These edited reports were originally posted to the Current Topics, Therapy Online, and Cyberpsychology list-servs, August 2006.  


2006 Convention Highlights:
Opening Session | Online Psychotherapy & Research | Psychological Vital Signs | Advances in Cognitive Therapy | Brock on Chaplin | Conversation with Aaron T. Beck - 2006 | Dr.Phil | 21st Century Ethics | Media: Town Hall '06


 

"Asynchronously Live" from New Orleans

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*DISCLAIMER*
I was very careful to take accurate notes during these presentations (including several pithy verbatim quotes), using handouts and/or photos of graphics to verify my notes. I apologize for any remaining errors or typos, and will be happy to immediately correct any mis-quotes, misattributions or mis-spellings brought to my attention. I welcome presenters' submission of additional online references which are relevant to (or mentioned in) these reports. Thanks, and... Enjoy! I hope you find this slice of psychology interesting and informative.

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. Nor was there any reference to Suler's wonderful description of the "online disinhibition effect"or any of the many books and articles generated by the International Society for Mental Health online and its members over the past decade.

Given that one speaker was stranded en route (leaving Dr. Michelle Newman to present on her specific area of interest, anxiety disorders), there was time at the end for an interesting discussion, moderated by the chair, Dr. Lynn Collins. There seemed to be increased audience participation over what had been seen in the past at presentations on similar topics. In that respect, along with the presentation of some recent published research, it was a positive experience even for those who have been writing about some of these issues for many years, and now just a bit surprised to see some of these ideas presented as if newly discovered. Online experience has been written about in depth for over a decade now! But of course there is so much more to learn, and so much power of the Net to be harnessed, understood, and explained in parsimonious ways which accommodate "daily life" in the 21st Century. We were happy to see an increasingly interested and sophisticated audience.

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*Note/Disclaimer* - These reports are from verbatim notes - I don't have everyone's names spelled out in front of me, though, and will have to add/correct a few prior to publication of these posts as complete articles! (Making it more difficult, a number of participants were unable to present, given chaos on opening days, in the airports.) Sorry about that... As always, I base these reports on extemporaneous verbatim notes along with presentation graphics and/or handouts, and endeavor to present this as accurately as possible; if there are any errors, I welcome correction!

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Session # 1137 Online Clinical Research - Advantages, Challenges, & Ethical Issues

There were two presenters on hand, one a university faculty (Dr. Heidi Keller) and the other (Mary Tramel?) an award-winning graduate student. The former addressed some of the design methodological issues while the latter covered ethics and practical concerns of conducting research. One participant was missing.

Just a few of the issues raised were the need to avoid contaminating future results when running, say, a study online, for example being sure word of mouth from one subject to the next doesn't exert an effect. Then there were issues of both design and ethics, for example trying to study chat room behavior under different conditions, which is not as easy at it might seem, as there needs to be disclosure, and the presence of researchers could create serious problems, for the group dynamics (e.g., trust) as well as contaminating results.

Some examples of how privacy can be violated rather easily were offered, and a study was cited (Hudson & Bruckman?) which explored how participants in chat rooms objected to being part of a research study. There were differences noted in terms of real effects on the groups, which varied between moderated and unmoderated chat rooms. In either case, the presence of researchers "can change the atmosphere" and prevent a true naturalistic study.

Examples of design challenges included sampling error, subject fraud, measurement, and an array of ethical issues, some noted above. Measurement can be muddied by extraneous factors not easily picked up, online. (Is a subject intoxicated at the time? In a noisy Internet Cafe? Using high versus slow-speed Internet?)

One of the ethical issues, relating to privacy/confidentiality is that of anonymity. Some discussion mentioned the pros and cons of allowing some anonymity (or up to a point), and the example was given of how even Microsoft had to forego written signatures on licenses and go with an "I accept" button as electronic signature.

The second presenter described different types of online studies, ranging from the 'CyberSurvey' to naturalistic cyberethnographic studies, to multi-method studies. Technical issues were discussed too: What if someone clicks "submit" a few times, due to connection problems or deliberate efforts to submit more than once?

Some demographics were discussed which have implications for International research, should that be a goal; 91% of the "Internet population" lives in advantaged countries, but that's at only 19% of the world's population in RL. (The digital divide is alive and well!)

Issues of duty-to-warn and other hot ethical issues were raised, citing a book by Humphreys & Pittenger, 2003 - sp? (I have the reference somewhere, will correct it before any publication in article form).

An interesting presentation.

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Symposium #1201 - Trauma, Play, Illusion, Reality -- Lessons from Charlie Chaplin

This was fun in addition to being a powerful stimulant in thinking about such concepts as humor, stress, repression, supression, and politics. Dr. Albert Brok presented several film clips of Charlie Chaplin films from early in his career. As context for the interplay between humor and trauma, a sensitive and topical issue, Dr. Brok noted how unlikely it is to see comedy about terror acts such as that of 9/11. There are situations which can be made light of, to master, like a child does through play, while other aspects of experience demand more direct examination. In parallel, a psychoanalyst might find value in not only exploring "working alliance", but also "play alliance", examining both client communication as well as countertransference. Citing Winnicott, the discussion focused briefly on how the child utilizes play to achieve a feeling of safety, at a stage where s/he is internalizing the mother as "being there" even if not immediately visible. He went on to describe various paradoxes, such as the freedom of play, yet constrained by unspoken rules. "There's no need to be conscious of rules and structure, but it's there", except perhaps with psychotic process.

An interesting observation was that "play can be killed by facts sometimes", and a thread of the presentation, which was largely the Chaplin clips, was how as Chaplin's films became more socially attuned and politically contentious, he was considered less funny as people were focused on the "facts" of his mocking the industrial revolution, or Nazism, or whatever. "The closer a film is to our own sense of fact and reality, the harder it is to see humor". Examples of movies which really tested the ability to find humor in sadness included "Life is Beautiful".

