Better Living Through Psychology

Email scammers using a variation of the 419 scam have started targeting professionals such as therapists and interpreters.

A couple of days ago I received this email:

fredpawlak@yahoo.co.uk
+447024099618

The language struck me as somewhat idiosyncratic, but not unlikely if the writer was someone for whom English is a second language – a reasonable assumption to make given the surname used. When I get enquiries for assistance with mental health problems from people outside my registration jurisdiction (i.e. the state of Victoria, Australia), I usually suggest the person contact their local Psychology association or registration or licensing board. However, like any compassionate professional dealing with the parent of a young person in distress, I didn’t want to put the gentleman writing to me through any more trouble than necessary. And for all I knew, he had fairly plausible reasons for not seeking help in Singapore or the UK: lack of local knowledge, distance, in the case of Singapore perhaps a lack of depth in the local practice community.

Consequently I replied to the email explaining my usual preference to talk with the “identified client” before giving a firm undertaking to proceed with an appointment. About eight hours later, I received this reply:

Hello Julian,
How are you and how has your day been? Wonderful I guess. Thanks for your swift response and I am so glad to read from with the detailed information. As I have earlier written, My son who is 19 years of Age and he speaks english fluently so i think it would be of great advantage to communication. He has heightened fears about people despite his Age, situations which He cannot face, and He continually feels low, most often with many complicated symptoms like poor sleep, negativity, deep anger, self-depression.
After reading your mail, I would prefer a Consultation of 60minutes a day and it would be held 2 times a week at your own scheduled time.
I am willing that I make the arrangements with you prior to His arrival because next week most probably, I will be leaving Singapore for some important business obligation. I am making contacts with a professional guardian who will be His driver throughout this Excursions / Consultations. He will be bringing Him over for the Consultation on the scheduled days. I hope to establish a contact between you and Him as soon as possible. Below are my own calculations for payment:

AU$XX0 for a Consultation / 60mins

i.e. AU$XX0 x 2 time in a week = AU$XX0
i.e. AU$XX0 x 4 weeks = AU$XX0
Total  Approx = AU$XXX0

I would Issue out an Upfront payment of AU$XXX0 before His arrival, so I want to know if it is OK. I expect to read from you with the following information so that I can have my Financier issue out the payment on my behalf.

Full Name: -
Full Contact Address: -
Phone Number {Home & Mobile}: -
Age: -

Please, I will want to count on you for this because I am a very busy person, I am doing this as part of my responsibility towards my children because I am a single parent and I hardly have time for them. I want to plead with you to make this a successful and adventurous Excursion / Consultation for my son.
Anticipating your swift response. Have a wonderful weekend ahead and my humble regards to you and your loved ones.
Kind Regards,
Fredrick Pawlak..

Address: – XXXXX XXXXXX#01-02,
XX XXXX XXXX Street, XXXXX, Singapore

The offer to pay upfront was the giveaway. I had indicated in my email that we might not go further than the first two or three sessions if I judged that my approach was unlikely to benefit the “client” – a precaution I routinely put in place when starting with a new client. So why the urgency to pay upfront for the whole episode?

To reassure myself that the enquiry was genuine, I googled the writer’s name. Nothing. So next I searched for phrases from the email. When I fed some of the details into 419scam.org it showed that the phone number, which I assumed was a UK-based landline, was in fact a UK-registered mobile which would divert to another country.  Jackpot! Thanks to Google Translate I was able to establish that German interpreters had been targeted earlier this year using a similar approach: an urgent requirement for work to be done over a brief period with payment upfront.

The way this particular scam works is that the fraudsters overpay you with a dud cheque or traveller’s cheque. Then before you cash it or draw on it and find out it’s worthless, they contact you requiring you to urgently refund them the overpayment amount. Enough honest people will fall for this that it’s worth their while sifting through the ones who ignore the initial approach or delay reimbursing the overpayment until the cheque has cleared.

Takeaway message

Vet your clients before you book them in.

