studies.
45:17Meta analyzed those studies that randomized
45:20different aspects of the relationship.
45:23The overall effect positive.
45:26So a better relationship,
45:28better health outcomes.
45:30It's small but statistically significant.
45:33The studies if you look at them,
45:37are not particularly well done.
45:40It's hard to manipulate relationship
45:43factors in actual clinical practice, so.
45:47Some evidence.
45:50Somewhat convincing 'cause
45:51it's a Mount Meta analysis,
45:54but the effect is relatively small.
45:59Let's now turn to psychiatry psychotherapy.
46:03So what do we know about psychotherapy?
46:07Well, it's remarkably effective.
46:09It's demonstrated in random
46:12randomized clinical trials,
46:14comparing psychotherapy to
46:16weightless controls or to some
46:19kind of attention placebos.
46:22He is also effective in practice,
46:25so it looks like that.
46:29Psychotherapist in practice meets the
46:32debt benchmarks of randomized clinical
46:35trials achieving comparable effects.
46:40Many trials show the psychotherapies
46:43as effective as medications.
46:45You know this.
46:46This research pretty well,
46:48so psychotherapies longer lasting
46:50so after medication is withdrawn,
46:53there's a greater relapse then
46:55there isn't psychotherapy, fewer,
46:57fewer side effects, and so forth.
47:02But the question is what
47:05makes psychotherapy work?
47:07So. Will look at this just.
47:11In a few very specific areas,
47:15let's start with therapist.
47:17OK, so here's an illustration of
47:21the outcomes of therapists in the
47:24National Health Service in England,
47:28where the service measures
47:30outcomes in all of their clinics.
47:34So here's.
47:37Residuals the difference between
47:39the average outcome and the outcome
47:42for each particular therapist,
47:44and you can see the green therapist.
47:51Consistently have better outcomes than
47:54average, so the confidence intervals
47:57are relatively great because measuring
48:00therapist effectiveness has has a lot
48:03of error because much of the variance
48:07is due to the patient, but even then.
48:10We can see that the best therapist
48:13consistently get better outcomes
48:16than average and the poor therapist.
48:20The Red Therapist consistently get.
48:23Our poor outcomes.
48:24So the question is.
48:27What characterizes?
48:28The most effective therapist.
48:34Oh, I just want to mention this.
48:37And it looks like the difference
48:41between therapists becomes more
48:43pronounced the longer the therapy.
48:46So interesting Lee,
48:48the red Therapist by session 15 have recovery
48:53rate of about 0% after the 15th session.
48:58That means that none of their
49:02patients will have recovered.
49:05If they're still in therapy and session 15,
49:09and you can see that the above average
49:13therapist continue to have increasing
49:16recovery rates quite remarkable.
49:19To get you involved in this,
49:21I'm going to have you identified the best
49:24therapist, so I'm going to show you.
49:29Several therapists and I want
49:31you to identify who you think is
49:34the most effective therapist, OK?
49:38I can't see the audience,
49:40but I know you're ready to look at these
49:44therapists and tell me which one you think.
49:48Is the most effective?
49:51Ready get set. Got up.
49:56It's not therapist, it's baseball hitters.
49:59These are all.
50:00All All Stars the best
50:02hitters in the major leagues.
50:04If any of you are baseball fans,
50:07it's a few years old now 'cause you see it.
50:11Russo Suzuki in the bottom one of my
50:14favorite players 'cause I grew up in
50:17Seattle batting champion in Japan
50:19as well as in the United States.
50:22Look at his stance very different then.
50:26Stance.
50:26He's got his knees close together.
50:29Other baseball players or hitters All
50:32Stars have their knees very far apart.
50:35Some hold the bats very high,
50:38some very low.
50:42What characterizes the best hitters is
50:44really hard to tell by looking at them,
50:47and the same is true in psychotherapy.
50:50So I like to say.
50:53It ruins the CBT therapist.
50:55Here's the psychodynamic therapist.
50:57Here's the emotion focused therapist.
51:00Here's the act therapist.
51:02So if you just look at what they do,
51:06they are very different.
51:08You know, it's remarkable
51:10that baseball statistics and.
51:13Psychotherapy statistics are very comperable,
51:16so a good hitter gets a hit
51:19about one out of three times,
51:21and that's enough to make.
