E9. Tony Rousmaniere – Improving Psychotherapy Outcomes

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Today we speak with Dr. Tony Rousmaniere, a psychologist in private practice in Seattle and a member of the Clinical Faculty at the University of Washington, Department of Psychiatry and Behavioral Sciences. Tony provides clinical training and supervision to therapists around the world with an emphasis on using deliberate practice to develop the clinical skills that enhance psychotherapy effectiveness. Supporting this work, his research is focused on improving psychotherapy outcomes.

Tony is the author of the books Deliberate Practice for Psychotherapists: A Guide to Improving Clinical Effectiveness, and Mastering the Inner Skills of Psychotherapy: A Deliberate Practice Manual, and co-editor of books The Cycle of Expertise: Using Deliberate Practice in Supervision, Training, and Independent Practice, and Using Technology for Clinical Supervision: A Practical Handbook.

We dive into the research around psychotherapy outcomes and how data and technology can be integrated into the training and practice of psychotherapy.

Show Notes

1:10 – An outline of the history of psychotherapy outcome research.

6:40 – Reflections on the training of psychotherapists.

10:35 – On the use of objective metrics in psychotherapy to confirm progress.

15:00 – On the evidence for the use of objective metrics in psychotherapy.

18:50 – On ‘deliberate practice’ in psychotherapy.

31:05 – On the evidence supporting ‘deliberate practice’ in psychotherapy.

34:55 – Other ways in which might advance psychotherapy outcomes as a field.

37:30 – Efforts to reduce cases where a client interacts with a therapist only once or twice before leaving therapy.

39:40 – On the implications of outcome measurement for the business and economics of psychotherapy.

45:05 – Advice to therapists just starting out.

1:10 – An outline of the history of psychotherapy outcome research.

Historically, research has focused on improving psychotherapy outcomes by trying to determine the most effective psychotherapy models. After thousands of randomised clinical trials on hundreds of psychotherapy models, outcomes from all/most psychotherapy models are roughly equivalent. This highlights the importance of factors common to all/most psychotherapy models, rather than the elements specific to any particular model, as the active ingredients. Research is now shifting to what about the therapist accounts for outcomes, other than the model of therapy they employ.

6:40 – Reflections on the training of psychotherapists.

The usual training and professional development of psychotherapists is largely unchanged from the time of Freud; a mix of intellectual learning and reviewing/discussing sessions with a supervisor. However, the focus of this training is almost totally on conceptual understanding and the process of therapy, with virtually no explicit focus on therapy outcomes. A closer eye on client outcomes can guide training / practice and lead to better client outcomes.

10:35 – On the use of objective metrics in psychotherapy to confirm progress.

Psychotherapy research consistently shows that there is way more variance in client outcomes explained by client and therapist factors, than due to the model of therapy used. This highlights that what is considered evidence-based practice should not only rely on clinical trials of therapy models, but actual therapist performance. The main pushback Ton’y hears against the use of objective metrics is that it’s a hassle.

15:00 – On the evidence for the use of objective metrics in psychotherapy.

The evidence suggests that the use of objective metrics improves outcomes for clients at risk of deterioration. That is, therapists are more able to course correct before the client’s symptoms worsen. But objective metrics tend not to be as effective in enhancing outcomes where a client is improving, perhaps because these measures tend to be more symptom focused rather capturing more subtle, positive outcomes.

18:50 – On ‘deliberate practice’ in psychotherapy.

Deliberate practice is basically the drilling of specific elements of psychotherapy. This is necessary as the evidence shows that therapists do not reliably get better with experience. Deliberate practice involves; 1) Observing work performance, 2) Getting expert feedback on performance, 3) Setting small incremental skill-based goals, 4) Repetitive behavioural rehearsal, and 5) Assessing performance. Objective metrics can inform such deliberate practice.

31:05 – On the evidence supporting ‘deliberate practice’ in psychotherapy.

Small qualitative studies have been completed. Larger more rigorous studies are just getting under way. Interestingly, Tony is not overly optimistic about such studies. We likely have a long way to go to be able to effectively incorporate ‘deliberate practice’; we need to better understand what and how to practice.

34:55 – Other ways in which might advance psychotherapy outcomes as a field.

Tony highlighted mobile-based therapy, which promises on-demand therapy at a lower cost, albeit only suitable in some cases. Also supervision over video conferencing and virtual-reality based training.

