It’s The Relationship That Heals:A New Spin on “Evidence-Based

Practice”

Jamie Marich, Ph.D., LPCC-S, LICDC-CSFounder, Mindful Ohio & The Institute

for Creative Mindfulnesswww.mindfulohio.com

About Your Presenter• Licensed Supervising Professional Clinical Counselor • Licensed Independent Chemical Dependency Counselor• 14 years of experience working in social services and

counseling; includes three years in civilian humanitarian (Bosnia-Hercegovina)

• Specialist in addictions, trauma, EMDR, dissociation, performance enhancement, grief/loss, mindfulness, and pastoral counseling

• Author of EMDR Made Simple, Trauma and the Twelve Steps, Trauma Made Simple, and Dancing Mindfulness (forthcoming)

• Creator of the Dancing Mindfulness practice

From the American Psychological Association

(2006)

An evidence-based practice in psychology is “the best available research with clinical expertise in the context of patient characteristics, culture, and preferences”

From Irvin Yalom Therapy should not be theory driven, but relationship driven (The Gift of Therapy, 2001)

The Every Day Gets a Little Closer experiment (Yalom & Elkins, 1974)

What does empathy mean to you?

Empathy

• Coined by the German philosopher Rudolf Lotze in 1858

• The German word, Einfühlung, translates as “in” + “feeling”

• Derives from the Greek empatheia, meaning “in” + “pathos” (feeling)

• Pathos is also the root of “passion” and “pain”

Empathy

Direct identification with, understanding of, and vicarious experience of another person's situation, feelings, and motives.Stedman’s Medical Dictionary (2002)

The Rogerian View of Empathy

“Being empathetic reflects an attitude of profound interest in the client’s world of meanings and feelings. The therapist receives these communications and conveys appreciation and understanding, assisting the client to go further or deeper. The notion that this involves nothing more than a repetition of the client’s last words is erroneous. Instead, an interaction occurs in which one person is a warm, sensitive, respectful companion in the typically difficult exploration of another’s emotional world. The therapist’s manner of responding should be individual, natural, and unaffected. When empathy is at its best, the two individuals are participating in a process comparable to that of a couple dancing, with the client leading and the therapist following.”

(Raskin & Rogers, in Corsini, 2014)

The Imperative of the Therapeutic Alliance

• Using a collection of empirical research studies and chapters from the psychotherapeutic professions, Norcross (2002) demonstrated that a combination of the therapy relationship, together with discrete method, is critical to treatment outcomes.

• Norcross further concluded that relational skills can be honed by therapists, and that it is the therapist’s responsibility to tailor these skills to the needs of individual clients.

The Imperative of the Therapeutic Alliance

Norcross’ contentions also supported by the massive literature reviews that appear in The Heart and Soul of Change: Delivering What Works in Therapy (Duncan, Miller, Wampold, & Hubbard, 2009)

The Common Factors

• Client & extratherapeutic factors• Techniques that engage and inspire the

participants• The therapeutic alliance• The clinician

The Common Factors

• The common factors are a listing of four qualities that all successful psychotherapeutic approaches have in common

• Developed by psychiatrist Saul Rosenzweig (1936), in response to the numerous philosophies of therapy asserting their superiority in his era

• A review of over sixty years of literature on psychotherapy and therapeutic change supports the common factors hypothesis (Duncan, Miller, Wampold, & Hubbard, 2009)

What Works for Trauma Processing?

• A meta-analysis examining all studies on bona fide treatments for PTSD (e.g., desensitization, hypnotherapy, PD, TTP, EMDR, Stress Inoculation, Exposure, Cognitive, CBT, Present Centered, Prolonged exposure, TFT, Imaginal exposure) conducted between 1989-2007 found no statistical significance amongst the treatments (Benish, Impel, & Wampold, 2008).

• The only factor leading to any statistically significant impact was therapist allegiance.

What Works for Addiction Treatment?

• A meta-analysis examining all studies on bona fide treatments for alcohol dependence and abuse (e.g., CBT, 12-steps, PDT, Relapse Prevention therapy) conducted between 1960-2007 found no statistical significance amongst the treatments (Imel, Wampold, Miller, & Fleming, 2008).

• The only factor leading to any statistically significant impact was therapist allegiance.

The Common Factors

• Client & extratherapeutic factors• Techniques that engage and inspire the

participants• The therapeutic alliance• The clinician

From the American Psychological Association

(2006)

An evidence-based practice in psychology is “the best available research with clinical expertise in the context of patient characteristics, culture, and preferences”

Partners for Change Outcomes Management System (SAMHSA:

2012)

For More Information on Client Outcomes Research &

Tracking:

www.centerforclinicalexcellence.com

www.myoutcomes.com

Marich (2012)

• There are several qualities of good therapists that must be examined to understand what clients most value in EMDR Therapy.

