Use at a crisis residential setting
Hi,
I work at an crisis center (short term-ish inpatient) where we have just started implementing MBCT. We will be getting a new director soon but I'm doing clinical supervision and have started training with staff (8 week experiential and they have to agree to meditate on their own twice a day.) The residents have been incredibly open to techniques which are quite different from what they are used to. (Hospital medical model) The residents are still working on attaining momentary concentration in order to begin mindfulness practice but we also work on changing perceptions of events, of thoughts, of discomforts, and this has been really amazing. (When I worked at a psych hospital and attempted to teach a patient to visualize and accept pain, then move it to a different part of the room, I almost got hit!) Here, people (even 2 in severe pain) told me how amazed they were at the amount of reduction that occurred from seeing the pain as smaller than themselves and also, as pain - still there but not exactly part of them anymore. We do a variety of pranayama, to balance, energize, or relax; no one has complained about yoga, reflexology, or reiki - no one has called me a nut.
Anyway, early changes happen quickly. (Some people have just come from hospitalization and don't initially seem appropriate.) But within a short period of time, there is a family feeling, people are acting more appropriately and really seem to understand their own responsibility in choosing whether or not to act out anger; to play the victim, etc. I can't wait till the whole staff is practicing mindfulness. (I'm Buddhist but I don't call it Vipassana at work.) I know that I sound overly enthusiastic since I have no idea how/if this will continue in these people once they have left but I feel hopeful.
I would love to hear from anyone using holistic techniques in psychiatric treatment. (We also use more traditional problem solving, values clarification, emotion recognition, motivational interviewing, etc.)
I'm a psychiatric nurse educator who is also a yoga teacher/therapist with certifications in massage therapy, reflexology, and reiki.
Isn't moving the pain to a different part of the room avoidance?
Isn't moving the pain to a different part of the room avoidance? This is a genuine question. I am confused.
re: mindfulness practices
Irene Javors
I have used mindfulness practices with private clients who are very anxious and or depressed. I introduce these practices as ways to reduce stress. I find that they clients become increasingly open to such meditation as they come to experience the centering effects of the work.
Sorry, I am lost
I am reading the above messages about the effectiveness of Yoga, Reiki, etc. in the psychological troubles and I am quite surprised or confused... How do match all those trends with "creative helplessness"? How do they improve personal acceptance and commitment with the personal vital way? Does it not imply a distortion of the essence of ACT?
Best regards
Ramiro - Spain
Explain use of yoga, etc.
Hi,
When we use yoga, mindfulness, etc., it's separate from "creative helplessness." We would have already gone through the metaphors (the "Chinese handcuffs" for instance), would have gone through numerous ways of explaining the idea of accepting emotions helps you let go, resisting makes them cling, etc. Actually, most of our residents have been through numerous crises and do realize that they are stuck. Other techniques we use include journaling, practicing unfamiliar things, value clarification, empathy training, and emotion recognition. What yoga does is helps you accept each moment fully without judging it, even if something doesn't feel particularly great, you just recognize that you can handle it with equanimity. Mindfulness improves personal acceptance because practice shows you so clearly that things are what they are. Change what you can but accept what you can't. You also get a clear realization from mindfulness practice that everything changes - rises, falls, rises, falls. No need to get panicked or upset - it'll change soon enough.
Does this explain it better?
Guessing what was meant
I'm guessing what Ramiro meant was "what does this have to do with ACT?" Actually this is in a "fellow travelers" section I believe, so it doesn't have to have anything to do with it really. But it does ... how much is in spin.
We are doing a preliminary Yoga + ACT study at Reno. I think you can use Yoga to support ACT processes and vice versa. We shall see.
But I do have to confess that I am a bit startled by the relatively thin research basis for such an ancient technology.
Research is not just a matter of justification -- it is a matter of modification. That is, I suspect, the real problem. Folks believe in this technology -- they don't want the scientists messing with it.
But it is not a control thing. Messing with it is to help those who receive it.
My guess: Yoga in an ACT context will be more consistently helpful. I'd make the same prediction for meditation by the way.