Interwoven between the Chaplin scenes and history, Dr. Brok encouraged thinking about the "play alliance" as well as the "working alliance". The play interaction can be particularly powerful insofar as "here and now" analysis (just as transference interpretation may be done here and now too, but usually at the more serious level). Yet in the Chaplin clips, Dr. Brok noted how at points it seemed Chaplin was showing his 2-year old side, or his exposure to psychosis as a child. As for the social context, "social realism reduced the efficacy of his communication with the audience; play and trauma don't easily co-exist".

Various anecdotes about Chaplin's life were shared, and some very funny (still) clips drew laughs from a 2006 audience.



This was a fun event (as it was meant to be) but also thought provoking and refreshing to see Chaplin approached through a psychoanalytic/object relations point of view.

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Presidential Address: Charles Spielberger -
Psychological Vital Signs: Anxiety, Anger, Depression, and Curiosity

Dr. Spielberger is a legend in psychology, a prolific researcher in anxiety and a longtime leader of APA.

As the name suggests, "vital signs" is derived from medicine -- blood pressure, in particular, as it is one of the indices studied with relation to anger. One of the many studies he cited concerned DBP among angry people, and he also discussed some questionnaire items which correlated with heart disease, and the "Type A" behaviors associated with heart risks.

Dr. Spielberger covered many aspects of anger, anger management, and depression. He highlighted the public awareness of anxiety (including a nod towards Mel Brooks' classic comedy/satire "High Anxiety") and cited Rosenfeld (1999, p.10) who called depression "the common cold of mental health problems that strikes the rich and the poor as well as the young and the old". He traced some of humanity's concern with anger and depression back to ancient Greek literature, and moved forward through the modern research into state-trait models of anxiety and anger, as well as a societal context stemming from what Camus labeled as a "Century of Fear". He also mentioned some of the research highlighting how men and women react differently in response to depression and anger.

I was interested in curiosity, seeing it as a sign of motivation and interest, prognostically good. He did not have time to expound on this at length, though he noted that "curiosity is something which psychology has neglected for a long time". He used the allegory of Pandora's Box, reminding us that although once opened the box could not be closed, left out of the box was still "hope".

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Poster Sessions -

I visited Clay Tucker-Ladd, who was representing a group of poster presenters involved with online support groups and marketing (his own efforts being with online self-help). He was presenting a paper describing the feedback he has received over an 8-year period from those accessing his Psychological Self-Help pages, which draw about 10,000 visits per month. Of the respondents, over 90% (Total N = 724) found his self-help offerings to be "comprehensive", "useful", and "understandable". Dr. Tucker-Ladd's pioneering Psychological Self-Help e-book has been available free of cost for over decade now, currently at www.psychologicalselfhelp.org .

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Opening Session

Drs. Koocher (President) and Anderson (CEO) welcomed APA members and re-affirmed APA's commitment to the city of New Orleans, this being only the second convention post-Katrina, and right in the very same Convention Center which the news media presented to the world amidst a scene of devastation and desperation. James Quillin, Ph.D., President of Louisiana Psych Association appeared to be extremely moved as he thanked the audience. (I cannot stress enough how genuine is the feeling among locals of gratitude for people coming back and spending time and money in N.O. Everyone has a story, some fortunate, some not, but talk about resilience in the Big Easy: I hear over and over, "Well, I'm here!".) One feels the hope, and can sense the trauma too. There were so many thank you's....

"The city runs on tourism. Your very presence here will contribute over 17 Million Dollars to the local economy", said the LPA president, who also noted so many other kinds of helping hands. "It makes me proud to be one of you."

The mayor could not attend but sent a proclamation, declaring Aug 6-13 Psychology Week in the City of New Orleans.

The lieutenant governor, Mitch Landrieu, was vibrant, poised, and funny, and also offered a "deep felt thank you", noting that "you could have chosen to go somewhere else" after Katrina. "We're in the convention business; our economy is in large part based on tourism. Pre-Katrina it was a 9.7 Billion dollar industry, creating 126,000 jobs." He said it may look normal still, around the French Quarter, but if one drives around (as I did) it can still hit home (no pun intended), how much devastation took place, and the enormity of the re-building effort.

Before digressing further, and falling asleep at the keyboard, I will just mention for now that the Keynote speaker was awesome, and I confess I was only slightly aware of her accomplishments, which are impressive.

Anna Deavere Smith began by asking if anyone knew of Studs Terkel, and then launched into an impression of him telling how he was born in 1912, the year the Titanic went down. She told personal anecdotes -- of being told, for example, "if you say something often enough, it becomes you", and speaking about her own history, originally seeing herself as going out and (like Terkel) interviewing bull riders and pig farmers. But (similar to Charlie Chaplin being more popular when funny), "nobody was interested in what I did until I got into race relationships". She did a skit from Fire in the Mirror about an observant Jew and Shabbas in Crown Heights, a story about Africa, and a dialogue about the "resilience of the human body" before tying it all into human resilience in general. Along the way, she put on a show which had the audience spellbound, at one point going out in the audience and asking someone for a hug. Wow. Powerful.

That is going to do it for a flavor of today here at APA in the Big Easy. Just came from dinner complete with Bananas Foster at Brennan's. (And a Mother's PoBoy for lunch). Time to go back on South Beach Diet! ;-)

In a few hours (time to sleep!) I'll be seeing what promises to be a lively event: Dr. Phil will discuss his work with peers (for the first time!). That should be interesting indeed.

Another full day tomorrow, culminating in a performance by the Preservation Hall Jazz Band.

Signing off, (asynchronously) Live from New Orleans.

Michael
aka "Dr. Mike" (not likely to be confused with Dr. Phil!)


Asynchronously Live from APA
August 11, 2006 (Fri)

Greetings from New Orleans, the Big Easy.

In reverse order, I've just ended a long day, and have been reflecting on the many contrasts to be seen and felt in N.O.

