Psychiatry Advisor Informational Page on Trichotillomania

Psychiatry Advisor Informational Page on Trichotillomania

I’ve been working with trichotillomania (i.e., hair pulling) for several years now and am always happy to see this understudied problem receive more press.

I recently came across a useful informational page on trichotillomania on the Psychiatry Advisor website. The page provides concise, up-to-date info on “trich,” including behavioral and pharmacological treatment, and diagnostic considerations. It is a great reference for anyone new to trichotillomania.

You can check it out here.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

More Avoidant Therapists Are Less Likely to use Exposure in OCD Treatment

More Avoidant Therapists Are Less Likely to use Exposure in OCD Treatment

In a previous post, I linked to a blog post about therapist reluctance to use exposure therapy. Exposure therapy is one of the most effective interventions for anxiety-related problems but, sadly, remains under-utilized by clinicians. It is an intervention that has been a major focus on my posts on this blog.

A recent study out of Drexel University looks at the role of experiential avoidance in therapist reluctance to use exposure therapy to treat OCD. Experiential avoidance (EA) refers to a tendency to avoid uncomfortable thoughts, feelings, and bodily sensations, and is a cornerstone in the model of psychopathology in Acceptance and Commitment Therapy.

Methods

The researchers recruited 172 clinicians who identified as cognitive behavioral therapists. Each participant completed self-report measures of EA, attitude towards evidence-based practice, thinking style, and treatment approaches. These therapists watched 2 of 4 possible video vignettes featuring actors portraying people with OCD based on scripts that were vetted by OCD experts. The therapists then rated how much time they would allot for different therapy techniques in treating the case example.

Findings

The researchers found that therapists who scored higher on experiential avoidance (EA) reported they would devote less time to using exposure for treating OCD clients in the vignettes they watched. This is striking as exposure is the gold standard treatment for OCD. Additionally, therapists who scored higher in EA showed a lower preference towards evidence-based practice. An interesting gender finding was that women exhibited a greater preference for evidence-based practice than men.

As the authors note, it’s impossible to derive a causal relationship between these variables. For example, they speculate that therapists who are more experienced in exposure may develop lower EA because of they themselves get used to doing exposure. In support of this view, the authors note that therapists who spent a larger portion of their time doing clinical work exhibited lower EA.

Overall, this study suggests that higher experiential avoidance may be a barrier to using exposure therapy and evidence-based practices.

Check out the article!

If you’re a member of the Association for Contextual Behavioral Science, you can download a copy of the article here if you log into your account.

Enough already: Let’s move on from meta-analyses of psychoanalytic psychotherapy and do the hard work of quality studies

Enough already: Let’s move on from meta-analyses of psychoanalytic psychotherapy and do the hard work of quality studies

The past few years has seen an increasing push to demonstrate the legitimacy of long-term psychodynamic and psychoanalytic therapies (e.g., Leichsenring & Rabung, 2008). It seems proponents of psychodynamic therapy are trying to play catch up. There’s an enormous amount of research support for cognitive behavioral approaches; by contrast, controlled research for psychodynamic approaches is sparse.

Since long-term psychoanalytic psychotherapy is a mouthful, we’ll follow the cue of those before us and call it LTPP for short.

It’s unfortunate there’s not a lot of controlled research on LTPP, as I think controlled studies carefully examining the processes and outcomes of psychodynamic therapies could only enhance our understanding of treatment. As a way to bolster support, some psychodynamic researchers have taken what studies exist and published meta-analyses of the existing research. Some of the recent ones concluded that LTPP is an effective treatment for a variety of psychiatric conditions (De Maat, 2009; Leichsenring & Rabung, 2008, 2011). These findings were not without controversy, however.

You may have noticed, for example, that Leichsenring and Rabung are listed twice. There’s a reason for this: their 2008 meta-analysis was widely criticized for miscalculating effect sizes. According to critics, the researchers had simply looked at pre-post changes (within-group difference) rather than comparing LTPP against the control conditions (between-group differences). The researchers redid their analysis in the 2011 meta-analyses and found LTPP was effective, albeit to a lesser degree.