51:24I don't know millions of dollars
51:26each year while the NNT for
51:29psychotherapy is 3 so we get about
51:32one hit for every three patients.
51:35So if you delve into the statistics,
51:38there's remarkable analogs between
51:39baseball and psychotherapy.
51:41But the point here is.
51:43It's very difficult to examine
51:46what therapists do by watching
51:49their videotapes an identifying
51:51with the critical ingredients are.
51:55So in the last 10 years or so,
51:58we've made great effort to identify what
52:01characterizes effective therapists.
52:02Here's what does not make a
52:05difference in therapists outcomes.
52:06The theoretical approach used in treatment.
52:10Clinical trials,
52:11as well as naturalistic settings.
52:14Very small or nonexistent differences among
52:17the outcomes of different approaches.
52:20Experience actually inversely related.
52:22Psychotherapist outcomes deteriorate
52:24not by great extent,
52:26but they'd iterate over the
52:29course of the careeer.
52:32Longitudinal studies have
52:33shown this age of the therapist
52:37doesn't make a difference.
52:40Some recent studies Big 5 personality
52:45characteristics don't predict outcomes.
52:48Here's one that that I like.
52:51Self reported social skills,
52:53so if you give therapists a
52:55standard social psychology,
52:57social skills test those who
53:00score higher and social skills
53:02do not produce better outcomes.
53:07In the United States, professional
53:09degrees psychologist, psychiatrist,
53:11licensed professional counselors,
53:13clinical social workers.
53:17All in Chief, almost identical outcomes.
53:20So several studies have looked
53:23at this, no differences.
53:28One that's that's.
53:31A little bit disturbing to many of
53:33us is that interviews of therapist
53:36by experts do not predict outcomes.
53:39We all believe that we can talk to
53:42therapist and discern who's going to
53:45be a better therapist by asking them
53:48about their clinical work about their
53:51themselves and make this decision.
53:53You know, this is the way we hire therapists.
53:57We often ask them to come for an interview.
54:01Find manager clinic.
54:03I want to interview potential
54:06therapist so you know in the.
54:09Industrial organizational psychology,
54:12but also studies in psychotherapy.
54:16The scores determined by interviewers.
54:21Have therapist do not predict outcomes so.
54:26What does so?
54:27This is an ingenious study,
54:29so Tim Anderson said,
54:30well, you know,
54:31it's really hard to look at videotapes
54:34of therapists and identify who's
54:36the most effective therapist.
54:38We know a lot of what goes on in
54:41therapy is determined by the patient.
54:44Interpersonally aggressive patients.
54:47Make therapist look relatively
54:50less competent, so clinical trial.
54:55Showed that competence ratings are
54:57often more a function of the patient
55:00than they are of the therapist,
55:02so Tim said I need a standardized.
55:05Patient so that all the therapists
55:08can see exactly the same patient.
55:12So what he did is because
55:16that's impossible to do.
55:18He showed a large sample of therapist
55:22videotapes of a particular therapy,
55:25particular patient statement so
55:27these were difficult patients.
55:30Tim went around the interpersonal
55:33circle and took.
55:35Or medix.
55:37Pulls from each octant of difficult patients,
55:41either interpersonally, aggressive,
55:43withdrawn, so forth.
55:46Then he showed these vignettes
55:48to the to the therapist and said
55:51respond as if you were the therapist.
55:54He recorded the therapist responses,
55:57encoded them,
55:58and wanted to see if he could
56:00discern in their responses what
56:03predicted the outcomes of these
56:06therapists and he was able to do this.
56:09So he called this the
56:12facilitative interpersonal skills.
56:14So here's the scales that differentiated
56:18the more effective therapists than
56:21the last effective verbal fluency.
56:24How cogent and how interesting
56:28and how persuasive.
56:30Were they therapist statements?
56:34Emotional perception.
56:38Modulation of the therapist own affect
56:42and their expressiveness of affect.
56:45Warmth and acceptance.
56:48I put these in red and blue because these
56:51are the dimensions we talked about earlier.
56:55Competence.
56:56How well can you communicate
56:59information about the therapy?
57:02As well as warmth,
57:04caring and understanding so the two
57:07dimensions we talked about earlier.
57:10Again,
57:11these are interpersonal skills that
57:15are demonstrated in challenging
57:18situations where emotion is difficult.
