https:/.../2019-01-18_CS_pt1_edited_2.mp4

What?
>> In the same way

that if I had somebody
who was an alcoholic

for example and was
drinking way too much

there would be a way
in which I could say

and I could frame it
as I need to help you

to be a better and
safer alcoholic.

Now that might not be
my first choice right

in terms of treatment,
my first choice in terms

of treatment might be to
say how can I help you

to stop being an alcoholic?

But if in fact that's not
available to me for whatever

reason or that type of
therapeutic work is not working

and isn't moving we would
at least want to say

for example, if you're going
to keep drinking,

I want you to stop driving.

>> Okay.

>> Instead of focusing
on trying to get you

to stop drinking,

I'm going to focus on trying
to get you to stop driving drunk,

and make you a safer drunk.

>> Okay, and that I--
>> It's a similar kind

of a way to think though.

>> That I get.
>> If he becomes a better

gambler he's less likely
to lose money.

That's less negatively
impactful for that person

potentially.

>> I thought I was proposing
something that would

be sort of off limits.

But there's this thing
called the harm reduction--

>> Harm reduction model.
>> Harm reduction model.

Which I guess in some
context could be construed

to say therapeutically
it's helpful to help your

client, patient engage in
>> More safely...

>> a more safe variation
of the detrimental,

problematic behaviors
that they've already

been engaging in.

>> At the far edge of this,
this can include things

like methodone replacement
for heroine for example.

Methodone is still a drug,
it's still addictive even

but it's less dangerous
than heroine and so

it's an improvement
over that even though our

first choice might be to
say hey no more heroine

for you, okay.

But if in fact that's not
going to work,

similarly we would say--
let's say abstinence is

the best choice for
teenagers in terms of sex.

Yeah great but let's also
use a harm reduction

kind of orientation on this
and say

that if you are going to
have sex,

please use birth control,
please use condoms.

All of those kinds of
things are harm reduction

interventions so it could
be that if you frame it

that way, now there's a
fine line here between

enabling and encouraging
the behavior or helping

it to be in a safer framework.

I think that's where some
subjectivitiy could

definitely come in and
if where for example

you yourself were
somebody who really

enjoys gambling--
this might have an impact

right on the subjectivity--
>> Right right right...

so once again, as both the
subject of the judgement

as well as the person that
gets to make that judgement

and execute on that
judgement you're--

the clinicians's on a very very
precarious role.

Wow, very complicated.
>> I think we're usually

in very precarious roles,
clinicians are.

Really often, that's one of
the things that I've often

thought about as a difference
between our worlds.

A lot of the time,
just kind of everyday,

clinical practice involves
a lot of like there's a lot

of stuff hanging in the
balance.

There are definitely
everyday these sorts of

decisions that we make.

It is not uncommon
for me to have to say to myself,

okay, how do I want to
respond to what this

person is saying to me
about a dangerous behavior

or a difficult behavior,
one that I think is not

ideally healthy for them,
how do I want to react to that?

Do I want to come at it
directly and actually say

perhaps that's not the
healthiest behavior--

very often that's actually
not the most therapeutic approach

for people and so we find
ourselves in a position

a lot of times of trying
to watch and wait for the

right times to intervene,

the moment when you're
going to actually be able

to have an influence
that kind of thing.

We have all kinds of
techniques set up,

motivational interviewing
for example is a technique

that I use really often.

Motivational interviewing is
a technique that allows

you to reduce resistance
and to increase motivation

for helping positive behaviors.

It's super manipulative
in some sense right

like it's a very deliberate
way of trying to adjust

what somebody is thinking
about a goal that they have.

A lot of the time we have
to do a lot of that type of work

just to get the place where
we're shifting things

for people's behavior.

It's not a very direct
thing very often,

it's very often a very
indirect approach and

takes a little patience
that kind of thing right.

>> So when somebody
comes in to see you,

and they pose, whatever
their issue happens--

>> They call this the
presenting problem.

>> Presenting problem,
okay.

You know your situation
is a little bit,

I think it's a little bit
different from mine.

So I guess in my
mathematical world,

I have people come
in with their presenting problem.

They've got their data
collection situation,

they've got something
they want to do,

they've got some research
question that they want to answer.