37:30 – Efforts to reduce cases where a client interacts with a therapist only once or twice before leaving therapy.

Jonathan Swift and Jennifer Callahan have done research into this question. We need more research done because it remains difficult to effectively match. Instead, the emphasis has been on the need for therapists to be responsive.

39:40 – On the implications of outcome measurement for the business and economics of psychotherapy.

Tony hasn’t seen this yet and would strongly recommend against it. This is likely to compromise outcome data as it is easy enough to game.

45:05 – Advice to therapists just starting out.

Expect failures. Don’t be discouraged by these. Remember that you are only as good as you practice and aim to gradually improve over your career.

Episode References

To learn more about Tony’s work, especially around deliberate practice for psychotherapists, please visit https://www.dpfortherapists.com/

Tony’s books, including Mastering the Inner Skills of Psychotherapy: A Deliberate Practice ManualDeliberate Practice for PsychotherapistsThe Cycle of Excellence: Training, Supervision, and Deliberate Practiceand Using Technology to Enhance Clinical Supervision can be found here.

The Great Psychotherapy Debate by Bruce Wampold and Zac Imel.

Tony’s outcome data and links to various outcome measures.

Tony’s article in The Atlantic “What your therapist doesn’t know”.

Jonathan Swift and Jennifer Callahan who have researched client dropout in psychotherapy.

E7. Lennart Verhagen – Ultrasound Brain Stimulation

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Today we speak with Dr Lennart Verhagen, a Post-Doctoral Research Associate at Oxford’s Department of Experimental Psychology who has bet his career on ultrasounic neuromodulation.

Lennart works with his colleagues at Oxford as part of a small network of research teams pushing the frontier of ultra sound brain stimulation and imagery. This technology has breakthrough even revolutionary potential thanks its ability to stimulate deep brain structures, non-invasively and with great precision.

In this conversation, Lennart gives me a crash course in ultrasound and, in particular, low intensity focused ultrasound. We dive into its history, significance and potential as a brain stimulation technology.

Enjoy.

Show Notes

0:06 – Why is a psychology department looking at ultrasound?

2:25 – Why are we making breakthroughs with an old technology like ultrasound?

7:15 – On the relationship of focused ultrasound to the high intensity ultrasound used in medicine.

8:35 – Why is low intensity focused ultrasound important as a brain stimulation technology?

10:40 – On his team’s work and why it is significant.

15:10 – On the clinical significance of longer duration effects and mechanisms of action.

20:35 – On next steps in his research program.

23:13 – On the safety profile of the new longer duration protocols.

27:10 – On the outlook to widespread clinical usage and lessons learned from the development of TMS protocols.

33:00 – On the clinical potential for focused ultrasound neuromodulation and what treatments might look like.

41:30 – On what undergoing ultrasound brain stimulation would involve.

46:20 – On its potential as a tool in basic neuroscience research.

0:06 – Why is a psychology department looking at ultrasound?

2:25 – Why are we making breakthroughs with an old technology like ultrasound?

We’ve known since the 1950s that neuron firing rates can be altered using focused ultrasound. However, recent advances in computational capacity mean we can now model how the ultrasound will travel through the skull and brain tissue, enabling ultrasound to be precisely focused and directed.  To date, ultrasound brain stimulation has been online, meaning that the effects only last while stimulation is ongoing. Lennart’s group has developed a protocol that enables longer lasting effects, up to an hour after the stimulation stops.

7:15 – On the relationship of focused ultrasound to the high intensity ultrasound used in medicine.

The technology being used by Lennart’s group is similar to the high intensity focused ultrasound being used in medicine to lesion and ablate brain tissue without surgery, though at a lower intensity.

8:35 – Why is low intensity focused ultrasound important as a brain stimulation technology?

Focused ultrasound is one of two technologies heralding a new era of deep brain neuromodulation. Prior to these two technologies, the only way to stimulate deep in the brain was invasive; surgically implanting electrodes. The other new non-invasive technology, electrical temporal interference, was first reported in 2017 and relies on electrical interference patterns. Lennart believes that focused ultrasound will prove superior due to its greater precision.

10:40 – On his team’s work and why it is significant.