Insist on a phone contact (for your own safety do this in preference to face-to-face meetings) before agreeing to take on a client who has contacted you via email.

If someone offers to pre-pay sessions and wants to send funds via the web, or for that matter to post cheques to you, ensure it’s for only one or two sessions, and then wait for the funds to be drawable in your account before you do anything like refund an overpayment.

And finally, if you suspect anything is too good to be true or it just ‘feels wrong’ search www.419scam.org or in Australia www.scamwatch.gov.au for phrases or email addresses and phone numbers from the emails you’ve received.

What does your doctor do when you tell her or him that you’re not getting better? What would you do if her response was “more of the same”?

I dare say you’d at least leave and see another doctor. That would make sense and it happens rarely because good doctors pay attention to signs of improvement – and their absence. Certainly if your condition worsened you’d expect the doctor to notice at least.

Unfortunately this is far from common practice when it comes to psychotherapy and counselling. Exactly how bad the average therapist is at this essential assessment task was recently revealed in an intriguing real-world study by Derek Hatfield and colleagues published in Clinical Psychology & Psychotherapy.

Hatfield’s group combed a database of over 4000 clients at a university counselling centre to identify cases where the client’s condition had deteriorated. All of these clients had attended at least two sessions where they were assessed with a standard test of psychological health. The researchers were only interested though in cases that met these two criteria:

1. Their intake score on the measure was in the clinical range and at some point in the course of therapy had deteriorated significantly, and;
2. They had only seen the one therapist during the course of the treatment in which the deterioration had occurred.

The first criterion ensured that the clients who were the subject of the study were not deteriorating through statistical artefact – otherwise known as regression to the mean. We all have ups and downs in life and “regression to the mean” describes a situation where someone who is functioning exceptionally well shows a deterioration that is simply due to these “normal” variations – what goes up has to come down, if you will. This criterion is also important because the most demanding, and therefore expensive-to-treat, clients are those whose status is the poorest during treatment.

The second criterion was important because it allowed the researchers to draw conclusions about the perceptiveness of individual counsellors.

Hatfield’s group examined the progress notes of a random selection of 70 clients who met these two criteria. Only 30% of the therapists in these situations referred to the client’s deterioration in their progress notes.

It’s hard to solve a problem you’re not aware of.

Why does this matter? There is a wealth of research on psychotherapy outcomes that shows that early gains in the course of therapy are a good basis for continued gains. Conversely, if a client is deteriorating the therapist may be able to alter the client’s trajectory by changing their treatment or recommending another therapist.

These courses of action have been found to improve the overall outcomes of individual counsellors as long as they have access to objective feedback (i.e. psychological test results) about the client’s progress. Many psychologists and other therapists do not use any form of psychological testing to determine progress. But even with the presence of test scores in the Hatfield et al study, only around 10% of counsellors even mentioned the change in scores in their notes.

So here’s the reason I ask my clients how they are going, and do it using a standardised measure of outcome: my perception of the client’s progress may be incorrect, it’s unlikely though that the client’s will be.

One thing I know I can count on – and Hatfield’s study backs this up – like every therapist, I am going to get a small proportion of clients whose condition fails to improve or actually worsens under my care. In the study, 9% of the original sample deteriorated significantly.

I have been measuring client outcomes since 2003. Combined with asking questions like “How was this session for you? What was missing from the session? Is this approach helping?” and then acting on the answers to improve the treatment for the client, this has enabled me to produce outcomes that are better than over 70% of therapists in standardised samples.

Sometimes when I ask clients, “What do you want to do with your life?”, they reply “I don’t know… I’m not sure I’ve ever really known.”

At this point, I find myself wondering, “Is it that she doesn’t know how to know what she wants? Or is it that she knows, but when she looks in that direction, the first thing she sees is an obstacle like lack of money, time, education or self-belief?”

To flush out these obstacles, I’ll often ask a question like, “Suppose you had all the time in the world available to you. And suppose that all jobs and careers had equal status. And suppose that you were already rich so you weren’t doing this for the money. Then what would you do?”