And I've got some array of
techniques that I can devote

to the question at hand.

Some number of those
techniques are going to be

the sorts of things that
would be generally well regarded

by the statistical community
as reasonable approaches

to take.

Some of them might not be.

So there's always a very
wrong way to do an analysis.

I mean there's some--
>> There's always a very

wrong way to do therapy too.
>> Right exactly.

So there's some clearly
wrong things I could do.

You could always just do
things that are completely

off the wall.

You could consult a Ouija
board or something like that.

And the status issue consult
the Ouija board

to give you the answer.

That's clearly wrong.

>> Not an empirically
supported technique.

>> It's not an empirically
supported technique, no.

And there would be a variety
of other sort of techniques,

even mathematical techniques
that would be more or less

the equivalent of the Ouija board
kind of thing.

And there are some things that
everybody would accept

would be within the range
of reasonable things to do.

So when somebody comes
to you with their presenting problem,

and what not.

Whatever it is that they're
talking about,

you've got a choice, I presume
of probably an even wider array

of reasonable techniques that
you could use, some of which

probably most of the time
has some research associated

with them.

Some of them maybe not.

Maybe something occurs
to you that's the product

of your own intuition about
the circumstances or what not

maybe not quite as far
afield as the Ouija board example

you know if you kind of
extend that analogy.

But something that's fairly
far afield,

are there sort of ethical
considerations--

again in my world if I
pick some kind of really

super obscure technique
and I get my client the answer

using that technique,
my client may or may not

know in that particular moment
whether I've done them well,

done them not so well
whatever--

they may or may not know.

They may later find out.

Then there might-- I suppose
there might be repercussions

for me, I guess I could get
essentially sued or something

like that if I do something
that's too screwy.

>> I guess.

>> But the fact of the
matter is in that moment

I can make that choice and
whatnot and I'm probably

on safer ground if I choose
something that's emprically

supported but then in
your world,

there's not necessarily going
to be you know if you pick

something that's pretty far
afield, who knows whether

there's going to be any
repercussions ever

so how do you make
that choice between things

that are empirically supported
versus not.

Are there some ethical
considerations kind of along

those lines and so how do
you kind of make that choice,

what are the ethical considerations
and kind of what does that

all imply about what you do?

>> Well there's a lot there right.

The first thing that we have to
think about is that you're right.

There's a zone here that we
would say there are some

techniques and some procedures
and some ways of thinking about

client problems that would
be considered sort of

centrally standard that would
be like this is very professionally

accepted, there's lots and
lots of agreement

that this is a very sort of
regular and accepted

way to approach this.

And there would be variablity
there but it would be

bounded variablity in much
the same way that it would

be for a statistical choice
that you would be able

to make.

There would also be things
that are clearly outside

of those boundaries and
a lot of times those are

things that have to do
with safety,

not just with efficacy
because of course therapy,

one of the I think the most
dangerous fallacies

about therapy actually
is that either will help

you or do nothing at all.

It's either neutral or beneficial
and that it actually can't be

damaging when we have
pretty good evidence

actually that there's some
types of therapy techniques

that can be damaging

and these can have even
iatrogenic effects right.

An iatrogenic effect would
be when you're trying to

help somebody with something

but you hurt them in the
process of trying to help them.

An iatrogenic infection would
be one that you kind of

obtain during surgery
or something along that line.

So an example of a technique
that would have

iatrogenic effects and very
well demonstrated would be

using hypnosis for particular
purposes so especially

trying to retrieve memories.
>> I've heard of that.

>> Of course and trying to
help people get a better

understanding of something
that's happened to them

in a distant past that they
don't remember well.

That particular technique
even though it used to

be much more popular than
it is now,

has now been very well
demonstrated to be

too dangerous for us
to be allowed to use it

and in most licensing contexts
that would be something that

would be considered
in appropriate.

>> Dangerous how?
Dangerous in the sense of

it may be generating her
wrong insights or dangerous

actually literally to the
client/patient.

>> Well it depends on what
you mean I guess by

just dangerous to the patient.

I think it's both psychological
and physically dangerous.

That's the type of distinction
that you're trying to make.

It's clearly psychologically
dangerous to the patient

and obviously you could
construct memories for

example of having been
terribly abused by a family

member when actually
that never happened and

the family member
actually never abused you.

