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Articles    H3'ed 2/15/10

Treatment Programs -" Do they work?

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"Live" from the Creativity and Madness conference in Santa Fe, New Mexico, February 14, 2010, Valentine's Day, we consider the question of treatment does it work? Treatment is a billion dollar industry in America. We have treatment programs for everything from alcohol users to drug users to people who have too much sex, to people who have too little sex, to people who eat too much, to people who eat too little, to people who eat and then purge, to people who cut themselves, to people who are too sad, to people who are too happy. So many people go for treatment and so many experts purport to tell people how to reform. The question does it work? Does treatment actually help anyone?

When I worked in Saskatchewan, we attempted to address the simple question of whether "28 day alcohol treatment programs" worked. In general, they didn't. People came home and quickly resumed drinking. At the time I was working with Native people in Northern Saskatchewan. The irony was that we had unlimited funds to send people south to 28 day treatment programs and no funds to organize local support for people coming back from treatment programs.

Previoiusly, when I consulted to an Eating Disorders Treatment Program, I was asked to do a follow-up study of their clients. I discovered that the most successful patients were the "bad patients", those identified by the staff as unlikely ever to succeed. The least successful patients were the "good patients", those who complied, who did everything they were told, who were pleasant and easy. Ironically, the relapse rate of this $1,000 per day, 28 day treatment program was greater than spontaneous recovery rates reported in the literature. Five years after people were diagnosed with eating disorders, 65% had recovered with no treatment. In the treatment program I studied, after 5 years, fewer than 30% recovered with treatment. Apparently treatment did no good.

At this conference, I spoke to a friend about this. He had worked in an adolescent treatment program. He had the same insight. The teenagers who were labelled as bad patients appeared to do the best. These individuals appeared to have "self-agency". They had enough sense of personal power that they could fight the authorities of the treatment program. They could rebel against the treatment staff. In his experience, these patients had the highest likelihood of responding, of recovering. What they had, which apparently we all need, is self-agency, a sense that our efforts can and will make a difference. The compliant patients, the good patients, lacked self-agency. They did what they were told and played the role of good patients, and, once discharged, had no role to play, no direction, and promptly relpased.

Treatment programs of all sorts consume a large amount of the health care budget. Let's examine the assumptions upon which these programs are based. Almost uniformly, they are based upon the assumption that a class of experts exist, who know more about other people than the people themselves know. These experts tell an inferior class of patients how to reform themselves and how to behave to live "the good life". The problem with this is that it doesn't work. Rational expositions of how to live rarely change people's behavior. Largely this is a waste of breath. Why? Because we do not behave as we do out of ignorance. We behave as we do because of our beliefs. They tell us how to behave. Cognitive-behavioral therapists figured this out. But from where do beliefs come? They come from our interpretations of our experience which exist in the form of stories. If you want to know how I cam to believe, ask me to tell a story about an experience which led me to form the conclusion that I have formed. Ask me to tell several stories. I will do so and, whether or not you agree with my interpretations of these experiences, you grasp that I believe my interpretations, and that these stories I tell have come together to generate my conclusions which I now believe wholeheartedly. If you want to change my beliefs (which is necessary to change my behavior), then you need to find stories that contradict the stories I tell to support my belief(s). They need to be compelling, believable stories. They need to convince me. Telling me to think differently or arguing with my beliefs doesn't work.

My friend had an excellent example. He told me a story of a patient who came to him to tell him that the treatment program was a crutch for the girls who were attending it. She described how they preferred to "freak out" and scream and come to treatment than to deal with their problems. He arranged for her to give a lecture to staff about her stories and conclusions and beliefs. She did, but mostly staff ignored her insights, since they definitely knew what was true and this teenager who had no training couldn't possibly know anything.

He told me another story about a girl who was assigned to him because no one else had been able to help her stop cutting. He asked her to talk to "cutting". What did it want? How did it help? She responded with the story of Austin Powers. She said, she had been frozen like him and awakened. When she awakened, she was full of pain. She needed to shut down the pain and cutting did that. It refroze her. My friend proposed a metaphor to her. He asked her to imagine herself as a greenhouse. Each time she tried love, someone broke a window and it got replaced with a wooden board. Eventually, he said, "your greenhouse is mostly covered with plywood and inside has become dark. You need to pick one board at a time to replace with glass, he said. This metaphor worked for her and her cutting reduced.

What was different? He listened to her story. He found a metaphor that resounded to her. He found a metaphor that she could use for change. He didn't tell her what to do. He didn't lecture her. He didn't pretend to know more about her than she knew. He listened to her and then responded to what she said in a way that indicated that he had understood her and then offered her a new twist on her story which could be even more useful. This is the essence of what we call narrative therapy.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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