57:22If we look at the science for this,
57:27these relationship factors
57:29produce relatively large effects.
57:31These were all meta analysis
57:34that appear in John.
57:37Norcross is book psychotherapy
57:39relationships that work.
57:41Compare those to the specific ingredients,
57:45treatment differences,
57:46adherence, rated adherence,
57:48rated competence,
57:49the relationship factors in psychotherapy.
57:52Seem to be critical to the success.
57:59So in the last few minutes,
58:02let's talk about what is it about
58:05the relationship that's health?
58:07Promoting? OK, so very briefly,
58:10because we don't have too much time.
58:13But again, as a psychology I'm interested,
58:17why should an interaction with
58:20a warm understanding healer.
58:22Who I perceive to be
58:25competent be health promoting.
58:28So four different hypothesis.
58:30One is that the relationship
58:33interacts with specific effects and
58:35this is the idea that of adherence.
58:39A second is that this relationship
58:42combats loneliness.
58:433rd, the Interpersonal Relationship
58:46is a very potent way to create
58:52expectations for success.
58:55And finally,
58:56the relationship promotes emotional
58:58coregulation so very quickly.
59:02If we have a good relationship with
59:05the healer, more likely to head here.
59:09To the healing procedure so and
59:12there's meta analysis to these so
59:16the physician communication leads
59:19to increased patient adherence.
59:21So there's some evidence for that,
59:25but there's also some evidence that
59:28adherence to a placebo has an effect.
59:32So those people who follow through
59:35taking the placebo medications
59:37actually in one meta analysis have
59:41decreased morbidity and mortality.
59:43So this is very interesting
59:47that both adherence to the.
59:51Effective medication,
59:52but at hindrance to the placebo
59:56results in better outcomes.
01:00:02Let's look at this idea of
01:00:05loneliness, so we know that.
01:00:09There are several health indicators
01:00:12that increase risk for mortality,
01:00:15obesity, lack of exercise, smoking.
01:00:18We can include excessive drinking,
01:00:22environmental, pollutions and so forth.
01:00:27What's a greater or equal risk
01:00:29than any of these factors?
01:00:32Yeah loneliness so perceived loneliness,
01:00:36lack of social support increases
01:00:39morbidity and mortality.
01:00:41So one thing that a good relationship.
01:00:47Does with a hilarious that
01:00:50it decreases loneliness long.
01:00:52This is often exacerbated by disease
01:00:56and illness, so were discouraged for
01:00:59mental illness were often stigmatized,
01:01:02may be rejected from social networks so.
01:01:08Our loneliness is is often greatest
01:01:11when we're suffering from a disease.
01:01:15Anna relationship with a healer
01:01:18helps to reduce that loneliness.
01:01:22Interestingly,
01:01:22human contact is now a luxury good,
01:01:26and especially during the pandemic,
01:01:29when we're socially isolated. So.
01:01:35Let's look at expectations so we
01:01:37all learn not to do this right.
01:01:40Stick a metal object in a electrical plug.
01:01:43I want you to think for a minute.
01:01:45How did you learn to do this?
01:01:48We're in audience.
01:01:49I can have you raise your hands.
01:01:51How many learn by classical conditioning?
01:01:53We stuck the metal object in
01:01:56the socket and got shocked.
01:01:59Well.
01:01:59When I do this in workshops,
01:02:02it's maybe one or two people in the audience,
01:02:06so Pavlov winner Nobel Prize for.
01:02:09Examining the mechanisms
01:02:10classical conditioning,
01:02:11but that's not how we learned this behavior.
01:02:14What about Albert Bandura
01:02:16and vicarious learning?
01:02:17You watched a sibling or a friend do this,
01:02:20while the maybe there's one
01:02:22or two in the audience.
01:02:27A third possibility is that we
01:02:29evolved to avoid electrical sockets.
01:02:31We have a module in our brain
01:02:33makes us afraid of snakes.
01:02:37Spiders and so forth,
01:02:39but not enough time has passed.
01:02:43To evolve to be afraid of electrical sockets,
01:02:45how do the rest of us learn?
01:02:49Verbal persuasion via trusted other.
01:02:53OK, this is where expectations
01:02:56are created and Lieberman in the
01:02:59book on the neural basis of soci
01:03:02Ality said our brains are designed
01:03:05to be influenced by others.