- S
Steven C. Hayes, University of Nevada
found my way
Ah, yes... I see the map of the site now. Thank you very much and I´m sorry for the message
Ramiro - Spain
Research
I am aware of some anxiety as I am forming this response, due to a concern for showing my ignorance in some of the areas of discussion.
It’s a tense situation because at the moment I think I’ve got an OK grasp of Behaviourism/Buddhism/ACT/RFT/Yoga etc……I use these in my clinical practice and personal life and generally feel things are working out well.
But there is a real danger that by exposing myself and joining in this discussion that a host of people could tell me how completely ‘off the mark’ I am in all of these areas. This could have pretty aversive consequences. It’s taken me a while to get this far and it would be as if I had to start all over. I’ve read my books, had my travels, painted my fences, been up and down and finely feel I’ve got something that’s working for me and my clients. So to put my ideas and understanding under scrutiny is far from easy.
However, I am also aware that by writing this response I am responding consistently with a valued commitment to better my own understanding of the processes of human functioning. As such I may find something that could help me and the people I work with to a greater extent. This is a higher value than my current emotional and intellectual state and can only be worked toward by taking a risk.
Similarly (as I am trying to communicate in a rather roundabout manner) I feel there is a real need to continually put what we (as a profession)are doing under the scrutiny of research. Whether it is yoga, meditation, ACT or RFT we should take the risk of being ‘off the mark’ and having to begin again. Our goal should be to increase an appreciation of the processes through which these things function rather than trying to promote their use in terms of form alone.
If our instincts or initial feelings are correct we have nothing to fear. But if Buddha or Skinner have taught us anything its that this is not always the case.
Research
I don't disagree at all. However, I think that some scientists in research go out of their way to make studies difficult. I mean, in order to have a true "does yoga help reduce anxiety?" study, there has to be this pure control group and the people in the study are not supposed to know they're in the study because that might change their feelings about their anxiety by itself. So how are you going to do that? I think researchers need to think outside the box a little. I mean, really, even clinical trials with medications that are supposed to be so totally double blind, they're not. The vast majority of doctors and patients know who is getting what. Sorry...off the subject...What I have researched is people's perceptions of how they feel (regarding depression, anxiety) plus their pre and post hospitalization rate. That's about as far into it as I can get. (I'm already doing enough; I can't be a full time researcher too.) So, to me, if they think they feel better and their rate of inpatient hospitalization goes down, that's good enough for me and I'll use it. I use a classical 8 limbed yoga path - not just doing breathing and asana - and have never had anyone write that it harmed them or gave them any bad side effects (unlike most of the antipsychotic meds they've been on) and the ones who stuck with the program required FAR less hospitalization. But again, no real control...I've worked with people with a variety of serious mental health problems for 20 years and nothing else has ever helped like this.
Yoga
Part of the challenge of integrating holistic techniques into treatment is learning how to research and develop them. I think part of what is cool about ACT, for example, is the willingness ACT researchers have had to look at mindfulness in new ways, without minimizing on the one hand or abandoning traditional science standards on the other. A lot of holistic approaches have eschewed "Western science" -- in my view a terrible mistake -- and I hope ACBS can be a force for a new approach.
In my lab we now are conducting a sudy on the combination of ACT and Yoga, so I'm thinking about this more. If the study works, my next question will have to be this: what about Yoga is helpful. And there is it a challenge because we are now messing with ancient technologies. Yes I see no healthy alternative. We need to pull nature at the joints, while always being mindful of danger of minimizing complexity to the point that its essence is lost.
Steven C. Hayes, University of Nevada
Yoga and ACT
The study I did in the psych hospital (with staff) was using mindfulness and yoga and "Does this combination improve self-efficacy?" Obviously, this is subjective, plus how are you going to have a control group anyway? I couldn't force people to be in the study so, of course, the people with a naturally high level of self-efficacy were the ones who volunteered for the study. I mean, I sort of knew it would be like that but whatever...I wanted to do it anyway. What's helpful about yoga in terms of mindfulness is that it's like a mini version of life. You stay mindful, for instance, if something feels like you can't hold a pose one more second, you just stay focused on this second, then this second, then this second...not looking into the future so you CAN do it. That's just the asana portion. The other parts of the path lead naturally toward mindfulness, acceptance of the unfolding Universe, contentment with what is, etc. Again, how that gets tested is beyond me. I get sick of people asking me about evidenced based studies, blah, blah. There are things that I know because I've seen it work, I feel it work, and there's just nothing in yoga that lends itself to a really scientifically controlled study. I don't teach yoga in any kind of trendy, "modern" way - my certification is in Raja, classical yoga - so all the residents (and students at the studio) have to learn about and follow the whole eight fold path. It may be ancient but the premise is completely relevant today. Thanks for answering,
Susi
What's helpful about yoga in
I frequently use the popular yoga quotation "falling out of the pose is part of the pose".