Obviously that would be
something that would be

detrimental in a psychological
way but it could also be

detrimental in a much more
practical or physical way

not just to the patient
but to their of course

entire context.

Let's extend that example
and let's say that family

member is still alive and
is still somebody that

you see and all of that.

It could even be that
that could effect

that person's life in a
very negative way also.

Even to the point where
we would say are there

legal actions that are
involved here,

that type of thing.

So (inaudible) among
many other researchers

have done an amazing job
of putting out there

lots of really imporant
work that then clinicians

like me and are licensing
boards and the associations

that help us to know
what we're supposed to

be doing have to be
able to pay attention to

this data that comes
in that says oh wait

this is not that this is
efficacious

that it could also be
damaging to people

in this way.

So there are always
going to be things

that are outside the
range right

conversion therapy having
to do with sexual identity

is another good example.

Something that's been
unfortunately quite controversial

here in Texas.

Why on Earth this should be
something controversial,

don't even get me started
on that, soap box.

I'm going to climb right up
on that and go ahh!

>> Maybe that's another hour.

>> That's right? We've got
a whole other episode on

conversion therapy for
sexual identity.

You know but sexual orientation
is something that we don't

actually believe that it's in
the client's best interest

when the client comes in
and would say something

like I don't want to have
the sexual orientation that

I feel like I have,
I want to change that.

That's not considered an
appropriate therapeutic goal

even if I am capable of
that and there's--

very unlikely to be the
fact that I would even be

capable of that.

I don't know of any
treatment that would

successfully actually
produce that effect

but even if were to
come up with such a

treatment we would say
ethically that's not an

appropriate goal and it's
one that you actually

have to say what underlies
the fact that this client

feels like that and it
needs to be the goal.

That they need to try
to change that aspect

of themselves,
there's some kind of stigma

some kind of horrible
things that are happening to

this person because of that
identity and let's see if

we can work with that.

Let's see what we can
do help them to adjust

to what's going on.

I think there are lots
of things that we would

say like in any moment
when somebody brings

a presenting problem.

There are limits to letting
the client determine

the presenting problem.

There are times when we
would say yeah,

I can't treat that.
I can't address that even

though you're saying
that's the problem

we have to reframe this
problem before I can even

try to help you with it.

But then there are also
lots of other times when

we would say you have
to take something more standard.

Somebody comes in and
they're depressed.

Okay there are many different
approaches that are

potentially appropriate for
treating depression.

It's not the case that we
would just say oh there's

one that's good and there's
one that's bad.

Which I think when we
have to start to get into

a conversation really about
theory right that there's

a theoretical basis for a lot
of these different choices

that clinicians make and
that you have a theoretical

identity--you identify as some
kind of theoretician in this way.

Something that you kind of
agree with and so for me,

a lot of the work that I do,
is a combination of two theories.

So I work with cognitive
behavioral theory

quite a lot.
I do a lot of CBT.

And then I use a lot of
humanism also.

I use a lot of humanistic
theory in trying to determine

the types of interventions
that I'm going to use.

The types of relationships
that I'm going to have with

my clients, the types of
ethical choices I make

and that kind of thing.

It helps to provide a
coherent set right of ways

you would make those decisions.

Is there some equivalent to
that in statistical world?

Do you have different theories
of the way that stats should

be interpreted in that sense?

>> To be completely honest
with you,

no, I don't think--
I really actually don't think

there is an analog there.

You know my field is a much
more cut and dry

in that respect.

Math is math and there really
is kind of correct math

in certain circumstances
and there's incorrect math.

Even though the sort of
techniques that one might

select from there are good
techniques and there

are less good techniques.

The dividing line between
the good ones and the

bad ones is a lot sharper
I think than it is in

psychologists so my life
in that regard anyway

is actually a lot easier.
Yeah it really is,

it's a lot easier so I mean
you have those sort of

theoretical perspectives that
shape what you do.

Along the way a few minutes
ago you mentioned some

other things, some other
types of therapy that

you know I guess maybe
aren't all that common

and would generally
maybe be frowned upon.

But sort of the dividing
line to me doesn't

strike me as nearly
as sharp.