01:03:08Most of what we learn and what
01:03:11we know comes from the verbal
01:03:15persuasion by trusted others.
01:03:18And this is what we do in psychotherapy
01:03:20and in medicine is that there's a
01:03:23lot due to the verbal persuasion.
01:03:27By the trusted clinician so.
01:03:31The final way that the relationship
01:03:34may be healing is this idea of
01:03:39emotional coregulation you know we
01:03:42talk often in mental health about.
01:03:45Disorders due to emotional dysregulation
01:03:48either over regulated or under regulated,
01:03:52and this idea that we need to teach people
01:03:57skills in regulating on an individual basis.
01:04:02Their relationship is maybe misplaced by
01:04:05this idea that we regulate our affect.
01:04:10In the presence of.
01:04:13People that with whom we're intimate.
01:04:17So this is the idea of emotional
01:04:20Co regulation.
01:04:21So this gives you some idea about
01:04:25different ways that we regulate
01:04:28in dyads or social groups.
01:04:30This Co regulation is the unconscious.
01:04:34That's not a conscious process,
01:04:36but unconscious regulation
01:04:38of two peoples affect.
01:04:41So in a sense,
01:04:43this is what we do in healing practices
01:04:47is that we help to regulate the patient's
01:04:52affect in this unconscious process.
01:04:56So very quickly I think we have time to
01:04:59talk about this study that James Cohn,
01:05:03who was a PhD student at Wisconsin,
01:05:06did with his advisor Richie Davidson,
01:05:08who we probably all know.
01:05:12So Jim work in a PTSD clinic
01:05:18for his predoctoral.
01:05:20Internship in had a patient with PTSD.
01:05:25Longstanding, chronic was a Vietnam
01:05:29era veteran who refused to do the.
01:05:34Prolonged exposure,
01:05:35that was the treatment.
01:05:38That was administered in
01:05:40the clinic at the VA,
01:05:42so Jim didn't know what to do.
01:05:45The patient absolutely refused
01:05:47to do the treatment,
01:05:48so Jim said it will look come back next
01:05:52week and I'll talk to my supervisor.
01:05:55Will figure out what to do.
01:05:57So Supervisor said you just have to
01:06:00do a better job of explaining it.
01:06:03Prolonged exposure is the most
01:06:05evidence based treatment for PTSD,
01:06:07so when the patient returned the next week,
01:06:10Jim went out to the waiting room
01:06:13to get him in the.
01:06:15Patient brought along his wife and said
01:06:18I want her to attend the session with me,
01:06:22so Jim said no to himself.
01:06:24I don't know much about couples therapy, but.
01:06:27Sure, bring your wife to the treatment.
01:06:32So again,
01:06:33Jim explained prolonged exposure, the.
01:06:38Patient folded their arms across their
01:06:40chest and said, Nope, I'm not doing it.
01:06:43And just at that time,
01:06:45the patient's wife without saying anything.
01:06:48Touched.
01:06:49The the patient's arm.
01:06:52Looked at him and the patient said well.
01:06:56Maybe I'll do it and Jim said, holding the
01:07:00hand of an intimate person has an effect.
01:07:04So we did this study.
01:07:06Three conditions with Maritally
01:07:08satisfied women.
01:07:09He stressed them by putting them
01:07:12in a scanner.
01:07:13He also gave them a small shock
01:07:16so that they were.
01:07:21Aroused and agitated.
01:07:24Three conditions, no handholding.
01:07:26All the women also in one condition
01:07:29held the hand of a stranger,
01:07:32the researcher,
01:07:33and in the third condition they
01:07:35held their husbands and member.
01:07:37These were all merely satisfied with,
01:07:40and it turned out.
01:07:42Holding the hand of the spouse
01:07:45reduced arousal, it was a calming
01:07:49influence without saying anything,
01:07:51and the more merrily satisfied the woman was.
01:07:56The greater the effect, and of course,
01:08:00because it's a neuroscience lab,
01:08:02they they verified this with the brain scans.
01:08:06So again, what we do and in healing
01:08:10settings is this metaphorical handholding.
01:08:13It's the coregulation of affect.
01:08:17In our sessions.
01:08:19So in conclusion, relationship is
01:08:22an important component of healing.
01:08:25Two aspects of the relationship,
01:08:28there's warmth.
01:08:29And there's also competence.