ps. Interesting discussion about research y'all.
Yoga and ACT
People practice and teach yoga postures and breathing for various reasons, the most obvious being flexibility and other health benefits - clearly useful goals for those who value health. Another is expansion/elevation of mind (vistara), transcendence, experiencing oneness, deep serenity - this may well function as a behaviour towards ones spiritual value(s); however it often also functions as emotional avoidance that can be profoundly problematic. Developing acceptance, being in the flow (rasa-liila) is a core component and reason for yoga practice, but it currently at least receives far less attention.
Some yoga-meditation techniques (eg seeing all that arises in my mind as Brahma) are examples of effective defussion techniques. Yet can also be the means of unhelpful control in the name of traditition and/or the guru - eg psuedo-acceptance of abuse.
In the psychiatric setting where I work directing slow stretches while emphasising body-awareness, followed by focus on breath techniques, while emphasing mind-awareness, are very useful for persons enmeshed in their thoughts, top-down management, to reconnect with and be in their body. Any visualisation I may use then is to awaken acceptance with compassion.
It seems to me the validity (from ACT persepctives) of these (or Susi's) assertions could be very wothwhile areas of research. That is, indepth critiques of various yoga practices and philosophies within ACT framework
Yoga/meditation
I've heard people say that before, that transcendence, oneness, serenity, etc. can be used to avoid the realities of life (and, of course, Freud, with his belief in its regressive nature...) but using mindfulness and yoga together really makes this impossible. (in my opinion) In Vipassana, you're not avoiding anything; in fact you run right into reality, whatever is going on, totally embracing the whole thing. The other stuff you mentioned (controlling people in the name of tradition and that whole guru thing) can certainly be an issue in some places. The yoga studio where I work part time (and where I studied) has really worked on what true yoga is vs. what's Indian/Hindu tradition and how can we make this work in a Western country. Also, I think more people are starting to practice yoga for the right reasons. Well, maybe they don't start that way; they start for the health benefits but then once they are educated to how much more it can mean for your life, a lot of people understand the differences and want to learn what it is. And those who don't just switch to a gym that has a yoga class.
Susi
This is all really exciting!
This is all really exciting! ACT, Yoga, Mindfulness, Breathing exercises.
I've been a volunteer for 3.5 yrs at a (short term-the goal) inpatient mental health facility. I was fortunate enough to have my own group discussion in which I introduced Yoga (specifically the sun postures) and focused breathing. The group was well received for the first 2-months but then I had to curtail it to very limited stretching exercises because most of the folks didn't have the motivation to expend that much energy. (I was VERY lenient, exact pose, time in posture not enforced)
My next group coined "Relaxation" which I've been facilitating these past 3years is centered on breathing and awareness. This has definitely had the most positive effect on the clients as a whole. I've narrated breathing exercises with the intent on learning everything there is to learn about the act of breathing; from feeling one's chest rise to the light exhaled breath slightly reverberating off the outer portions of ones nostrils. Similarly, I've used soft "meditative" music and eating as other tools of focused attention on ones experience; this ultimately led to the practice of observing ones thoughts without judgment.
What I've found from the group is that these techniques do in fact help them relax, as they themselves expressed and I in fact noticed a reduction/ to none at all, in "psychosis, mainly self talk" from the clients that were exhibiting this behavior.