Of course, that last assumption – extreme wealth – sometimes prompts comments like, “Well, I’d retire obviously. I wouldn’t have to work, so why would I?”

Answering that question can be the topic of another post, but last Friday I came across a story of a guy who already has plenty of money and decided that there wasn’t much worth having that it could buy him. Here’s the story: http://www.theage.com.au/executive-style/luxury/tycoon-trades-high-life-for-bedsit-20100209-npsx.html.

This story beautifully illustrates the challenges and joys of living in pursuit of your values. Notice that he says for many years there was a conflict between holding on to the ‘good things’ and pursuing his truth – that he was trapped by what common sense and convention told him should have made him happy. The price was that he wasn’t living his ‘real life’.

Mr Rabeder was clearly trapped by an old rule – work more to achieve more material things – that may have served his family well in the past, but was no longer suitable to his circumstances or his nature. Getting to the point where you can choose the direction of your life, rather than living out someone else’s dream for you, is what Acceptance and Commitment Therapy, and the ACT Of Living program, are about.

One last thing. I really admire him for adding that last humble claim: ”I do not have the right to give any other person advice. I was just listening to the voice of my heart and soul.”

Robyn Dwyer re-started the Group in December 2009. You can contact her directly or contact me and I’ll pass your details on to her. The group meets monthly for 90 minutes 6.30-8.00pm first Wednesday of the month.

Currently (July 2010) we’re meeting for the foreseeable future at my premises: 203 High St Northcote.

Many clients wonder why I so frequently ask them questions about how the session was, whether we are on the right track, whether there’s anything I did or said that didn’t work for them, and so on. Some also wonder whether it’s really worth the effort to record their session ratings. (I use a session rating scale that gives me feedback on whether the person felt heard, whether we are talking about what is important, etc. If you are a therapist you can obtain this instrument from www.talkingcure.com)

I appreciate you may feel these questions and the rating scales are burdensome and unnecessary. After all, you’ve come to see me to get help with your problems, not to help me learn how to do therapy better. That is quite a valid point of view, however recent research at Brigham Young University showed how seeking this feedback can at least help protect you from ‘bad’ therapy. Richard Friedman discussed this research in New York Times article. His advice for seeking a good therapist is worth quoting:

In a study published last month in the journal Psychotherapy Research, Michael J. Lambert and Cory Harmon, psychologists at Brigham Young University, gave psychotherapy patients a questionnaire about how they were feeling and functioning. They randomly gave feedback from the questionnaires to half the patients’ therapists; the other half received strengthened feedback, which included patient self-assessment plus specific information about how the patients viewed their therapists and their social supports. These two groups were compared with a control group of patients whose therapists received no feedback.

The researchers found that giving feedback to therapists clearly improved treatment outcome: When therapists received no feedback, 21 percent of their patients deteriorated. With therapists who received regular feedback, 13 percent of patients deteriorated; with strengthened feedback, 7 percent of patients deteriorated.

The clear implication is that therapists are not always the best judge of how their patients are doing, perhaps because they are blinded by their own optimism and determination to succeed.

Some therapists might even view worsening during treatment as a sign of progress – a misguided ‘no pain, no gain’ view of psychotherapy.

It’s probably easier to say what is bad psychotherapy than what is good, but there are qualities that all good therapies share. You should feel that you are understood as an individual, and that your therapist is compassionate and nonjudgmental. Good therapists should be able to explain the nature of your problem, and which of several treatments might help you.

Protecting you from treatment deterioration is important. There is a medical principle called primum non nocere – first do no harm. In other words if you come to counselling for help, you should expect at least not to be any worse off. However, like any treatment, psychotherapy has its treatment failures.

Most studies in this area show that, depending on the therapist, negative treatment outcomes are likely in an average of 10% of cases. Which therapists have the worst outcomes? The ones who don’t ask for feedback from their clients.

Of course, I’m not so naive or arrogant as to think I won’t have treatment failures like anybody else. But if that is going to happen, I want to find out as soon as possible so that I can change my approach or refer that person to someone more suitable.