01:08:34So the healer qualities and actions
01:08:37are critical in psychotherapy,
01:08:39but also in medicine.
01:08:41So attention to relationship is needed.
01:08:44But we need much more research
01:08:47on this so very few studies in.
01:08:51Placebos and in medicine,
01:08:53looking at the effects. Of.
01:08:56Relationship with the healer.
01:08:59So. Hopefully we have a
01:09:03little time to ask questions.
01:09:06So I'm going to stop sharing.
01:09:10And I think we have some
01:09:12time for those questions.
01:09:15Great thank you Doctor
01:09:16Wampole that was beautiful.
01:09:18It really should have brought us
01:09:20down to sort of the key elements
01:09:23of what goes on in that in that
01:09:26therapeutic relationship. So we are.
01:09:29This is open for questions.
01:09:30I know we have a few minutes.
01:09:32If anybody has questions you can use
01:09:34the chat box or you can also just
01:09:36raise your hand and unmute yourself.
01:09:38That would be OK as well.
01:09:44I'm sorry I couldn't be there in person,
01:09:47it's it's hard not to look at the
01:09:49audience and get your reaction
01:09:51to this, so I I hope I made my
01:09:55my points cogently let let me start as
01:09:58people are typing their questions in.
01:10:01One thing there were two
01:10:03thoughts I was having. Bruce.
01:10:05The first was just how far?
01:10:08You know we still have to go
01:10:10not just with the research,
01:10:12but also in the clinical space.
01:10:14We are challenged in this covid era of
01:10:16the need for support and for healing.
01:10:19And yet there's such a drive to
01:10:21sort of give somebody a pill or
01:10:23a quick session or something,
01:10:25and that is of course,
01:10:26contrary to what what you're talking about.
01:10:29So that was one thought I had,
01:10:31and you might have a comment about that.
01:10:34But the second thing that I
01:10:36was thinking about it is.
01:10:38Some of this seems nonspecific,
01:10:40and yet some aspects of of the in
01:10:43key ingredients in the relationship
01:10:45do seem kind of specific.
01:10:47So what about training do are these
01:10:50elements that that are can be
01:10:52learned and or is it very natural?
01:10:54Some people have it, some people don't.
01:10:57In terms of the warmth,
01:10:59certainly one could say that so
01:11:01just your thoughts about that.
01:11:03Yeah,
01:11:03great, and I have lots of thoughts
01:11:06'cause there are great questions.
01:11:08Very quickly about the relationship
01:11:10and in covid times, you know,
01:11:13we know and I showed the graph that the
01:11:17therapeutic alliance or relationship are
01:11:19highly related to outcomes in psychotherapy.
01:11:23Well, it turns out that that alliances is
01:11:26a stronger predictor in Internet based,
01:11:30not Tele medicine,
01:11:31but Internet based treatments where
01:11:33there's a limited relationship.
01:11:35But there is a relationship.
01:11:38So don't discount the relationship because
01:11:41you're doing treatments at a distance.
01:11:44It's really important to think
01:11:47about that relationship is still.
01:11:50Very critical.
01:11:52Not only desired,
01:11:54but important for outcomes with patients in
01:11:57this covid times OK to the second point,
01:12:01and I know it this best from
01:12:04the psychotherapy literature.
01:12:05It there is some basic emotional
01:12:08intelligence if you want to talk about it,
01:12:12that's necessary to be an
01:12:14effective therapist.
01:12:15Team Anderson as well as the group in
01:12:18Germany measured these facilitative
01:12:20interpersonal skills at the beginning of
01:12:23training of clinical psychology students.
01:12:26And it predicted the outcomes
01:12:28up to five years in the future.
01:12:31So this is the skills before
01:12:34they got any clinical training,
01:12:36so that's interesting.
01:12:37So that's kind of the substrate.
01:12:40Whether this is Geno type or or tutor,
01:12:43early childhood experiences
01:12:45and attachment and so forth.
01:12:47We don't really know,
01:12:49but it seems that that's important.
01:12:51But training also makes the difference.
01:12:54So we can train these skills.
01:12:57So I'm involved in an others are
01:13:00involved to breakdown the skills.
01:13:02Verbal fluency affect perception,
01:13:04warmth,
01:13:05caring these are all skills that
01:13:08can be taught.
01:13:09Anna really important,
01:13:11you know more and more.