What if somebody has some--
what if there are clincians

out there who have unusual
theoretical perspectives on

things so it leaves them to
engage in some unusual

practices with the aim
of trying to genuinely

help their clients.

But maybe some things
for which there's really

no empirical support.

>> Okay now we're
getting down to it.

>> Really kind of maybe
things, their theoretical

perspective is driven
more by their own intuitions

about things than it is by
sort of a research base.

Is that number one,
do such people exist,

I suspect they do.

But I guess mire importantly
then is that in itself an

ethical problem?

>> Yeah it's at least an
ethical question.

>> And how does it get
resolved then?

I honestly don't know.

Is there I mean if the
people--if there's a

therapist out there that's
engaging in these sort of

more intuitively based
kind of things

and their clients are happy.

>> Well this point kind of
gets down to the cracks

actually of I think where
our perspectives kind of

come in as clinician,
statistian is just sort

of think about what
role do you think

actually that empirical
data should play

in terms of determining
what kinds of things

clinicians do.

They're going to be many
situations in which we

don't actually have access
to a clear cut set of

treatments that have
been perfectly well

demonstrated to be
efficacious.

Certainly there are going
to be lots of times

when that's not available
to us but I would also

say that if it is available
to us we have some

ethical obligation to
go toward that.

And that's one of the
things that's so difficult

about the situation of
psychology now I think

that there are some
theoretical orientations

that pull for more research
support than others.

So being trained as a
primarily cognitive behavioral

technician in those ways
that's an approach that's

been very looked at.

It's been investigated a bunch.

You know tons and tons of
research has been done on it.

Certain things have
been very well demonstrated,

other things are mushier
and haven't been as well

demonstrated that kind of thing.

Just because we have the
data on that theoretical approach

doesn't necessarily mean that
we've ruled out efficacy on

all of the other approaches.

Like their could actually be
equivalently efficacious

approaches that just haven't
been tested in the same way.

The way that I tend to
come down on this ethically

is that if empirical support
for a treatment is availbe

and appears to apply
appropriately to the

particular client that
you're talking about and

of course you've got a lot
of things with socio

demographics and all
kinds of issues that might

apply there right in terms
of where was the research

done and with whom
and does this actually

apply to the person I'm
looking at right now

across from me right.

But that if empirical
support is available and

certainly if empirical
data is available suggesting

that something is dangerous
then we definitely need to

avoid that. That can rule
things out for us as an

approach but then when
we don't have those data,

when we have no indication
that something is dangerous,

instead we have indication
that it's probably efficacious

in this situation okay,
well then that makes sense

to me that that would drive
some of my decision making

as a clinician that I would
say why look cognitive behavioral

therapy or an even better
example would probably be

dialectical behavior therapy
for certain types of

emotional problems.

Marsha Linehan is the person
who came up with

dialectal behavioral therapy,
one of my great heroes.

And I use the work that
she has done and

come up with her whole
research team for many years.

I've used that work
a great deal in clinical practice.

The fact that it's so well
demonstrated to work

with particular types of
problems means that

I can very easily say oh
I have very strong justification

for why I would choose
DBT as a way to approach

an eating disorder,
a self harm behavior,

suicidality with a lot of
relationship chaos.

Various kinds of things
that sort of all approach

something like borderline
personality disorder

which was the core problem that
it was originally, treatment was

originally developed on.

So in those situations I feel
like it is an ethical obligation

I would say this to me
in terms of my interpretation

of what ethics are telling me
to choose that over

a treatment I don't know
if it's going to work.

I have no data on it
at all, much less a

treatment that I actually
have data that suggests

that it would be counter
productive right.

That's a relatively
small subset of the type

of work that we do I think.

>> Do the ethical guidelines,

the APA's ethical guidelines
compel you to use those

kinds of treatments.

You're not required to?

>> No, you're not required to.

Instead, you're certainly required
to not use treatments that

have been demonstrated
to be dangerous.

You're required to take
into account that type of--

>> This is kind of an analogous
thing in those guidelines

of the kind of do no
harm kind of thing

that's in the medical.

>> Not just kind of it's
specifically in there.

>> It really is in there?

>> Yep malfeasance is
the word that we use for that.

So non-malfeasance
is the number one guideline

where you would say
first do no harm

and then of course
beneficence

comes in very shortly
after that.