While waiting for a colleague to come out from an incredible concert by the Preservation Hall Jazz Band, I spoke with a NOPD police officer. I mentioned that this morning Dr. Phil had described a benefit he did yesterday for the first responders of NO, to help with children's education costs among other things. The officer said they'd heard about this but that rank and file were wary about money going to the police department rather than directly to the officers, given experience with government bureaucracy etc. He said he was in fact on duty last year during Katrina, working 12-14 hour shifts and then, like 80% of officers, finding himself with no place to go when the workday ended. (There is still a huge trailer park primarily for first responders). He compared the trauma here with that of 9/11, through the filter of horizontal versus vertical disaster zones. Like everyone else, he agreed that many people have been quite resilient and hopeful, thankful to be alive, while others have been deeply scarred in one way or another. N.O. 8/2006.

Back to APA specifically, in a moment; though for any psychologist not to register the realities of life in New Orleans would be remiss as a professional and human being...

Again, I and many colleagues have seen over and over how eager and grateful local residents are, to see life getting back to something like "normal". The conversation at Mother's is about mortgages and electricity and FEMA, and the flower cart lady on Bourbon Street smiles and talks about the survivors who met at Johnny ("We Never Closed") Whites, and the taxi driver grumbles about FEMA and the corps of engineers. And 10x30 foot trailers are everywhere, beyond the French Quarter.

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Invited Address: Dr. Phil



The day began with an invited address by "Dr. Phil" McGraw, who addressed the audience on an open stage rather than standing behind a podium. He was introduced with a video highlighting his many appearances as a celebrity as well as clips from his own show, highlighting his use of powerful examples (live and on video) to educate the public about anorexia, OCD, schizophrenia, and other serious mental illness.

Dr. Phil then recounted his career while also sharing some personal anecdotes about his upbringing, interests, and recent experiences with tabloids. He was clearly proud to share with colleagues his many efforts at publicizing psychology and "using his platform" to do positive things. Even among some skeptics, he seemed totally commited to his mission, and unapologetic about the "entertainment" aspects of his show, noting that one needs to engage an audience to keep it, and that behind the scenes those who seek his input and/or help are both screened at the front end and debriefed/referred after the show is taped.

Dr. Phil underscored how he feels he is now doing what he believes he was meant to do, and how he has tremendous respect for psychology. His father in fact became a psychologist late in life. (Other family tidbit: His son is getting married tomorrow!) He remembers that psychology way-back-when was often seen as an underling of medicine, as 2nd class, not "real doctors". While he resented this he is now "totally cured" and is in awe of how "we have an interesting role in this world". He had worked at first as a psych associate, and worked for 12 years in a hospital practice, oriented around neurological pain and its treatment. Later he worked as an expert for litigation. "I grew up as a jock", he said, "so I really like clear outcomes. You can't look at x-rays of depression. I liked litigation because there was a clear outcome." Now he has taken on a much bigger challenge as he focuses on dealing with "the silent epidemics of our time", because he has the opportunity to do it. Wouldn't you, he asked, if at age 50 someone came along and said, "how would you like a national platform?" (In his case he was encouraged and nurtured by Oprah Winfrey.) So he wound up with "a show based on psychological science that matters to people who care" and his constant goal is to take a topic and "deal with it with dignity and respect.... a psychosocial show that portrays real issues". He repeated a mantra which I have often cited myself: Science informs practice and practice informs science. Now "what if we could provide a forum about mental health, on a daily basis, and deliver it every day? Would anybody watch a show like that? The pros all said no", and that was rather intimidating given how "Hollywood has a 13-week mentality" in the first place.

Dr. Phil was adamant in clearly stating that on his show "we're not going to provide an 8-minute cure. I understand psychotherapy and that's not what I'm trying to do."

Returning to the here and now, Dr. Phil said he's been here in N.O. all week, filming and presenting benefits, including the one last night for first-responders and their children. "This disaster isn't over", he said, and we know this to be true. He has been speaking with families, including one with 9 people living now in a 10x30 trailer.

In terms of treatment providers, "before there were 196 practicing psychiatrists. Twenty-two returned. We're at the height of trauma, and the low point of services."

Demographically, 2/3 of females report chronic acute anxiety or severe depression, and this is true for 50% of children. "How many people read my book?", he asked, and only a few hands went up. "How many people see my show?" Usually a wave of hands results when he asks the 2nd question, and he underscored how people learn via access to media, not necessarily from reading books. He sees television as a means of spreading the word. "We have a helping profession that needs to be de-mystified."

Responding to the impression some have that he's doing "entertainment", Dr. Phil replies, "I hope so!". "Don't you just talk common sense?". Again, "I hope so! Common sense is just not that common any more!" As for his stock phrases he's often caricatured for, he said "'How's that working out for you?' I didn't mean that to be a mantra. It just made sense to me. If something isn't working don't do it! It's like the old joke where a patient tells the doctor his arm hurts when he moves it like this, and the doctor says, 'so don't do it'." [My waitress at the Red Fish Grill that evening asked me, while enjoying a delicious salad, "So how's that working out for you?"]

Doing the Dr. Phil show is "not just an hour a day" of work like he said his mother thinks. "I work from 7AM til 5". He has a 250 person staff and $40M/year budget. ("Hollywood isn't cheap!")

Dr. Phil had 170,000 audience sets so far and 5000 guests. "The topics we get come from the audience". In choosing the show's focus, Dr. Phil asks, "What's the take-away?" Lessons about parenting, self-esteem, money, conflict, and mental illness top his list of most important and accessible topics. Each segment is completely researched and subject to a full lit review, plus scrutiny and input from a 12-person advisory board. We bring in the leading experts. I might not always agree, and I'll say so if I don't.... How do we find our guests? They all write in." His policy is to never accept guests currently in treatment without written consent by the provider attesting that it would not likely be harmful to the treatment. Minors are always protected as well.