Although I think meta-analyses on psychodynamic therapy have been over-played of late, I was excited about a new one published in Clinical Psychology Review (Smit et al., 2012). This article is a collaboration of Dutch researchers and John Ioannidis. I perked up at the mention of Dr. Ioannidis’ involvement.

Who is John Ioannidis?

Not to give short shrift to the others involved, but I was really excited by Ioannidis’ presence on this article. Ioannidis, a medical researcher with several academic appointments, has become one of the foremost experts in the credibility of medical research. He published a hugely influential paper arguing that most medical findings are inaccurate, and he was even profiled in The Atlantic. With his name attached to this piece, I could be confident that the methodology of this meta-analysis had been scrupulously thought out and executed.

A little background on meta-analysis

Meta-analyses are a way of consolidating a number of studies on a particular area of focus that allows for comparison across studies. Researchers may then draw more general conclusions from a bunch of data. This is done by converting the results from each individual study into effect sizes.

Like any tool, meta-analyses are only as good as the way they are used. Researchers make decisions about what studies to include (and not to include), what outcomes to look at, and how to run the analyses. As they say, “garbage in, garbage out.” Moreover, meta-analyses are no substitute for rigorously controlled studies.

The bottom line: meta-analyses of low quality research lead to low quality conclusions

The reason why I’m hoping this article will be the final word on this topic for now is that it ultimately points to the need for more high quality data.

In contrast to previous meta-analyses, the researchers in this study had difficulty drawing firm conclusion about LTPP because the available research was generally of low quality. Their main criticism is that LTPP was often compared against substandard treatments. The authors call these “straw man” comparisons, as there is little reason to believe these control conditions are effective. In the few studies that compare LTPP against evidence-based treatments such as dialectical behavior therapy, LTPP does not fare so well, according the researchers.

What this means is that without well-controlled studies of LTPP against established treatments for specific psychiatric problems. It is difficult to gauge the effectiveness of LTPP. The few highly quality studies available suggest that when LTPP is compared against bona fide treatments, it doesn’t appear to be particularly effective. Hopefully, researchers will now take a break from meta-analysis and focus their efforts towards creating more high quality, controlled studies comparing LTPP to treatments with a strong track record.

Let’s move on and do the work…

I think we’ve seen enough meta-analyses on LTPP for the time being. If a strong argument for LTPP is to be made, it will require a focus on quality, controlled research that compares LTPP to bona fide treatments for specific conditions.

But don’t take my word for it: I highly recommend reading the study yourself. For a scientific article, it’s actually quite lucid and readable. I obtained it by following James Coyne’s suggestion in the blog post that alerted me to this article, and emailing the author, Arnoud Arntz, who quickly and thoughtfully sent me a copy:

Arnoud.Arntz@Maastrichtuniversity.nl

Marketing For the Evidence-Based Therapist

Marketing For the Evidence-Based Therapist

As a large body of therapies have been identified that are demonstrably effective, the field has shifted toward dissemination and implementation. For those who are out in practice, a main way we get evidence-based therapies to clients is through effective marketing. As the director of a growing clinic who has worn pretty much every hat (e.g., entrepreneur, biller, therapist, manager, bookkeeper, receptionist, accountant, janitor), I’ve had to learn a lot about marketing over the last several years. In particular, I’ve found that online marketing has been especially fruitful for our business.

In the process of doing some of our online marketing, a colleague asked me to make some recommendations for key books relating to marketing a private practice. I realized that I had no one book that covered most of the material that I had learned, but instead had learned through a variety of resources over the years, many of them online. Below lies a smattering of links and resources on online marketing that I’ve found useful over the years as well as some general comments about the important elements of a building a business as a therapist.