There are too many variables (both known and confounding) to say exactly what factors helped bring about the positive, relaxed affect on the group. It could be the safe, quiet room that we were in, removed from the rest of the population (~200 beds in this facility). Or maybe, the dimmed lights or the music or the idea of the group, “relaxation”, or may be the food; I typically use nuts and dried fruit for focused eating. What is fundamentally clear though, “minding” (from ACT) is one of the root causes of pathology (I’ve also gained this view from learning about Buddhism, the philosophy), if we can give a different perspective to a client from “minding” then I believe we can dramatically shift the person from being “John who is Schizophnic” to “John who has these thoughts, behaviors (maybe less if he accepts these thoughts/behaviors?) of schizophania. Ultimately this will lead to a person who has more purpose than before and more bouts of independent rather then rehabilitation living (my little speech… ).
I was thinking, as Susi said, it is very difficult to have random trials within an inpatient facility (what if your whole population if study wants to participate in this one group) yet this is one of the best places to interact with folks whom are clinically ill. What if we ran different techniques at different hospitals and pooled the data together? If we can make some assumptions, meaning the groups come from the same overall population; as can be described; psychosis, bipolar, schizophrenic, we may be able to pool them together and claim same population, even if it is across the country? I’ve wanted to take this to the next level, to see what brings about change for this inpatient population.
Well, if this sounds feasible to anybody please let me know. I’m interested in participating!
All the best,
Ricky
Research into yoga
It definitely sounds like an interesting study to compare effects at different places, etc. The problem with research (if you want something peer reviewed or really looked at seriously) there has to be a controlled study. And your group who is the yoga/meditation group obviously know they are doing the practice. (The control group obviously know they are not.) So then you're adding other variables - maybe it's working because they feel they're doing something different in general so it feels positive. Maybe the asana portion of the yoga is just getting people who generally sit around to move a litttle more so they feel better from just moving. Maybe the breathing is helping oxygenate their brains. There are just different things that skeptics could (and do) say. At least, that has been my experience.
I mean, I think it works because I see it work, and really, I don't even care why it works. It doesn't hurt and it does help, so why not? I do think there are lots of things (that more people seem to be realizing lately) in psychology and mental health issues that can't be shown with graphs, control groups, etc. It has too much to do with relationships and people getting the point that life will never be "perfect" (ie: the way they think things "should" be.) But then they get that regardless of outcome, it really is perfect - just as it should be. And that's very difficult to see in a graph or a chart.
Susi
Yoga
The aspiration to conduct well designed and controlled research, far from being problematic is essential, as is the very thing that distinguishes us as scientists. The process of research is often a long and arduous one. I am currently doing my thesis for my clinical training and am somewhat in the thick of it. We should not, however, allow these difficulties to lead us down science-blind alleyways, where common sense explanations are accepted because they make sense and look good. When I look out of my window the earth appears to look flat, and if I did not know what I do about gravity, it would make sense to assume that it is. After all, assuming it is flat might work for me and in the short term at least is unlikely to cause me any ill effect and it looks right. Science should entail more than this and has much to offer, as difficult a process it might be.
Observing that something works is only the first stage of a continuing process. If treatment technologies are to be supported we need to know how they work and why they work. I feel that this is fundamental if such technologies are to be refined and improved in order that they reach and help as many people and to ensure that we are doing no harm to our clients.
With Yoga, many people may derive a benefit from it. This does not however mean that it should assume a place along side empirically validated treatments by virtue of this alone. Is Yoga as beneficial as whole behavioural treatments such as ACT or BAT. Is it equal as a component to cognitive techniques such as PMR or ACT components such as Cognitive Defusion or mindfulness. Being able to operationalise Yoga in a way that allows it to be measured and tested will facilitate such this process and be of benefit not only to Yoga practitioners but also to clients, if Yoga does indeed have something worthwhile to offer us as a treatment technology.
I’m sure there are many ways in which Yoga could be tested.
1. Yoga V ‘Placebo’ exercises
2. Yoga V Yoga with ‘Placebo’ instructions as to expected outcome
3. Mindfulness V Yoga
4. ACT with mindfulness V ACT with Yoga
This could be done with ACT and Yoga naïve clients. With placebo studies neither group should know if they are on the active or placebo trail, but all should know they could be on either. I agree that this is harder with psychotherapy. Using clients naïve to certain treatments or procedures can help this. I don’t think at present I could tell the difference between Yoga and placebo exercises and Yoga can always be compared to other treatments or a therapy waiting list where no treatment is being received.