01:13:13We deemphasized the relationship
01:13:15because in psychotherapy we're
01:13:17training evidence based treatments.
01:13:19You gotta get trained in.
01:13:21CBT or whatever protocol it
01:13:24is and we forget that the.
01:13:27Therapist delivering it is what
01:13:29makes it effective,
01:13:30and these are skills we can teach and so.
01:13:34You know,
01:13:35in medical training there is
01:13:37attention to relationship,
01:13:38but it's pretty cursory in my
01:13:41experience and I think we need
01:13:44to break these skills down.
01:13:48And. Teach them. Using deliberate
01:13:52practice, you know chess Masters.
01:13:57Performance musicians,
01:13:58athletes all use deliberate
01:13:59practice to become experts,
01:14:01and we do the same thing
01:14:03with interpersonal skills.
01:14:05It's not just some mystery thing,
01:14:07either God or don't.
01:14:09We can teach this great well sorry,
01:14:12it just gets me going.
01:14:14Another another lecture I I'm
01:14:16retired so I don't have an audience,
01:14:19so I'm glad to be able to,
01:14:22to profess about any of this. Now
01:14:25that's that's great. Thank you.
01:14:27So Sandy Bakens has asked what
01:14:29is known about the inverse
01:14:31relationship between effectiveness
01:14:33and experience that you described.
01:14:36Well, we've looked at therapist
01:14:38over their careers up to 18 years,
01:14:41and it looks like.
01:14:45Their effects decreased slightly overtime.
01:14:49On average, OK.
01:14:51There's some therapists who get better
01:14:53over the course of their careers,
01:14:55but there's some boot deteriorate,
01:14:57so on average they're not improving.
01:15:00I would say that the decrease is so small,
01:15:03let's not focus on that part, but it's
01:15:07clear that this differentiates therapist.
01:15:09From experts in other fields who gradually
01:15:12improve over the course of their careers.
01:15:15OK, they ask Pablo Casals.
01:15:17Why do you practice three or four years?
01:15:20You're the best.
01:15:22Tell us in the world, he says,
01:15:24I think I'm still improving.
01:15:27So you know,
01:15:28we could talk about this in greater detail.
01:15:31But therapists don't get good detailed
01:15:34feedback on what they're doing and.
01:15:37I don't know so much about physicians,
01:15:40but very little feedback about
01:15:42the interpersonal part of it.
01:15:44Most of the feedback would be technical
01:15:47skill rather than interpersonal feedback,
01:15:49and if you do get feedback.
01:15:52It's often very general.
01:15:54You know when I go to a physician
01:15:57I always get the consumer surveys
01:16:00afterwards because it's a good
01:16:03faith effort to improve this.
01:16:05What your satisfaction.
01:16:06But the the the level of feedback is
01:16:09useless just to know on a gross level
01:16:12patients are relatively satisfied
01:16:14or dissatisfied with my interaction.
01:16:17That doesn't tell me what I need to do.
01:16:21It has to be.
01:16:24Observed.
01:16:24Identified and practiced to get better.
01:16:30Great thank you.
01:16:31These are critical questions.
01:16:35Other comments or questions?
01:16:41I'm looking here. Please jump in
01:16:45'cause we can't see everyone.
01:16:46We still have a pretty large
01:16:48number of folks who are here.
01:16:59Regina, I don't see any hands up and
01:17:02right now you looks like there's
01:17:04one more just to comment in chat.
01:17:08Yes, the comment is. Thank you so much.
01:17:11I've been introducing your work to the
01:17:14Pgy three psychiatry residents at the
01:17:17beginning of their outpatient year.
01:17:19For the past few years,
01:17:21so that's a comment in an gratitude
01:17:24and referring to work. Yeah.
01:17:28And we have another comment,
01:17:30a question from Amit Oren.
01:17:33Does conducting psychotherapy
01:17:34on line dilute those factors
01:17:36that contribute to its efficacy?
01:17:38I know you commented on it briefly.
01:17:40Yeah, you know,
01:17:42we're just starting to see.
01:17:44Some outcome data from
01:17:48psychotherapy delivered.
01:17:52Electronically mediated over zoom or other.
01:17:56Platforms and it looks like that the
01:18:00efficacy of psychotherapy is not decreasing,
01:18:04so we all thought that the
01:18:07camera to camera interactions
01:18:09were going to be less personal.