Beneficence is to do
active good for someone else

and all of your decisions
for a client are supposed to be

beneficent decisions right.

But then you also have
to protect client autonomy

and client autonomy of
course is the ability to

self determine and make
your own decisions for

yourself as a person.

It's also my requirement
as a clinician to really

respect your autonomy
and try to encourage it.

So you can see that
we can kind of get into

some messes there
sometimes.

>> There's some serious
balancing acts there yes.

>> Yes, absolutely and those
conflicts very often come

around things like is it
beneficent to protect autonomy.

Which of those--classic example
there comes in--

the classic example comes in
when we talk about

in patient hospitalization,
involuntary in patient

hospitalization right.

If your decision is that
you don't want to be

in the hospital.
>> I don't.

>> Me neither. Who does?
So often so few people do.

But if your decision is that
you don't think you don't

need to be in the hospital
and you don't want to be there

but my perspective as your
clinician is that you're

going to be dead if I don't
put you in the hospital.

And therefore it's actually
beneficent for me to

put you there even though
this is not what you want.

That's a very common
kind of place where we say

okay are you going to prioritize
the clients autonomy,

where they're getting to choose
to make their own mistakes

so to speak because
by the way those of us

who are not mental patients
we get to make our own

mistakes all the time.

(inaudible) It does happen
of course, all the time.

Or are you going to try
to figure out how do

you know what is beneficent
for this person.

I think that's one of the
things that's most dicy

about the concept of
elevating benefience

to the top is that it
does then kind of give

you this assumption that
you can figure out what

the right thing is for
another person

and maybe even better
than they do what's

right for them.

That's one of those
fundamental ethical

assumptions that's sometimes
a little dicy for me.

>> The cool thing is that you
are not required to use research.

You're not required to use
database kind of techniques

or anything like that?

>> (inaudible) because
otherwise we wouldn't be

allowed to do anything at all
in so many situations.

If I were required to use
research to tell me what

I'm allowed to do,
then we would be required

to have the research in place
before we were allowed

to do anything.

What if you come in and
you say, okay I've got

this particular problem
and I say,

oh that's never been
researched,

>> We've never heard of this.

>> Well or if even we've
heard of it,

but the money hasn't been
there to set up an NH study

and nobody is actually

investigated whether
this is something that

this problem could be treated
with this therapy or

that therapy.

Maybe we don't have
good outcome studies on that.

Maybe there are only 15
people that have

been demonstrated to
have this problem or whatever.

In those kinds of situations,

if in fact the ethical guidelines
required me to use research

I would be stuck and unable
to do anything at all.

So instead what they weigh
in on is the idea that you

want to be able to use
rational theoretical

and hopefully at times
empirical guidelines for

determining what's
best for the client,

but that overall it's the
sort of Gestalt thing.

Like you got this overall
professional perspective

and you have to use your
own professional judgment

in trying to determine
what is actually going to

be in the best interest
of the client.

That takes us like full circle
back to the subjectivity question

right where we're like
there it is.

My job definitely has a
lot of subjectivity to it.

And yours it sounds like
has a lot more subjectivity

in the interpretation
that it's like in sort of the

same way that I would talk
about assessment right.

So when we do assessment,
we get concrete very often

quite objective data
on what a person's behavior

is looking like what they're doing.

And it's a matter of how to actually
interpret those results.

Does this level of vigilant
attending on a particular

computer task indicate to me
that ADHD is a likely

explanation for this behavior.

And it's not in whether
to like how do I actually

get the data.

It's in what do the data mean
that would be the real

subjective part.

>> Yeah, yeah I mean
in my world yeah.

The analogous is actually
fairly well cut and dry,

we've talked about before.
There's good techniques

and we usually try to focus
on those.

And the question of what
is the meaning and then

what is the action that then
builds upon that.

Those are all the places that
you know and again

good news for me frankly,
personally is

>> It's all about you, Greg.
>> Well those of us who

do the things that I do,
and a real difference between

my world and yours is that
for the most part

the decisions about what to
do with the information

are not mine.

I'm simply responsible
for crunching the numbers,

telling the people who are
paying me or are otherwise

working with me telling
them what the numbers say,

what's the knowledge
that we just extracted

from the data but then
the actions upon that knowledge

where to go from there
are usually--

that's usually not what
I'm involved in.