To accept something merely because I have seen it is, as Dave says, to let our selves of the hook. It is also I feel to miss the point of research to label it as confirming that which we could already see, much like G.B. Shaw’s satirical criticisms of Pavlov in ‘The adventures of the black girl in her search for God’. (see Skinner’s Science and Human Behaviour)
I have no doubt that many people do find Yoga beneficial but also agree with Dave in that we have a duty of care to improve our services and to maintain the efficacy of our treatments. I feel that good scientifically controlled research should be the way forward with this process and I look forward to reading more about Yoga and how I might be able to use it to further help my clients.
I don't have time - I'm dealing with real people
Once again, you guys are talking about yoga like it's a bunch of exercises. It's not. And secondly, what are the three (and only three if you include shelved studies, etc) things that make a difference in psychotherapy? 1) Clients' belief in efficacy 2) relationship between client/therapist 3) fairly rapid treatment after problem begins. So we've already discovered that the belief of clients has an enormous effect on outcome regardless of what type of therapy used. (And this does not only include therapy: it's the same if you use CBT, analysis, or just having a friendly supportive neighbor.) You can make supposedly objective research look almost however you want it too. Besides, it's like the old analysis. Yeah, you can spend years in therapy - suffering, not getting too far for years. I don't have that time. I have real people who are currently suffering, who currently are between a rock and a hard place. They can go to prison, to a restrictive in-patient hospital, or to a fairly loose outpatient program and learn how to focus, concentrate, meditate, and deal with the realities of their lives. And then go out and live a life. It seems unreasonable to say, "Why don't you spend the next couple years in the psych facility at the county prison while I do some more research?" Even if they're REALLY bad and go to the state hospital, sometimes I think that's worse.
Everything should be open to research
I guess the problem with placing our faith in something because we ‘see it working’ is problematic for a number of reasons. The first reason is that we don’t know whether what we are doing is worthwhile – we think we see people getting better but how do we know that they actually are? Without some form of measure demonstrating how the individual felt/behaved/functioned prior to the intervention, how can we tell it is what we are doing with them that is making the difference? Perhaps the change is actually within us as therapists; after spending more time with our clients, the relationship we have with them develops, and WE interpret their behaviour differently, without any actual change occurring to the benefit of the client. Conversely, how do we know we are not doing any damage? There are psychological interventions within the literature that have demonstrated their effectiveness in the short term, but over a longer period appear to be worse for the clients than if they had received no treatment at all.
Without some form of pre and post measurement, how can we tell that the intervention is better, or even worse, than a placebo/nothing/other treatment? To suggest that some of the newer techniques/older traditions (yoga/mindfulness etc.) that are beginning to become more commonplace in behaviour therapy are beyond measurement is to let ourselves off the hook too easily. I feel there is a real danger of not trying hard enough to validate what we do as practitioners, and accepting superficial explanations for what we see before us. If behavioural science is worth anything, it should (and in my opinion can) provide an operational definition of the processes that occur whilst using these different techniques, in order that they can be developed and improved to help as many people as possible, or passed by if they are found to be ineffective in the long-term.
The difficulties that arise when conceptualising research ideas shouldn’t put us off continually trying, and lead us to accept ‘common sense’ explanations; it should make us strive and work harder towards a better understanding of behaviour so that we can help as many individuals as possible.
Again, research
Well, first of all, if a placebo works well, I'm all for it. I take a vitamin every day; I'm convinced it makes me healthier. I have no idea if it does or doesn't change anything physiologically and I don't care. I believe that it makes me feel healthier; I do feel healthier. I practice Vipassana meditation and metta meditation; again, no clue whether or not scientists have found that people are happier, more compassionate, more patient if they do so but I know that I am. It certainly could be that I started out with a patient, happy personality and my belief that meditation would increase these things, made them happen. Who cares? I still ended up as a more patient, compassionate, etc. person regardless of how I got there. As I wrote earlier, particularly in mental health issues, there are so many extraneous things that could "mess up" that traditional double blind controlled study. I think, because it's not that simple - those extraeous things - relationship with the therapist, in particular, make a huge difference. I have no doubt that I could teach my same patients and students yoga with a flat affect, a uncaring attitude, giving off an aura of apathy, and it would not be helpful. So there you go - maybe it's not the yoga - but why would I do that? I think in any therapy the most important thing is the relationship. How can you put that in a box and try to control it?