01:18:13It's more difficult to.
01:18:16Detect and decode affect of the
01:18:19patient in these circumstances,
01:18:21but it looks like the outcomes are
01:18:25comparable and it also looks like the
01:18:29therapeutic factors are as important
01:18:32or even more important because.
01:18:35The patient still needs the
01:18:37interpersonal relationship.
01:18:38Those factors I talked about so
01:18:40clearly we're going to do more
01:18:43research and I'm involved in some
01:18:45projects that are looking at data
01:18:48from Tele Health and this way.
01:18:50But my guess is that these
01:18:52factors are even more important.
01:18:56Thank you, I know some people may
01:18:59have to leave, but we are still here
01:19:01and there's some questions coming in.
01:19:03So those who have to go obviously will
01:19:06will go ahead and take that leave.
01:19:08But we have one comment in question.
01:19:10It seems like physiologic effects like pain,
01:19:13antihistamine, IK effect positively
01:19:14related to the relationship.
01:19:15What is your sense of general outcomes
01:19:18within primary care like diabetes,
01:19:19hypertension, and the effect
01:19:21of the relationship there?
01:19:22Yeah, well we're getting a little bit
01:19:24out of my area of expertise which.
01:19:27I don't say very often,
01:19:29but you know there was this idea
01:19:32that placebos are going to affect
01:19:35some kinds of disorders more than
01:19:38others were surprised by the placebo
01:19:42effect in Parkinson's disease, but.
01:19:48There's debate about.
01:19:51The effects of placebos,
01:19:52which is a lot due to the
01:19:55relationship for some disorders.
01:19:57I mean you think hypertension.
01:20:00Would be. Unrelated,
01:20:01but there are both cultural effects
01:20:04or some countries were placebos
01:20:06were to a greater extent and
01:20:09hypertension than in other countries.
01:20:12But I think that in many of
01:20:14the areas we're talking about
01:20:17like hypertension and diabetes,
01:20:20that the effect of the relationship
01:20:23may be through adherence,
01:20:25because adherence to the
01:20:27regiments and protocols for these
01:20:29disorders are really critical.
01:20:31In a good relationship,
01:20:33Anna with a persuasive position
01:20:35is going to make a difference.
01:20:38So I would say relationship.
01:20:40You know I talked about
01:20:42the four ways that that.
01:20:45Relationship may work in these disorders.
01:20:48It may be that the adherence
01:20:51is the primary pathway.
01:20:54But I wouldn't discount
01:20:55the other pathways either.
01:20:58I was really taken up with your emotion,
01:21:01cool regulation notion and seems to
01:21:03be at the heart of this therapeutic
01:21:06or the healing relationship and your
01:21:08point about it being unconscious and
01:21:10I was wondering if it was you know
01:21:13in in which way are we thinking of
01:21:15it as unconscious and nonconscious?
01:21:17'cause there seems to be also a very
01:21:20the way you were talking about.
01:21:22It seems like there's a very dynamic
01:21:25transactional piece going on.
01:21:26On one level.
01:21:27There's of course conscious awareness
01:21:29of what's being said and.
01:21:31And on, but there's clearly the the
01:21:34perceptual effects are happening,
01:21:36and there's a response to that that occurs.
01:21:39So if you could say a little bit
01:21:42more about that,
01:21:43yeah, that's interesting.
01:21:46The people that study emotional Co regulation
01:21:50and there are a number of groups who are
01:21:54studying this in experimental situations.
01:21:57They talk about.
01:21:59It is not unconscious process,
01:22:01so there isn't a intentional effort by
01:22:05one of the partners to calm or to arouse.
01:22:09If there there needs to be some more arousal.
01:22:15We've noticed this in psychotherapy.
01:22:18There's two studies now that
01:22:20shows that there is Co regulation,
01:22:23but I think there is also
01:22:26an intentional effect.
01:22:27So when I do workshops,
01:22:30one of my favorite videos is Keith Dopson
01:22:34doing a panic induction with a panic patient.
01:22:38And he intentionally uses a
01:22:41very calm and soothing voice,
01:22:44so I think that's an example of an
01:22:48intentional attempt at emotional
01:22:50coregulation He he, as he describes himself,
01:22:54is very anxious about it.
01:22:56He's being filmed,
01:22:57the patients being induced to have
01:23:00a panic attack in the session.