Why would people expose their angst to the world via the Dr. Phil show?

"Why would people do it? (1) Some people aren't sensitive to it: We all have problems... (2) People think I have a unique perspective they want to hear; (3) Some people are just exhibitionistic. Thank goodness for that! Otherwise it would just be me talking..."

As for the debriefing and/or referral to treatment after a show, "I can be an emotional compass but the real work doesn't start until they go home"

Dr. Phil shared his formula for success: "I tell a compelling story through videos to which I then react in some meaningful fashion. That's what people will watch." He gave some examples of very dramatic and emotionally arousing clips (e.g., a woman seeing her baby abducted in a car theft; a navy SEAL who accidentally shot his brother, parents feeling guilty about fighting in front of a child). So the vehicle is "a compelling story with a solid, meaningful direction to follow". Obviously it worked for him as he is now living in Beverly Hills with people trying to hop the fence to his property, and bizarre stories in the tabloids each week ("Oprah and me are having a 3-headed baby"). He also ridiculed reports of his intimate involvement in the lives of some celebrities who "I wouldn't know if they parked their trailer in my driveway"

Dr. McGraw (his real name, and reflecting a real Ph.D. in psychology) seemed quite earnest in his reflections about how he has been blessed by the opportunity he has. "I've had the privilege of bringing my message" and partnering with various organizations to improve people's lives. "Could I do better? No question. We're starting our 5th season next month. But the times are a changin'. When I was growing up there were 3 [TV] channels." Now there are hundreds of choices. Similarly, a child can listen to many voices. "We might not be the only voice in our children, but we need to be the *best* voice. As for me, know that I take this platform very seriously. People know the truth when they hear it. Sure, I'm not for everybody. That's why we have a remote control." Lastly he repeated emphatically, "I love psychology. It has been my life and I have tremendous respect for y'all. That's my story and I'm sticking to it."

And so said Dr. Phil McGraw.... who was then praised for his many achievements and given an award by APA President, Dr. Gerald Koocher.

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From that I went to hear Drs. Judith and Aaron T. Beck (daughter and father) speak on advances in Cognitive Therapy.
 
Plenary Address #2163
Advances in Cognitive Therapy



Anyone familiar with psychology and/or my web site knows how important Beck is -- "father" to the field of cognitive therapy, and renowned for his work with measuring and treating depression. Daughter Judith has become a leader in this field as well.

Dr. ("Tim") Beck began by recalling Isaac Newton's comment that if he was able to see farther than others it was only due to his standing on the shoulders of others. He said that his vision is supported by the foundations of Horneye, Sullivan, Kelly and others -- (jokingly adding) "you can leave Albert Ellis out". [They have had a friendly rivalry over the years, and later Beck praised Ellis' contribution sincerely.]

Beck repeated his famous axiom that "having a good theory doesn't mean anything without empirical evidence to support it". He is very pleased to report that 90% of studies reported in a recent meta analysis supported his theory. For him a big goal now is to test out treatment (especially looking at relapse rates) using the "gold standard" of antidepressant medication. He cited 8 studies citing the value of cognitive therapy. There was another important finding which was that experienced therapists did better than ADM (anti-depressant medication) alone. He also elaborated how nonspecifics and interpersonal skill are basic aspects of what makes an effective therapist.

Briefly here, Beck described the process of "chain analysis" whereby an analysis is made of where and when patients escalate in anxiety or depression, and described a model for treatment which begins with establishing a "safety card" and then entering a working phase of identifying self-defeating responses to stress. One study identified a 50% reduction in suicide with his approach. At the end he was asked about the difference between grieving and depression, and he spoke about depression as a "tremendous deterioration in sense of self, and hopefulness about the future, whereas with grieving a person is more focused on the loss and looking back.

Judith Beck, in underscoring the central role of dialogue about beliefs, mentioned her father's recent conversations (about a year ago) with the Dali Llama where the two shared some thoughts on Buddhism and cognitive belief systems.

Like her father, Dr. Judith Beck was very research oriented, in addition to being excited about the successes seen in clinical treatment, using specific cognitive therapy techniques. She defined "cognitive therapy" in terms of working with specific constellations of individual beliefs, and drew from many techniques, ranging from some which resemble Ellis' "mud wrestling" approach with self-harming beliefs, to some more complex protocols like Linehan's DBT, which emphasize awareness of there being middle grounds and that situations need not require catastrophizing responses. She underscored the importance of working with underlying, often rigid "core beliefs" such as feeling of being "unloveable and worthless", illustrating with a diagram how (especially with Axis II personalities), there may be a tendency to only allow in negative percepts, through a direct channel, while "positives are qualified, or unheard". Often the resulting coping strategies may reflect a belief that "if I show people my true self, people will dislike me." She underscored how it is a gross simplification to describe CT as simply "changing thinking" without having a historical or interpersonal context. A really good cognitive therapist, she said, will "conceptualize accurately, in an empathic way", and utilize a strong alliance, but orienting towards "setting an agenda with every session - 'what problem do you want help with today?'".

In terms of outcome, Dr. Beck's research undertakings highlighted how people who had CT also had 1/2 the relapse rate of those treated with meds alone. (Her father presented the results of quite a few controlled studies as well.)

I do want to share the url (web address) of the site mentioned by Judith Beck as the authoritative source of some of her presentation material (and home to the "world's most interesting list-serv") -- at the Academy of Cognitive Therapy (of which she is President), at http://www.academyofct.org .

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I've mentioned that it's hard to be in 2 places at once, often desirable at these huge conferences. It is even more challenging with a convention hall the size of some small countries! Well, in the next 2 hours I squeezed in a Town Hall Meeting and Presidential Address. In order...
 