Even more on research!
I think you’re right in that it is very difficult to attempt to control extraneous and confounding variables in research, especially when working within ‘mental health’. I’ve always had a bit of an issue with the “it’s not the therapy, it’s the relationship” thing though. If that is true, why don’t we just hire people off the street that are pleasant? Why spend all this money on education etc. if all we have to do is to be nice people? Surely if the relationship is the most important thing (and I still have never seen any strong evidence to support this position, despite coming across the assertion all of the time), then sitting in a room with someone and just being pleasant with them should help them with their difficulties. I think we can safely say that’s probably not the case.
I don’t doubt that the relationship IS very important, but to just say “it’s the relationship” tells us absolutely nothing at all. Why is the relationship important? Do I need to like my therapist to feel better? How can you improve the relationship to enhance therapeutic gains? What if I’m attracted to my therapist and show immediate improvement, but severely relapse after the sessions have ended? What if I suffer from anxiety, and I want to make my therapist happy with me, and my improvements are to achieve that aim rather than to help with my life? I really like the Bob Kohlenberg stuff on this (functional analytic psychotherapy). I just think that the issue gets skirted over by the trump card “it’s down to the relationship, stupid”.
I also take your point about placebos. I think a great deal of clients would benefit from being taken off their antipsychotic medication and given something safe. Let’s face it, it can’t be any less anti-theoretical than psychopharmacology already is…The placebo effect is an interesting one, and if that is all that is occurring when an individual practices yoga etc. then maybe there are more efficient ways of obtaining those treatment goals. I personally feel that there is more to it than that, and I think that the path of scientific investigation is the correct tool to find out. My general point is that placebos and placebo effects are interesting, but what if we learned tomorrow that long-term vitamin tablet consumption causes cancer? The point being that in my opinion, it’s never good enough to say ‘if it works, who cares’, because that is a dead-end: no need to try to improve, no need to assess safety/benefits, no need to try to increase our knowledge. It just works.
I think people are certainly finding the older traditions beneficial, and I think it is our duty as care providers to find out how and why, in order that we can be even more effective as practitioners.
The relationship thing
Yeah, it does make a difference. Check out shelved studies sometimes. There really is not a statistical difference between having a great therapist and having a nice next door neighbor who is very empathetic and happens to have a natural ability to read situations well. And no, you don't necessarily have to like your therapist. Your therapist, while he/she could have serious problems with your lifestyle, your opinions, whatever, does have to have a sense of lovingkindness towards you, a sense of wanting the best for you. And you can do a study showing that pretty much anything causes cancer; depends how you do it. Running around changing your diet, your lifestyle depending on every study that comes out, is not trusing your intuition. You know, some people die in car accidents because they had a seat belt on and went under water and couldn't get out. Does that mean I'm not going to wear a seat belt? No. We live in a society that trusts intuition very little and science and studies very much. Seriously, look into the issue of shelved studies. Drug companies love to do it...they want to prove what they want to prove and things that don't fit in, well, they just get sent somewhere else. Like I said in another post, I have real people with current problems - many of them could be dead before a "real" study is conducted. (Some drug companies have said they will make it impossible for any non-drug alternative to gain acceptance because they will continue to argue that nothing can be really proven without the standard control and double blind studies. And they have the money to do that. I know I am doing better than a standard medical model. We've been using that for over 50 years - if it was going to work, it would have atarted working by now.
More on research and relationships
I’m certainly not talking about an ‘either/or’ approach to research; research isn’t something you do while people continue to suffer unaided, it’s a process that you embark upon IN ADDITION to what you would be doing anyway. A good example of this is work with individuals that have committed a sexual offence. The research into the factors that contribute to an individual committing an offence is still patchy (although there is a lot of it), but we know that offering certain intervention programmes reduces recidivism. So as practitioners, we provide treatment at the same time as undertaking research, in order to continually improve the efficacy of the intervention. Although the double-blind approach is supposedly the gold standard of research, that does not have to be the starting point. It sounds like people are benefiting from meditation/yoga etc., that is a good starting point. The next would be to examine how these people fare in the longer-term compared to individuals that didn’t receive the intervention. There are a number of small steps like this that help to accumulate an evidence-base, which then make it easier to undertake a multi-site investigation. I’m certainly not suggesting that it’s your responsibility to be doing all of this! I’m just suggesting that adding small snippets to the evidence when we can and always asking ‘why?’ is all of our responsibilities as clinicians.