01:23:03It's scary.
01:23:04But his voice is very calm,
01:23:08so that's a more intentional
01:23:10emotional Co regulation I think.
01:23:13And that's falls under Tim Anderson's
01:23:17affected half active modulation.
01:23:19So I think it's both in awareness
01:23:21or out of awareness unconscious,
01:23:24but also intentional.
01:23:25Yeah,
01:23:26great,
01:23:26so we
01:23:27have a couple of questions about technology.
01:23:29Patients do not have access to technology.
01:23:32How do you maintain a
01:23:34relationship based on voice only?
01:23:36I think your point just now
01:23:38is relevant there and then.
01:23:40Similarly, is there any difference
01:23:43in therapeutic alliance for
01:23:44psychotherapists who provide
01:23:46treatment using audio only or
01:23:47combination of video and audio?
01:23:50I haven't seen any studies of that.
01:23:52I mean, we're just starting to collect.
01:23:54Data I'm involved in a clinic in Calgary,
01:23:58which is the biggest provider in in Alberta?
01:24:03And. They're doing most of it video.
01:24:08I'm going to ask them if they do some audio,
01:24:13but it's interesting we adapt as
01:24:16humans to these technological ways of
01:24:19having a relationship remarkably well.
01:24:21I mean, it's surprising to many
01:24:24people that you know there's.
01:24:27Relationship using text video audio.
01:24:33Isn't it remarkable how adaptive we
01:24:36are in our social relationships?
01:24:41Yeah, it's as if there is a hunger for
01:24:44it and as we get limited one way or the
01:24:47other that we find alternate ways and
01:24:49then we explore them to the to the Max. We
01:24:53have another question,
01:24:54let me just one more thing about that.
01:24:56You know, there's this literary
01:24:58theory about the relationship we form
01:25:00with authors, and so even though.
01:25:02We don't have a relationship with
01:25:05the author by reading their novels,
01:25:08we put ourselves in that relationship
01:25:12and it's an interesting idea.
01:25:14About how we form.
01:25:19Not just relationships in the moment,
01:25:21but in our minds in various ways,
01:25:25we need more, more work in that area, yeah.
01:25:30With one more question, Clement Hill,
01:25:32what is the lowest hanging fruit in terms
01:25:35of improving clinical relationship skills?
01:25:37In other words, what one or two things
01:25:40could you recommend that could be most
01:25:42easily implemented with best efficacy?
01:25:45Well I contact is 1,
01:25:48so that's a relatively easy one.
01:25:50You got to be a little careful
01:25:53'cause there's some cultural groups
01:25:55where I contact in some diagnosis
01:25:58for some autism spectrum patients I
01:26:01contact must might be too intense,
01:26:04but eye contact is 1 to monitor.
01:26:07One for me is when critical
01:26:09points in treatment.
01:26:11I used the patients name.
01:26:13I never thought of this before.
01:26:16But it's a very intentional thing you can
01:26:18do and something that's very impactful.
01:26:21I've noticed it and patient responses.
01:26:24So those are two very quick ones.
01:26:29Great. Well, thank you so much.
01:26:33This is very fascinating, important,
01:26:35very much part of the bread and
01:26:38butter of the work that we do.
01:26:41It was also critical in terms of as
01:26:44I think about said, an acids work.
01:26:47There were elements in his
01:26:49interactions with students, but it,
01:26:51particularly in the therapeutic
01:26:53relationship which you know as you said,
01:26:55came naturally for him there was
01:26:58substrates that were natural,
01:26:59his warmth, his compassion in.
01:27:01Reaching out verbal fluency.
01:27:03Putting things together,
01:27:04which he did so brilliantly.
01:27:06But the skill with which he obviously
01:27:08then built on that it just it just
01:27:11comes together beautifully in in
01:27:13the way that you have, of course,
01:27:15broad data and quantified these
01:27:17really important elements of the
01:27:19psychotherapeutic relationship.
01:27:20So it was very apropos.
01:27:22I think Sid would have loved to hear this,
01:27:25and would have had a lot to say.
01:27:28Thank you so much,
01:27:29Doctor Wampold,
01:27:30for your presentation for getting us too.
01:27:33To think about these really critical
01:27:35elements of psychotherapy and
01:27:36for all of you to attend today.
01:27:38Thank you again.