Quite remarkably, the literature had contained hints of the potential for the effects of ultrasound stimulation protocols to have relatively enduring effects; there were cases where the effects were still present one minute later when the researchers stopped measuring. By utilising repetitive and slightly longer duration and therefore higher energy protocols than had previously been explored, Lennart’s team and their collaborators around the world, (including Jean-Francois Aubry), had achieved effects that lasted up to an hour. These effects are apparent not just at the neuronal level, but in subtle measures of behaviour. For example, the saccade behaviour of monkeys.

15:10 – On the clinical significance of longer duration effects and mechanisms of action.

The clinical significance of longer duration effects vs. repeated shorter duration effects as seen in TMS is an open question. Mechanisms of action include: (a) altered neuronal firing patterns, which, since neurons that fire together wire together, could lead to lasting change, and (b) increasing the ability of certain circuits to display plasticity, that is, to become more susceptible to retraining.

Enhanced plasticity is closely related to long-term potentiation (increased strength of connections that neurons form) understood to be relevant to clinical depression. Fascinatingly, the clinical utility of inducing a ‘plasticity window’ effects is likely to require either: (a) psychotherapy, where treatment efficacy relies both on the quality of the psychotherapy and how ‘plastic’ or susceptible to training and change the brain is, or (b) continued lived experience from which the client may  be able to better learn and grow. Long term plasticity is a key research focus of the group because it is this effect that has the potential for a significant role in mental health treatments.

20:35 – On next steps in his research program.

Next steps include indexing long term plasticity via changes in neurotransmitter ratios, investigating how learning might be effected, and confirming the risk profile of long term usage.

23:13 – On the safety profile of the new longer duration protocols .

No new adverse effects have been detected.

27:10 – On the outlook to widespread clinical usage and lessons learned from the development of TMS protocols

Clinical trials are required, so widespread clinical use is some years away but likely significantly less than a newly discovered drug. However, clinical efficacy is yet to be established, so talking timeframes to market is hypothetical at this point. And in fact, given the promise, Lennart often finds himself having to try to temper expectations. In doing so, he hopes to avoid the rushed and ultimately somewhat wasted efforts in studying TMS protocols, due to the hype that initially surrounded the technology.

33:00 – On the clinical potential for focused ultrasound neuromodulation and what treatments might look like.

Major Depressive Disorder is an obvious first target given its impact and association with deep brain structures. However, MDD is a very heterogeneous disorder, and only certain subtypes are likely to be more amenable to treatment with focused ultrasound. Anxiety and PTSD may also be profitable targets. Neurological disorders, such as Parkinsons, Alzheimers and Tinnitus are also potential targets, where focused ultrasound will likely be used in preventative and complementary ways. Again, effective treatment is likely to require both the physiological changes brought about by the ultrasound stimulation, and people incorporating their subjective experiences whether with a therapist or just living life.

41:30 – On what undergoing ultrasound brain stimulation would involve.

The first thing is to take a high fidelity image of the skull, ideally a CT scan. This enables detailed modelling of how the ultrasound will travel through the skull.  Then, after applying a gel to your head, infrared sensors would direct the ultrasound from a small head-mounted transducer, perhaps in a kind of helmet. No anaesthesia is required. Further developments will see the gels done away with, and radiation-free MR scans used instead of CT scans.

46:20 – On its potential as a tool in basic neuroscience research.

Focused ultrasound holds significant potential as a basic neuroscience tool, and in fact these are likely to be the first applications of the technology. We are able to image the whole brain well, but we have not been able to non-invasively stimulate deeper brain structures. Doing so, will enable us to better establish causal relationships of deep brain structures and circuits. Other use cases include sonogenetics, which is likely to supplement optogenetics in basic neuroscience research, and selectively opening the blood brain barrier which can facilitate drug delivery.

Ultrasound is also likely to be used as an imaging tool, which could deliver micrometer accuracy with millisecond temporal resolution; “FMRI on steroids”. This may be a decade away, but it is largely an engineering problem from this point, as high fidelity, high temporal and spatial resolution performance has already been achieved in rodents (with their thinner skulls).

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Episode References

Lennart’s website and Twitter profile

Lennart’s Paris based collaborator,  Jean-Francois Aubry

Long-term potentiation

Magnetic resonance spectroscopy

Extinction

A paper, published on the day of the interview on Ultrasonic Imaging of Gene Expression