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.