It's not the situation that
you have where having

established what's going on

you work with your patients,
your clients to then devise

a course of action that's
ultimately hopefully

going to be helpful and
sensable and all that.

In my case, most of the time,

frankly the actions to be taken
I don't really--

I don't really have to be involved
in them so again

I really have a much,
I have a much simpler life.

I have a great deal of envy
for or not envy--

>> Reverse envy?

>> Right I'm not envious
of the situation that y'all

find yourselves in.

I don't know how you stop
from thinking about

this stuff.

You see your clients and
you're confronted with all

of these different circumstances
that pose this variety of ethical

dilemmas and what not.

I don't know how you
stop from thinking about it

at nighttime,
just constantly cycling over it

and all of that.

>> I'm going to talk about that
for a second, how we do that.

But first I want us to just
really notice

how much validation we're
getting. Like look at this guy.

This is a statistician.

He's absolutely saying like
phew that's a tough job,

I don't know how you guys
do that.

Yeah it turns out there's
like this huge extensive amount

of training that teaches
us how to do things

like compartmentalize.

So I compartmentalize my
clients and that's how I stop

thinking about them
at night otherwise of course

I wouldn't be available
to my clients

because I would be such a
mess myself.

So in order to be an
effective clinician

you have to be trained in
and have to practice

and usually this is a big
part of the whole graduate

school process and everything

is that you're supervised
by people who will

also encourage you to
learn how to put those

things away so that it
doesn't pervade through

your entire existence
that way.

So as most of you know
it can sometimes be

challenging to do that.

There are times when
we still do bring them home

and I still remember that
from the beginning of my training

when I was a new clinician
that there was definitely

much more of that.

It was much more of a
challenged to not bring the

emotional aspects of
my work home with me.

And then over time you
get better and better

at being able to not
do that and just kind

of show up everyday ready
to deal with the problem.

>> In this complex maze
of stuff that you deal with

then and all of the different
ethical dilemmas that

your day to day life poses
for you,

if you cannot solve them
for yourself,

and you don't want to
percolate over them at night,

what do you do?

Do you talk to other people,
I mean how does that resolved?

>> This is part of our ethical
guidelines too, is

how to deal with this so
as most of the people

listening to us will probably know,

if in fact you find yourself
in an ethical quandary

and you're really not sure
what to do about it,

there are of course resources
that you can use to

try to weigh, get information
and try to get help with that.

One of the ways that of
course we do that

is by talking to fellow
clinicians so anybody in your

same licensing category.

Most of us choose a
couple of people that

we're really close to and
we'll actually talk through cases.

We tend to of course try to
be as subtle and careful

about that as we can.

We don't want to share
more information than

you have to that kind
of thing.

But you're absolutely
allowed to do that.

Then the other thing you're
allowed to do is of course

look up, you know a lot
of the times there's actually

lots of writing that's been
done on these ethical questions

and lots of weighing in has
happened as far as all of

these decisions go.

>> The internet has an answer?

>> The internet may have
an answer,

be careful about the answer.

The internet may have the
wrong answer,

but yeah there's lots of
published stuff about

different ethical guidelines,
different ethical quandaries

and that kind of thing that
people get into.

That's a lot of how you do it.

Now, believe it or not,
you have survived an hour

of the clinician and
the statistician.

That has happened.
You have managed to make

your way through this process.
>> Congratulations.

>> Congratulations, and we have
managed to make our way

through an hour of this.

I feel like it's always the case
that in our conversations

I'm like cutting us off in
this process

because we could talk for hours.

>> We have other things
sometimes that we have to get to.

>> We do. (laughter)

>> We have to terminate.

>> Terminate? Oh my goodness,
no no. Instead this is is more

analogous to the end of a session
rather than the end of a relationship

therapeutically and so I would
say instead tune in next time

to see what crazy stuff
Dr. Hixon and I are talking about.

I think we've been bouncing
around lots of different possibilities

for the kinds of things that
we'll talk about next time.

So I'm just going to leave
that mysterious and say

tune in and we hope we
get to see you again soon.

>> Absolutely.

>> Thanks for being here.
>> All right bye bye.