Presidential Address (#2240) - Koocher

"A Primer on 21st Century Ethics"

This was engaging and included several funny cartoons (e.g., a morphing .gif image of a well-known leader) as well as some very serious discussion about confidentiality and privacy in particular -- not only in regard to therapy but also with various governmental tools already being used to either gather personal information or to defend against hacking. Dr. Koocher, APA President with a long and distinguished career, spoke about "tele-psychology" and the "4 C's" which comprise the core concerns about online consultation: Contracting, Competence, Confidentiality, and Control.

The last issue has to do with the still-open question of who might regulate this area. Other questions:

How do we obtain informed consent? How often do we need to update a site? Do we need to be available 24/7? Will our fee structures change? Will we have emergency backup planning? How will we train? He spoke about the existing standards (which he helped develop) and noted intentional areas of vagueness where there are still emerging issues and practices, as well as liability issues. And he described some insidious sounding software which can be used to intentionally breach computer security (by government mostly) - for example the infamous Carnivore program.

Dr. Koocher asked the question some of us have continued to debate for some years now -- On the Internet, "where is therapy taking place?". Dr. Koocher noted that there is no consistency from place to place. He highlighted the twin mandates of helping people and doing no harm, adding incidentally that the Hippocratic Oath has no mention in it of informed consent. Following that thought led to identifying some implications for involuntary submission to information gathering, as well identifying an impact on the work of some "invisible psychologists" such as professional experts working for attorneys, or police departments. Several court cases were mentioned to provide examples. In some instances, the work being asked seems so troubling that one wonders, "should psychologists decline" some roles (e.g., military) in the same way anesthetists have refused to assist in executions?

Finally (for now) the audience was reminded, in the context of the Brave New (electronic) World, that in order to function professionally in the near future, one will need (in the US) a provider enumeration ID.

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As for being 2 places at once, the last address ended after 50 minutes while another presentation still had an hour to go, so I went to that just as one speaker was ending and another -- Dr. Judy -- was about to begin.
 
Town Hall Meeting (Div 46, Frank Farley moderating, from the floor): Sex, Love and Psychology

Who can resist a title like that?

Dr. Judy Kuriansky, nationally syndicated radio host and pioneering researcher in the areas of love, sex, and relationships, presented a very engaging overview of current societal trends, both in marketing and social behavior. She touched on how the drug companies were disappointed by Viagra's not being effective for women, mentioned some negative reactions to some new medications, and spoke about the new approach towards stimulating pleasure centers in the brain rather than focusing on blood flow to organs. In passing she also commented on the psychological differences between genders, as well as the latest fads on campus (e.g., what Dr. Phil Zimbardo, in the audience, referred to as "friends with benefits") and cross-cultural trends in addressing both sexuality for its own sake, as well as birth control and AIDS protection around the globe. She mentioned some of the approaches which have have shown to be relatively effective (e.g., the ABC method - abstinence, being faithful, condom use) as well as some of the approaches which are counter-productive (but reflect political or cultural mores). There were some lively comments and provocative questions from this energetic audience.

Although I'd missed most of first part of the presentation by the prolific writer/researcher Lisa Firestone, I received a handout, which cites extensive work in areas of both love and sexuality, as well as in suicide prevention, much of this under the auspices of the Glendon organization, which has a densely packed website, accessible at www.glendon.org .

That's the essence of (the second hour) of this 2-hour "conversation hour". And that ends this day of convention activities.

Tomorrow, very early, is another in a series of "Conversations with Aaron Beck".

As the sounds of the Preservation Hall Jazz Band drift through my weary brain...



To be continued...

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As always I want to emphasize that I take verbatim notes and refer to visual graphics and handouts, as well as referring to the oral presentation, all in effort to try to be as accurate as possible while presenting a report with the flavor of the event as well. If I inadvertently err -- in spelling, presenting a statistic or citation, etc. -- I will be grateful for having any such errors brought to my attention and of course will make corrections immediately.
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Asynchronously Live... from New Orleans, the APA Convention
12 August 2006


Today began very early (ugh!) but was worth the effort as this morning's main event (for me) was what has become an annual tradition, a Conversation with Aaron Beck, "father of cognitive therapy", moderated by APA/media luminary Frank Farley. (In the past Albert Ellis has participated as well, but he is now convalescing, though described today as so "resilient" that at age 90 he is beginning a new book on love.)

By chance, while Ellis was not here to provide counterpoint (not to mention entertainment), we were fortunate that the legendary Bandura was in the audience and participated as well. Now we had, as Dr. Farley described, the greatest living psychiatrist and the greatest living psychologist, in the same place, conversing with us today. It really was a conversation too, expanded to 2 hours this year, and with Dr. Beck comfortable pausing between his responses to questions posed by Farley to take follow-up questions from the audience. As always, when it ended Dr. Beck was mobbed with admirers wishing photos with him, autographs, and answers to questions about all sorts of things.

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A Conversation with Aaron T. Beck
12 August 2006

This very special presentation began with Dr. Frank Farley leading the audience in singing Happy Birthday (his 85th) to Dr. Beck. Farley then noted that he'd observed a hot discussion between Beck and another person sitting in the front row, Albert Bandura, and prompted the two legends to plan for a full-session discussion between the two of them in this forum next year. They agreed! You're hearing it here first.

Beck, referring in part to a discussion about theory and practice which he'd participated in the previous day (with his daughter as well), explained why it was necessary to develop a new framework beyond psychoanalytic thought, which was a question asked but only partially answered the previous day. He'd reflected on it and decided that the main departure, even though he fully believed in the importance of many aspects of the psychodynamically oriented approach including exploring some of the origins of what eventually become dysfunctional beliefs, psychoanalysis is oriented around Freud's own contention that "the cardinal feature of psychoanalysis is the focus on repression and the unconscious". Reaction formation and the other defenses which ward off painful/unacceptable unconscious experience comprise "the blueprint in which all the psychoanalytic and psychodynamic therapies are based." Of course there are similarities in approach, as both psychodynamic therapies and his own style of cognitive therapy are "both introspective therapies.... Freud put patients on the couch and used free association [and interpretation] so that repression would be identified. New therapies see a continuum. Some things are always going to be unconscious," he said, adding that some things (such as unimportant bodily states) *should* remain unconscious rather than cluttering up one's conscious awareness.