The trouble with intuition is that it is completely governed by our own individual learning histories, and is often very wrong. Some research I did into psychologists/psychiatrists predictions of risk showed that their intuition (or clinical judgement) when assessing an individuals risk of committing a further offence was at the chance level. Forensic tools that are designed to assess predictive factors with no clinical judgment involved (e.g. VRAG/HCR-20), however, showed significantly more predictive validity. The ACT approach is also a good example of intuition being misguided. Intuition is the thing that convinces us that if we formulate a problem in a different way, we will be fine. Of course we know that we end up trapped, constantly trying to reformulate/workout our problems. If I am scared of dogs, intuitively I know to avoid them. I also know as a behaviourist that I (counter-intuitively) have to be around dogs as much as possible if I am to overcome my fear, despite all the feelings of dread I get when I am near them, and all the cognitions telling me to hide.
I absolutely agree about shelved studies by the way (at least studies undertaken by drug companies). I think that their approach is often profoundly unethical and flawed. The situation is not particularly bad in the UK at the moment, in that a great deal of psychological (probably most) research gets undertaken without any finance from drug companies, with research grants being granted for mindfulness groups etc, which is positive. Psychiatry, however, is another story.
I still disagree about the relationship though. It’s related in part to intuition. Most people do rely on their intuition (often with intermittent success that maintains it’s use), but as in the above example, some of the things we need to undertake to relieve a problem are counter-intuitive (in ACT, stop struggling, don’t just keep trying harder). That’s the reason I would benefit from one kind of advice from my Grandmother (learnt from experience), and another kind from a therapist (learnt from scientific investigation).
research therapy and relationships
I think we are making some progress in understanding each others positions. By arguing for research I was not proposing that people continue to suffer unaided or that no one should do Yoga until we have some RCT's under our belt. My point is that scientific enquiry goes hand in hand with this. That is one of the things that make us contextual behavioural scientists (in my opinion).
Yoga may indeed be more than just exercises, but I suppose the scientist in me says, "How do we know". Maybe the exercises (breathing, stretches, moves) are the active ingredient, maybe its something else, maybe its placebo. As Steve mentions in a earlier post the question becomes "what is it about Yoga that is helpful". The fact that people are benefiting from it is not in question and I feel the important question will always remain why.
If I understand what the active ingredient(s) in Yoga is then I can make it more applicable to individual clients learning experiences. I have some clients who would probably scoff at the idea of Yoga, regardless of whatever benefit they might receive from it. However, if I understand how or why it works I can attempt to design a different technique rooted in and faithful to the underlying empirical evidence.
With the relationship thing, I'm not totally convinced either. The relationship may be important for many reasons but why then do some therapies consistently outperform others? Are CBT and behaviour therapists nicer people than psychoanalysts? Do particular therapies support particular relationship variables better than others and if so what are those variables? Again, this is not to say we should therefore ignore these until we have ‘evidence’ but on the contrary we should be mindful of them in our own work and practice so we can see what works and with whom. Once we have these observations we can begin to measure them in a variety of ways. I believe some of the FAP people are beginning to do this in a treatment outcome lab.
Is it a question of the therapeutic relationship as a technology? Is there something about having worthwhile human relationships in your life (such as a nice neighbour), why do some people have this and not others? Being in a good relationship may be one thing, getting there is another. During my training I’ve been told that the relationship is one of the most important things but few if any have told me why. That to my mind, is not science.
I feel that the questions about the relationship are extremely interesting and as interesting as those about Yoga, but I feel that they are still questions at this stage and that as clinicians and scientists it is our responsibility to answer them if we are to continue to use these techniques and therapies.