• These qualities, as defined by former clients, include therapist personality, an ability to empower clients, flexibility, intuition, a sense of ease and comfort in working with trauma, and a commitment to the small measures of caring that clients identify as helping them feel safer.

Cindy & JoElle: Description of Negative Experience with Their First EMDR

Therapist • rigid• scripted • detached • anxious• unclear • uncomfortable with trauma

According to Cindy (Regarding 2nd Therapist):

“My EMDR therapist played a very significant part in knowing exactly what she needed to say to me to either bring stuff out or to move onto something else or to focus on this. And I think it was huge, actually, in making that connection that was so important.

[EMDR] is something that’s very personal and very involved and I think it takes a special kind of counselor to pull stuff out of you.”

According to JoElle (Regarding 2nd Therapist):

“She was a natural for this job. I could think something and she would say it. She was just amazing and she knew so much… she just knew a lot about me and she was really easy to talk to. She used, to me, a lot of common sense along with counseling. That’s not always done. She was the greatest.”

Now It’s Your Turn…

• Write up a brief case, typical for your clinical setting (5-7 characteristics):

- An actual client (using a pseudonym)- A composite client- A “famous” example- A fictitious case

Break Time

Participation Exercise

Reactions/Discussion From

Empathy Exercise

The Case of Anna: Qualities of a Good Therapist (Marich,

2014)• To know and understand a client’s diagnosis.

• To get to know you, where you're at (are you externally and internally safe???), where you've come from (historical context; triggers, traumas, what to be aware of), and where you want to go (short- and long-term goals).

• To be a person who believes in TEAMWORK.  Both the professional and the client do work, lots of it.  There is not an aggressor in the equation, ever.  When/if it happens, stop.

The Case of Anna: Qualities of a Good Therapist (Marich,

2014)• To have compassion and empathy—NOT PITY,

ever.  I have seen pathological psychiatrists who don't like humans. Pity is just destructive to what is supposed to be happening: growth and healing.  Pity is never a foundation for that.

• To have a sense of connectedness.  For people without a diagnosis, when they're going through a hard time, the baseline is to find someone you connect with.

• To never, never, never put their own moral thing (e.g., Christianity) above the code of treatment.  Ever!!!!!  No dogma at all should be in the way of the client finding her way.

The Case of Anna: Qualities of a Good Therapist (Marich,

2014)

“Bad therapy is worse than no therapy.  I have learned this experientially.”

-Anna

Best Practices for Assessment &

Interactions with Clients• Do not re-traumatize! • Do ask open-ended questions • Do be genuine, build rapport from the first

greeting • Do consider the role of shame in addiction,

trauma, and grief• Do be non-judgmental• Do avoid the “you need to” language• Do make use of the stop sign when appropriate • Do assure the client that they may not be alone in

their experiences (if appropriate) • Do have closure strategies ready

Principles of Trauma-Informed Care (SAMHSA, 2014)

• Promote trauma awareness and understanding• Recognized that trauma-related symptoms and

behaviors originate from adapting to traumatic experiences

• View trauma in the context of individuals’ environments

• Minimize the risk of retraumatization or replicating prior trauma dynamics

• Create a safe environment

Principles of Trauma-Informed Care (SAMHSA, 2014)

• Identify recovery from trauma as a primary goal• Support control, choice, and autonomy • Create collaborative relationships and participation

opportunities • Familiarize the client with trauma-informed services • Incorporate universal routine screenings for trauma• View trauma through a socio-cultural lens• Use a strengths-based perspective: Promote

resilience

Principles of Trauma-Informed Care (SAMHSA, 2014)

• Foster trauma-resistant skills• Demonstrate organizational and administrative

commitment to trauma-informed care• Develop strategies to address secondary trauma and

promote self-care• Provide hope—recovery is possible

Read the entire SAMHSA Treatment Improvement Protocol:

•Substance Abuse and Mental Health Services Administration (2014). A treatment improvement protocol: Trauma-informed care in behavioral health services. Washington, DC: Author.  