There are variations in how deep one can or should go in order to explore aspects which might fall under the general heading of transference, or resistance. For example, "If I'm talking right now, my thinking might be 'I want to get my point across'. And underneath that: 'I hope I'm getting my point across'. And under that, 'What a nice audience!'" But, it's not possible to focus on everything, all the time. A case study was presented as an example, following his own illustration above. A patient was asked what she was thinking. "I want to impress you." And how was she feeling? "Anxious". Beck proceeded to explore this and found that the patient also confessed to "a little fleeting thought that I might be boring you". Beck immediately gleaned important information from this, relevant to underlying beliefs and/or sense of self, and could see from this very early-on exploration of "transference" that this was an example of "thinking which is 'correctable' ... We try to correct dysfunctional thinking."

Beck feels there is "not always a need to discuss parents" or other aspects of childhood, though of course many beliefs do stem from earlier experience. "We try to get transference out of the way in the first 5 minutes" rather than using it as an ongoing vehicle for interpretation. He might ask "what are you thinking?"

Patient: "I'm annoyed I've been kept waiting." OR ... "You took me so quickly I must be seen as really sick". A lot of information is derived in this manner.

Beck presented several other case studies, which clearly reflected both his clinical acumen as well as his use of cognitive therapy in a way which draws on both subjective and objective experience. In one case he described how he did role-playing with a woman who felt rejected and devalued after her father died, as her mother seemed to withhold further love. Beck role-played the mother at first, being self-centered in describing her pain at losing her husband. Then the patient was asked to role-play her mother and was able to see now, her mother's point of view: "Yes [Mother], I realize how bad you felt when Daddy died, but think how it affected me too." It was like pricking an abscess, as she understood suddenly the dynamics behind her feelings and beliefs of being devalued. [Here Beck noted some related approaches such as "schema focused therapy".]

Someone in the audience asked how someone might know what sort of psychologist to choose, as a potential client. Beck noted that "the usual resources are on the Internet" -- just type in "psychotherapy" on Google and it will lead to sources such as the NIMH and other clearinghouses which discuss various types of available treatments.

Dr. Farley introduced the very topical and important area of terrorism (this was a week in which a huge plot was intercepted and US airports became tangled up in new security measures). Beck said that while he's not an authority in this specific area, it seems to him that hostility can be a defense. "When I look at 2 warring parties, what strikes me is that they have identical images of the other: We're saints, they're sinners, we're all good, they're all bad." (In passing, he later mentioned Kernberg and BPD concepts, and this example of "splitting" seems very relevant). The dominant belief is "we're all good, they're all bad". Returning afterwards to watch the international news, including interviews with citizenry in the Middle East, this us/them good/bad split is clear to see.

"With a moderate threat we [humans] try to moderate them. With extreme threat we try to exterminate it." He described how a colleague in Pakistan interviewed a Jihadist in Pakistan, and heard how "America is filled with expansionist people" and so on, all negative. In Europe there is negative opinion too, though less extreme. As for the terrorist groups, Beck reminded us that "groups are made up of individuals, and collective thinking can feature the same extreme reasoning. If you want it broken down to bare bones, it's a matter of survival." He cited one example of a leader scaring and rallying people: Hitler. "Nothing will get people aroused so much as thinking here is a danger to their self, or collective society." He mentioned that there are some DBT/empathy groups designed to bring groups together.

There was a question next about: schizophrenia.

"That's a very exciting area," replied Beck. "Cognitive therapy actually has a great deal to offer in terms of treating schizophrenia." Beck described a major study having been done in the UK and producing very powerful results. In fact, he mentioned several studies which compared CBT with or without pharmacological treatment.

A $10 million controlled study by Kady highlighted how 1/2 of all psychiatric patients don't take their medications anyway, out of discomfort, concerns about weight gain, Parkinson-like symptoms, or feelings of being drugged. As it happens, there is some evidence also that psychotherapy can help even without drugs, despite schizophrenia being a biological disease. Four subjects in the study did as well as those on medication, though they were not.

A Cornell study on brain changes found differences in the reactivity of the amygdala after undergoing a course of cognitive intervention.

Here a member of the audience asked about implications for children, whose developing brains are quite elastic. Beck cited 18 studies with depressed children whose parents were depressed as well.

A question was asked about computer based program, particularly a CD developed by the Wrights and Dr.(Aaron) Beck, who described how this CD been "used as a way of demonstrating automatic negative thinking". They found that utilizing the CD cut down subsequent visits (for f2f treatment) by 1/2. "So computer-assisted approaches can be effective. The Internet is being used effectively too, in some places where there are no therapists available: There are ways of transporting cognitive therapy across the airwaves."

Dr. Farley commented about various meetings of the minds, such as Beck and Bandura today, but also a few years back when Beck met and then interviewed John Nash, the brilliant -- and schizophrenic -- mathematician who was the subject of "My Beautiful Mind". On first meeting, Nash seemed quite "strange" and tangential. Two years later Beck had dinner with him and he seemed entirely "normal" despite being off of medication. Beck wanted to know the secret, and sought to do a very careful and sensitive interview/evaluation without any great risk of setting anything off. He found Nash to be quite "stable" with no evidence of fuzziness or cognitive slippage. So how did he recover? Beck reviewed the psychiatric history and symptomology. Not long ago, Nash had been in Europe, believing that he was on a mission to save the world. While he thought he had a proper goal, his wife and other significant others became estranged. He reasoned to himself that perhaps even though he was right in his goal, he should let it go, as "there were consequences". By the time the book (on which the movie was based) was written, Nash was no longer overtly psychotic.