While RCTs are considered the research gold standard, they do have their limits in terms of homogenising heterogeneous groups and in terms of time and resources to name a couple. But they are I feel one of the best tools we have. However, as therapists and behaviour therapists we also have the tool of the single case experimental design as a way of evidencing our own practice. This too could have much to offer in terms of supporting our practice as therapists.
All in all I feel that if something is providing help and benefit to our clients we should use it. This should not, however, exclude us from our responsibilities to evidence our own practice, as best we can in either RCT, multi-site studies or through series of single-case experimental design.
more on compromise
The kind of ‘middle road’ to research and clinical practice that Dave and Aiden have alluded to seems bang on the money for me. It forms a good balance of values between assisting clients and forming a solid basis from which to do so
As functional contextualists the validity of our work needs to be grounded in our ability to predict and influence events. There is a bit of a descriptive contextualist slant to the current discussion for arguments that favour not conducting research into yoga/therapeutic relationships. There seems to be a suggestion that we shouldn’t or couldn’t remove any aspect of these fields to see how it influences the other aspects…without the entire thing falling apart. This may well be the case as I appreciate Yoga to be a well developed system.
However, I was wondering whether it would be viable, as an initial question, to ask who Yoga works for and who it doesn’t…..or which aspects of people’s learning histories are related to their success. To do this you wouldn’t need to breakdown the collection of behaviours that makeup Yoga and could remain true to any holistic principles that seem important. But importantly at the same time you would be answering questions about prediction and influence. All you would need to do is look at individual differences on a range of variables between those in the yoga group and compare to pre and post measures. For instance are there sex, age, SES, educational differences?
Although this is a small step it would be an important one and fit with the alternative to an all or none approach to research. Any additional information could be of help, and in reference to a previous e-mail…..it is true that finding out seatbelts sometimes increase the chance of death in a car accident may not stop me wearing a seatbelt generally but it might increase the likelihood that I remove it when driving around a lake.
Who yoga works for
I think I wrote in an earlier post (maybe not, I forget) that I did a research project in mindfulness and whether or not it improved self-efficacy. I did it at work and part of the research ethics at our hospital is that people have to volunteer to be in projects. (I mean they have to volunteer for the group they want to be in.) So that meant the "control" group were the MDs and RNs (all the psychologists wanted to learn it) who didn't want to learn it. Just seeing the names on the sign up sheet made me laugh. The people with a naturally high degree of self-efficacy were the ones who signed up.
At any rate, I do keep stats currently on which residents won't participate in what. 1) Nobody has ever refused relaxation. 2) Mindfulness training is only offered after momentary concentration can be achieved which requires some initial work. No one who was asked to participate ever refused. 3) Yoga is initially refused by lots of people who don't understand it. They say, "I'm not flexible. I can't do it." etc but when the whole thing is explained, I rarely get a refusal. I have had refusals from people of a certain religion and I can't remember which one. The first woman who told me it was against her religion, I thought was misunderstanding me; I couldn't figure how it could be against her religion since I do it without any mention of religion. She told me she would send something after she left to explain and she did. She sent a religious tract - I really can't remember what religion but definitely a Christian one - and it said very clearly that all yoga teachers are agents for Hinduism, trying to convert people, and also that certain poses allow the devil perfect access into your body. Since that time, two other women from the same religion told me the same thing so I never questioned or tried to explain to people of that religion. The people who participate fully and say they get a lot out of it...some of them amazed me. From looking at some of them, particularly older people who look like they're stuck in their ways, close minded, and ultra conservative, my initial reaction used to be "Oh they won't do it or they'll complain." They are sometimes a little timid at first but in a brief period of time, they're totally into it. I have a wide range of patients - 9th grade drop outs to PhDs. Men, women, all religions except that one I mentioned, or no religion. The biggest improvement people have expressed is a reduction in anxiety. They can notice the anxiety starting to arise, accept it and let it go before it has time to turn into a panic attack. The second highest improvement is in depression and along with this is a decrease in upper respiratory infections (this could be from the increase in deep breathing) and I've had more people quit smoking (without asking anyone to) in the past 5 months than I had in over 12 years of being the employee health nurse where I was forced to nag at people about smoking. (6 people quit smoking as opposed to 2 in that 12 year period.) I think that's amazing.