Search engine optimization (SEO)

Once you build a website, you need to hire someone to help you optimize your site and drive traffic to it. Just building a website is near useless if you don’t figure out how to get people to visit it. You should be able to get someone who can help you drive traffic to your website for $400 a month or less. You need to spend money on marketing in order to grow your business (or even to have a business usually). Marketing works, that’s why we have so much of it around us. It changes behavior and will bring people to your doorstep. SEO professionals know how to bring more clients to your door. This is money well spent, once you have a website already up. 

Some links to get you started on what SEO is and how to do it:

http://www.seomoz.org/blog/the-beginners-checklist-for-small-business-seo

Private practice marketing

If you need some help with business strategies overall, most areas of the country have a small business development center. Look up your local center. They often provide very affordable and expert training that is perfect for mental health professionals trying to expand their business knowledge. I’ve learned a lot from my local SBDC. http://www.sba.gov/content/small-business-development-centers-sbdc

Some good articles can be found here: http://www.uncommonpractices.com/articles.html

This is my favorite book about running a private practice in terms of recommendations on how to do marketing: Getting Started in Private Practice: The Complete Guide to Building Your Mental Health Practice

Website design

Three tips:

1) Put a contact form on the front page of your website and the contact page, rather than relying on people to call you. You’ll get a lot more contacts that way. 

2) Learn how to use WordPress to set up your site. It’s simple and easy to use once you’ve learned how to set it up.

3) Get your site noticed and convert visitors to clients:

Business blogging and writing good content

Here’s a basic primer on writing good blog posts by a leading blog developer: http://www.davidrisley.com/blog-writing/

One of the oldest and most prolific blogs about blogging: http://www.copyblogger.com/blog/

General online marketing

Here’s a graphic to help you see all the possibilities for online marketing and organize your thinking: http://assets.unbounce.com/s/images/noob-guide-to-marketing-infographic-1800.png

Some basics on online marketing: http://counsellingresource.com/lib/practice/internet-marketing/

Some webinars if you like to watch those: http://www.hallme.com/archived-webinars.php

Social Media Marketing

Some tips on how to embrace social media and the latest changes in Google to your advantage: http://www.psychotherapynetworker.org/magazine/recentissues/2012-mayjune/item/1708-in-consultation

A psychotherapist’s guide to Facebook and Twitter: Why clinicians should give a tweet – http://www.psychotherapy.net/article/psychotherapists-guide-social-media

Dr. Keely Kolmes’ private practice social media policy – http://www.drkkolmes.com/docs/socmed.pdf

Online business models

You might want to write a business plan. Here’s a template:

http://www.copyblogger.com/smart-people-business-plan/

I don’t know of anyone better at it and who produces better content on running a business online than Pat at Smart Passive Income. His podcast is super-popular, interesting, and very relevant: http://www.smartpassiveincome.com/

Pay-per-click advertising (PPC)

 

Really the only place you need to advertise is with google adwords. It’s not too hard to set up a basic account, set a budget and try it out. Here are some ideas on how to do that: http://adwords.google.com/select/Login

Adwords for therapists: http://www.uncommonpractices.com/adwords.html

Optimizing quality score: http://www.redflymarketing.com/blog/how-to-improve-quality-score-the-ultimate-guide/

Newsletters

Before putting your efforts into blogging, first create a following with an email list to directly connect with local, potential clients in a more direct way   

http://uncommonpractices.wordpress.com/2009/04/22/why-blogging-is-a-waste-of-time-for-private-practitioners/

http://www.smartpassiveincome.com/email-list-strategies/

I like Mailchimp because the interface is very simplified and you are able to get a feel for creating and using newsletters for marketing your business without having to invest right from the start.  Your account is free as long as you have less than 2,000 subscribers and you send less than 12,000 emails per month.

http://mailchimp.com/

Other popular services include:

http://www.aweber.com/

http://www.constantcontact.com/

Face-to-face networking

My favorite book on this topic is: Never Eat Alone

And if you are looking to improve your social skills, speaking abilities, and ability to just interact with others and make conversation, I don’t know a better place than Toastmasters, which I have been a member of for years. To find a meeting near you: http://reports.toastmasters.org/findaclub/

See if there is a meetup group in your area either of therapists or other professionals in your area of interest.