Someone suggested to Beck that "maybe he was doing cognitive therapy on himself". Beck was of course curious about this prospect and eager to hear more from Nash himself. Nash was in fact happy to talk about himself, thinking it might help others. In addition he wanted to resume his lecturing in the area of math, in which he was brilliant. He was feeling more confident of having his thinking skills at his disposal now. He told Beck that before he knew he had gotten sick he wrote what he felt was a great article, which in fact received praise by reviewers. But later, some grad students pointed out serious flaws. At this point there ensued a bit of discussion of about schizophrenia and the family, Farley noting that Einstein's son was schizophrenic and was never visited by his father.

Dr. Farley turned next to the topic of suicide (which had been discussed the day before in Beck's presentation with his daughter.) Asked to briefly comment on the topic, Beck noted that in his experience, "often as depression clears up, suicidal ideation clears up. To prevent suicide you have to address one issue in particular: Hopelessness." Hopelessness is intimately related to suicidal ideation, for readily apparent reasons.

But aside from clinical experience, there is also empirical evidence, with a hopelessness scale proving to be a good indicator of suicide. Without hope, suicide becomes an attractive alternative to going on suffering eternally, in the experience of some. "In some people, the suicidal wish is a craving which is so strong, it's like that of a substance abuser. We need to provide ways of dealing with that."

Beck presented another case example, in this instance of someone with bipolar disorder, a very high-risk group. Beck went over the reasons for living versus reasons for dying with this person, and it was clear s/he had many reasons for living. He made a pie chart and asked "what percentage of you wishes to die?" At first he replied that the vast majority wished to die. He was then asked how much value his family and friends deserved, and after giving them value he ended up left with only around 10% of his pie suggesting the value of suicide.

Beck also employs the use of a "coping card", a sort of cue card summarizing problematic thoughts as they occur and facilitating use of a successful strategy. Beck's patient went rapidly into depression at times, and on one occasion it was severe, but he remembered and utilized the card. Beck noted that although widely employed as a strategy with suicide-oriented patients, contracts may be of little help where someone is really intent on suicide.

Beck cited a 10-session treatment study where it was found that cognitive therapy cut down re-attempts by 50%.

--

The question was asked, what about OCD, another prevalent condition where it would seem cognitive approaches would be appropriate.

Beck noted that "the mind can think of the most extreme things", with convictions about pending disasters, or moral convictions, etc., though with OCD the recurring obsessions can be looked at, the thoughts being "ego alien" rather than invisibly integrated. However, for reasons which can be readily understood with some reflection, "a ruminating person is at higher risk for suicide". [See above, for example, about hopelessness.] In fact, on a scale of suicidal ideation, "aside from hopelessness, planning was the most powerful predictor" of suicide efforts. In therapy, just talking about this planning can be very important. "You want to get the plan out in the open; if they can just talk about it they may be relieved" and the danger somewhat lessened as the pressure gets vented.

----

Farley, noting that we were in the presence of "the world's leading psychologist and leading psychiatrist", invited Bandura to comment on any of the discussion thus far.



Bandura conceptualized some of the dynamics of the case presentations as related to the "locus of treatment" having shifted away from psychoanalytic to cognitive factors. He presented his own case study, of a youngster with problematic anti-social behavior, living and being ejected from foster homes, due to fire setting and other behaviors. His inclination would be to "make a distinction between historical causes and contemporary causes", meaning that of course the youth may have had a basis for his feelings of rejection and mistreatment, but it was his response to situations now which were the problem. "The problem was what he had learned as a mode of behaving." He would provoke instructors, for example goading and insulting them. On one occasion Bandura left the room while with this youth, trusting him for a short time, only to return and find his walls mightily marked up and defaced. He began thinking about a "confirmatory loop": you trust him, he violates it. Understanding this gives us "something to work with. We aren't treating the past. His problem is the contemporary causes, not the historical. Look at the confirmatory loop." And thus is a somewhat different way of conceptualizing "here and now" cognition with a bit of behavioral analysis as well, seen through the lens of the "confirmatory loop".

--

Farley returned to Beck and asked if there were any new applications of CT he might share. Beck cited a study coming out of Lyons, France, which was looking at heart arrhythmia and a device being utilized to deliver a shock when needed. The study found that among patients who were given cognitive therapy, less shocks were delivered. His take on this is that reduction of anxiety was exerting a tangible impact on heart function.

In passing Beck mentioned some other work with high-functioning autistic adults, or Asperger Syndrome adults. The focus was on providing social skill training to try to ameliorate negative self-attitudes. (This makes good sense to me, as someone who has worked with Asperger children, teens, and adults; I discussed one case with Beck, after the presentation, where the complaint, in what I think is a clear cognitive example, was that "nobody wants to be my friend because they already have their friends", which became a self-fulfilling prophecy at times, or perhaps what Bandura referred to as a loop.)

---

More questions from the audience were invited. The first was from someone whose work centers on "creativity" and who noted that many people are resistant to medication as they believe it interferes with their creative edge, or output. Beck replied that he doesn't have a lot of experience in this precise area, but in his work with bipolar disorder he has encountered individuals who felt similarly, and hated taking lithium. He found that offering CT often could help, even despite the non-compliance with a course of medication. There was an additional problem with bipolar populations, unmedicated, seeking to stay in the hypomanic phase. There were "advantages and disadvantages" of doing this, most basically the inevitability that "if you go high, you're going to go low again".

Beck recalled treating one patient who was "depressed because he expected to win the Nobel Prize" but hadn't, and this consumed him. As with an earlier case presentation (above), Beck utilized a pie chart and asked the patient how important the Nobel Prize was to him relative to the entire 100% of his life (as represented graphically by the pie). The answer: It was 100%. "But what about the rest of your life?" OK, maybe 10% could be allocated to that. "And what about your marriage?" OK, another 10%, with the Nobel prize now occupying 80% of his life. And his friends, what were their value? 10%. And his children? "Oh gosh, they're terrific kids, though I haven't gotten much out of them." Now the focus shifted, as Beck sensed something important. "What was YOUR childhood like?" At this point the patient seemed ready to cry, and gushed out how he had himself felt neglected to the point of vowing that no matter what he would be a better parent to his own children. "So then, how important are your children to you?" 80%. After appraising this and the value of wife and friends, the importance of the Nobel Prize was now seen in context with life as a whole, and assigned 10% of the pie. In the end, this person "never got the Nobel Prize. But he is happier."