•Available online: http://www.ncbi.nlm.nih.gov/books/NBK207201/

Mindfulness & Self Care• Promoting mindfulness in psychotherapists-in-training could

positively influence the therapeutic course and treatment results in patients (randomized, double-blind controlled study; Grepmair, Mitterlehner, Loew, et al, 2007)

• Health care professionals participating in a mindfulness-based stress reduction program (MBSR) were able to more fully identify their own themes of perfectionism, the automaticity of “other focus,” and their tendencies to always enter “fixer” mode; this recognition led to numerous changes along personal and professional domains (grounded theory; Irving, Park-Saltzman, Fitzpatrick, et al., 2014); a similar study that exclusively studied nurses yielded similar findings (Frisvold, Lindquist, McAlpine, 2012)

Mindfulness & Self Care

• In an extensive mixed methods research study with working psychotherapists from a variety of theoretical backgrounds, Keane (2013) concluded that personal mindfulness practice can enhance key therapist abilities (e.g., attention) and qualities (e.g., empathy) that have a positive influence on therapeutic training.

• Mindfulness practice could provide a useful adjunct to psychotherapy training and be an important resource in the continuing professional development of therapists across modalities.

Beutler, et al. (2005)On the Connection Between Therapist Traits

& Client Outcomes

• Effective therapists are interested in people as individuals

• Have insight into their own personality characteristics

• Have concern for others• Intelligent • Sensitive to the complexities of human

motivation• Tolerant• Able to establish warm and effective

relationships with others

Charman (2005)

• mindful• not having an agenda• having concern for others • intelligent• flexible in personality • intuitive• self-aware • knows own issues • able to take care of self • open • patient• creative

ReferencesAmerican Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285. Benish, S., Imel, Z., & Wampold, B. (2008). The relative efficacy of bona fide psychotherapies for

treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28(5), 746–758.

Beutler, L., Malik, M., Alimohamed, S., Harwood, T., et al. (2005). Therapist variables. In M. Lambert (ed.). Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5th

ed.,pp. 227–306). New York: Wiley. Charman, D. (2005). What makes for a “good” therapist? A review. Psychotherapy in Australia, 11(3),

68–72. Duncan, B.L., Miller, S.D., Wampold, B.E., & Hubble, M.A. (Eds.) (2009). The heart and soul of change: Delivering what works in therapy. (2nd ed.) Washington, D.C.: American

Psychological Association. empathy. (2002). Stedman’s Medical Dictionary. Retrieved February 18, 2012, from Dictionary.com website http://dictionary.reference.com/browse/empathyFrisvold, M. H., Lindquist, R., & McAlpine, C. P. (2012). Living life in balance at midlife: Lessons

learned from mindfulness. Western Journal of Nursing Research, 34, 265-278.Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., & Nickel, M. (2007). Promoting

mindfulness in psychotherapists in training influences the treatment results of their patients: A randomized, double-blind controlled study. Psychotherapy and

Psychosomatics, 76, 332-338.Imel, Z., Wampold, B., Miller, S., & Fleming R. (2008). Distinctions without a difference: Direct

comparisons of psychotherapies for alcohol use disorders. Psychology of Addictive Behaviors, 22(4), 533-543.

ReferencesIrving, J.A., Park-Saltzman, J., Fitzpatrick, M., Dobkin, P.L., Chen, A., & Hutchinson, T. (2014).

Experiences of health care professionals enrolled in mindfulness-based medical practice: A grounded theory model. Mindfulness, 5, 60-71.

Keane, A. (2013). The influence of therapist mindfulness practice on psychotherapeutic work: A mixed-methods study. Mindfulness. DOI: 10.1007/s12671-013-0223-9.

Marich, J. (2012). What makes a good EMDR therapist?: Exploratory clients from client-centered inquiry. Journal of Humanistic Psychology, 52(4), 401–422.

Marich, J. (2014). Trauma made simple: Competencies in assessment, treatment, and working with survivors. Eau Claire, WI: PESI Publishing & Media.

Norcross, J. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.

Raskin, N.J., & Rogers, C.R. (2014). Person-centered therapy. In R.J. Corsini & D. Wedding (Eds.), Current psychotherapies (pp. 133-167). Belmont, CA: Thomson Wadsworth.Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415. Substance Abuse and Mental Health Services Administration (2014). A treatment improvement protocol: Trauma-informed care in behavioral health services. Washington, DC: Author. Yalom, I. (1973). Every day gets a little closer: A twice-told therapy. New York: Basic Books. Yalom, I. (2001). The gift of therapy: Reflections on being a therapist. London: Piatkus Books.

To contact today’s presenter:

Jamie Marich, Ph.D., LPCC-S, LICDC-Sjamie@jamiemarich.com

www.jamiemarich.comwww.drjamiemarich.comwww.mindfulohio.comwww.dancingmindfulness.comwww.traumamadesimple.comwww.traumatwelve.com

Phone: 330-881-2944