Finding your passion

And Don’t do any of these things if it doesn’t align with your passion: http://zenhabits.net/the-short-but-powerful-guide-to-finding-your-passion/

Team Up

Check with your state’s psychological association to see if they have any events scheduled to learn more about marketing.

See if you can find a “practice buddy” — another local mental health practitioner who has similar goals and who can meet with you to brainstorm ideas regarding seminars, networking groups to attend, accessing each other’s networks, and setting goals for putting these tips to work.

Do you have favorites? Send me a message about those and I’ll check them out. Who knows, maybe they’ll make it onto the list.

The medical and mental health community speak out about the dangers of “antipsychotic” drugs and proven, non-drug alternatives

The medical and mental health community speak out about the dangers of “antipsychotic” drugs and proven, non-drug alternatives

A couple of decades ago, big pharma promised to revolutionize the treatment of serious mental health concerns with a new class of atypical antipsychotic drugs such as Abilify and Seroquel. In terms of financial success, those two drugs were “revolutionary.” They are now the 5th and 6th most commonly prescribed drugs in America — despite mounting evidence that questions the efficacy and safety of these drugs (e.g. the huge CATIE and CUtLASS trials). Prominent members of the psychological and psychiatric communities are sounding the alarm about the overuse of these drugs and the erosion of other forms of treatment, particularly evidence-based psychosocial approaches.

In a recent article in the New York Times, Richard Friedman, M.D., expresses concern over increasing use of these drugs for unproven conditions, calling the use of “antipsychotic” drugs to treat everything from anxiety to insomnia as “unbelievable.” Studies on the use of antipsychotics to treat anxiety have failed to show that they are effective and there is no FDA approval for any atypical antipsychotic for the treatment of any anxiety disorder. Despite this lack of evidence, a recent study showed that prescribing of antipsychotics by psychiatrists for anxiety almost doubled between 1996 and 2007.  In this study, 21% of individuals who sought treatment from a psychiatrist for an anxiety disorder in 2007 were prescribed an antipsychotic drug versus  11% in 1996. Moreover, as Dr. Friedman points out, antipsychotics, including  newer “atypical” drugs, frequently have serious side effects such as increased blood lipids and cholesterol, irreversible movement disorders, and weight gain. If these statistics are correct, there are hundreds of thousands of people in the US alone who are taking antipsychotic medications for conditions they have been shown to not work with and suffering under the serious side effects of these medications.

Dr. Friedman is not alone in sounding the alarm. Just this year, the editor of the British Journal of Psychiatry (BJP), probably the most influential psychiatry journal in Britain, called for an “end to the psychopharmacological revolution.” In this piece in BJP, he stated that the prescription of antipsychotic medications needs to be drastically reduced. He stated that the side effects of antipsychotic drugs are too extreme to justify their limited benefit, even in the treatment of schizophrenia and bipolar disorder, for which there exists the largest evidence base supporting the use of these drugs. He stressed that non-drug therapies, such as cognitive behavioral therapy, are proven, effective, and affordable alternatives that need to be used much more frequently. This statement comes from someone who is a prominent member of the medical and psychiatric communities, where drug treatments are usually preferred over psychosocial interventions.

Psychological treatments for schizophrenia, anxiety, and other mental health conditions continue to advance and are becoming more readily available. Based on the current state of the evidence on the use of antipsychotics and the rapidly growing evidence for the use of psychological versus pharmacological treatments, consumers of mental health services need to understand that there are effective alternatives to medications. While it is our opinion that there can be a role for medication in the treatment of mental health difficulties, we want consumers to be informed about the limited effectiveness of antipsychotics, the large potential downsides of using this kind of medication, and the availability of effective psychological treatments. Big pharma is not going to send this message, and people need to be able to make informed choices about their mental health care.

Many in the scientific community are sounding the alarm about the rapidly growing use of antipsychotic medications. But is that alarm loud enough to be heard above the incredibly well-funded big pharma marketing campaigns? We hope so.

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