Bandura commented that he often encounters the dynamic of "regret" among patients, and underscored the importance of social relationships. "No one on their death bed ever regrets that they didn't spend more time in the office."

---

Beck was asked, after having referenced Linehan's DBT and Kernberg's object relations approaches to BPD, if the dynamic of "splitting" creates as difficult a time for him using CBT as it does for clinicians using other approaches, often finding it extremely difficult to achieve positive results due to the fragmenting and splitting. Interestingly, Beck's response began with highlighting the importance of patients feeling understood. He said that he admires Linehan's work with this population and in terms of the process, "she calls it validation. We call it empathy. I'm not sure of the difference. You need to really tune in -- [to the] patient's frame of reference. Once you have established a bridge, [then you] will look at the way a patient jumps to extreme conclusions." [This also seems consonant with the function of Beck's pie graphing, illustrating how things are relative.]

What Beck will also do is try to recreate experience in vivo (as he did in the early example of a role play). A patient for example might say "my husband told me [xyz]" and Beck's response would be to ask "how did you *feel*? You can't ignore feelings!" The patient, it turns out, felt rejected and tended to jump to extreme conclusions. (One day the husband was a total angel, the next he was a worthless devil, that sort of extreme splitting.) Beck might "reconstruct it", the event and context which caused this woman to become upset when her husband told her whatever, for example in this case the husband had indeed forewarned about an upcoming meeting but when he mentioned it was imminent she went into an extreme reaction. He spotlighted the sequence of events here, and dissected the husband's comment and then her reaction to it. This form of query, Beck said, is "something Ellis does so well." He continued: "It doesn't mean extreme thinking will go away. And sometimes it's valuable. But you [the person with this tendency, learns to] catch it and correct it. And oh yes, sometimes they set you up as omniscient. You have to calm that down, and become a partner.

---

The last question was about any special issues or considerations in working with older populations.

Beck noted that this population is often feeling bereaved. Some may have had no practice with social friendships and/or may now have lost their friends. He mentioned that one of the nation's highest suicide rates is seen in Dade County, Florida, home of a great number of elderly people. Many "have social isolation, medical problems, and a tendency towards depression". On a functional level you may find someone once active in playing tennis, who cannot now see the ball well enough to play, losing one of their greatest pleasures. Such people may benefit from *coaching*. "You need to make certain compromises, learn techniques" which work. He gave an example of one patient living with Parkinson's disease who was very self-conscious of his tremor and was anxious about picking up a beer mug. What he found is that he would shake less if focused on talking with his friends as he was drinking rather than on the beer mug. It did not need to be an "all or nothing" proposition, and the sense that it was could be lessened.

---

From here, as time ran out, a long queue formed, as seems always to be the case, as admirers and colleagues sought to offer comments, ask questions, take pictures, or get autographs. And that was this year's conversation, to be resumed next year with Bandura as a full participant!

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And that may be it for this year's asynchronously live reports, as the conference ends tomorrow, and I need to get to the exhibits before they close, and also try to rush around a bit less and "catch up" and process, to say nothing of packing (without any carry-on liquids!).

I will expand and correct prior to posting some of these reports as web articles, and use the many slides of charts and quotes etc. which I have as digital images, not readily accessed at this time as I try to get these reports out on the same day as the events.

As usual, I tried -- for myself as well as for the purpose of sharing and "giving away" some psychology -- to partake of both some mainstream psychology topics as well as aspects of online treatment and research, media, cognition, and psychotherapy outcome research. As always, it was not possible to get to as many things as I'd like, or be in 3 places at a time. There were many "unofficial" gatherings and impromptu discussions as well. And some iconic presenters as well, like Dr. Phil, not to mention evening events including Bill Cosby tonight, who I must say showed some profound understanding of human nature and had us laughing so hard and often that I'm sure he was worth his weight in gold for offering *us* some stress reduction.

It was a bittersweet venue, New Orleans being a classy and classic city, but one which has been in pain. Between the circumstances of the city, fears of hurricanes or health risks, and now problems with air travel on the first day of the conference, the turnout was smaller than usual, but still this city has been swarming with psychologists and families and allied health professionals, and there is no question: it was a very good thing for the economy and for the people whose livelihood is tourism, and I felt nothing but appreciation from all the people I spoke with, from cab drivers to waiters to police officers to hotel workers. Everybody had a story of loss, and so many still have stories of hopefulness and resilience.

City of hope, the Big Easy... New Orleans.

Truly and asynchronously Live from New Orleans, I hope this has been interesting and educational, and apologize if I've not managed to provide a sample of your own specific interest areas. Obviously, psychology is a diverse profession, and yet we're all about people, aren't we? And life.

Once again, I bid adieu for now, good weekend, Happy Summer, and please do feel free to comment, discuss, share related references, whatever.... I'll be traveling and then recharging for a few days, but everyone is welcome to contribute to on-topic discussions,

Take care,

Michael Fenichel, Ph.D.
http:/www.psychservices.com

INDEX OF 2001 APA Convention Articles:
Behavioral Telehealth | E-biz of Mental Health | 2001: A Cyberspace Odyssey


INDEX OF 2002 APA Convention Articles:
CyberSex & Cyber-Infidelity | Beck & Ellis 2002 | Behavior Therapy | CyberPsychology | E-Ethics

2003 Convention Highlights: Full Text | Aaron Beck 2003 | Quality of Online Health Info | Sternberg's Vision

INDEX OF 2005 APA Convention Articles




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