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Jacqueline B. Persons, Ph.D. - Guest
Dr. Persons is the director of the Oakland Cognitive Behavioral Therapy Center and works with clients using Cognitive Behavioral Therapy (CBT). Dr. Persons is author of the book, The Case Formulation Approach to Cognitive Behavioral Therapy and has published numerous articles and two other books. Additionally, she is the past president of the Association for Behavioral and of Cognitive Behavioral Therapists, is a clinical professor in the Department of Psychology at the University of California, Berkeley, and has published a video series through the American Psychological Association in which she and her co-authors teach the basic skills of of clinicians to learn Cognitive Behavioral Therapy. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton: (00:22)
Welcome to the Therapy on the Cutting Edge podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the director of the Institute for the Advancement of Psychotherapy. Today, I'll be interviewing Jackie Persons Ph.D, who is a psychologist in private practice in Oakland, California providing Cognitive Behavioral Therapy (CBT). She is the director of the Oakland Cognitive Behavioral Therapy Center and has published numerous research articles and books, including, "The Case Formulation Approach to Cognitive Behavioral Therapy." Dr. Persons is the past President of the Association of Cognitive Behavioral Therapists is a professor at the University of California Berkeley and create a video series for training clinicians through the American Psychological Association on the treatment of depression, using cognitive behavioral therapy. Let's listen to the interview. Well, welcome, Jackie.
Dr. Jaqueline B. Persons: (01:18)
I appreciate the invitation.
Dr. Keith Sutton: (01:20)
Thanks for joining us today. So Jackie, I'm in the Bay Area and you're also in the Bay Area. You're one of the big CBT folks, and I've gotten some consultation from you on some of the CBT teachings that I've done. I know you have a consult group that some of my interns, who are associated non-profit, had gone to. It really had a great success and really enjoyed all of your work. I was also involved in one of the research projects you were doing, looking at outcomes and so on, and feedback monitoring in the sessions some time ago. So we'd love to hear a little bit about kind of what you're doing and how you got to where you're working and what you're working now.
Dr. Jaqueline B. Persons: (02:02)
Well thank you. I appreciate your interest. The thing I'm especially passionate about right now, and I'm devoting more time to is helping clinicians think about whether they might have interest in, and want to conduct some research in their private practice setting, which is something I have done all my life. Fortunately I was trained to do research, so I have some research skills. Although after so many years after my training, my skills at data analysis, for example, are weak. Also I'm learning I'm not very good at managing databases, so I always need help. But one of the things about research is you can always get help and people who have the skills you don't can help. But the thing about clinicians and practices, they see a lot of patients of a wide range of types and of psychopathology, especially in these days when we're very attentive to these issues of race, culture, diversity stigma, with the fact that clinicians in the community are taking care of these patients.
Dr. Jaqueline B. Persons: (03:31)
And if they're doing evidence-based practice, they're collecting data to monitor their patients progress and treatment, and they may be doing, we could hope they're doing, evidence-based treatments. If they're doing that, even a single case, they are collecting data that is useful to the larger research community. Because if you think about it, some people who are especially attentive to these issues of race and diversity and equity are aware that most of the empirically supported treatments that are currently available in our field, were developed by white people, and the randomized trials that were conducted involve a lot of white people. And so we don't have very much data. Do Black and Brown and other diverse populations benefit from these treatments? Do they find the treatments, meet their needs?
Dr. Keith Sutton: (04:40)
Hi, Jackie,
Dr. Keith Sutton: (04:46)
Hi, Jackie, I'm sorry. It froze up there for a moment. Apologies, can we go back to your saying, "I'm not really sure if these treatments meet those needs for people to,"
Dr. Jaqueline B. Persons: (04:59)
Yes. And for these people from other races cultures, do these treatments meet their needs? Do they seem culture friendly? Do they seem like they're the kind of treatments the person would want to, or feel comfortable engaging in? We don't have that information. We do know that dropout rates for minorities is higher than for white people. So maybe the treatments aren't very culturally, what's the term, relevant, so then talented clinicians are probably modifying these treatments to make them more suitable for these patients. If they would want to collect some data, showing a beautiful successful outcome in response to some adaptations the clinician made, that would be a contribution to the science. And so I'm just trying to say to clinicians, you have many contributions that you can make to science, that is just one example.
Dr. Keith Sutton: (06:07)
And I know for you, and originally one of the significant books that you wrote was, well they're all significant, but the [one] around kind of the treatment planning, because you know that in evidence-based treatment, often times it's very kind of focused on a particular diagnosis, and the clients that are being seen for that treatment model or that research, are kind of narrowed down. In the real world, we're seeing a lot of clients that have a lot of co-morbidities, both co-morbidities with different mental health issues. But like, again, as you're also saying, there's a lot of diversity in clients around culture, around race, around sexual orientation, gender identity, socioeconomic status, religion, ability, and all these kinds of things. Tell me a little bit about you, cause I know that you're really big on doing research in private practice and kind of, you know, that's always been an aspiration of mine. At grad school, I was like, doing all this research, and it takes a lot to do it. You know, it's a lot of organization and keeping track and kind of managing all these things. Yeah, I would love to hear kind of what you're doing around that.
Dr. Jaqueline B. Persons: (07:26)
Well, the kind of research I like- and I'm working on a paper on this topic right now. I have a plan to submit it to the American Psychologist. It's titled, "How to Do Research in Your Private Practice."
Dr. Jaqueline B. Persons: (07:39)
The kind of thing I would encourage clinicians to approach is related to the point you made, which is research can involve a lot of organizational details and cumbersome things. We would like to try to minimize that. And my thought about the best way to minimize that, is to base your research on data that you are already collecting to guide your treatment. And I'm sure you, Keith, are teaching your young people and yourself, you know, to collect progress monitoring data, to monitor progress at every session. And if you do that for long enough, and it doesn't even have to be very long, after a while you have a lot of gorgeous data.
Dr. Keith Sutton: (08:28)
Yeah. We use the outcome rating scales and the session rating scales from Scott Miller and Barry Duncan for next session outcome as well as feedback. And so a lot of data that's just not necessarily crunched.
Dr. Jaqueline B. Persons: (08:42)
Exactly. And you have data, you have both processed data related to the Alliance, I think, and outcome data. And of course our field would predict that the one is related to the other, and we might expect that there's a paper published in the JCCP recently showing that improved Alliance in one session, leads to reduced symptoms in the following session. You have the data to test that hypothesis because you have session by session by session data, and in the randomized trials, which of course are designed to answer different questions, but these trials, they're bringing these patients in to do these empirically supported treatments. They're typically not measuring progress on a weekly basis, so they don't have the intensive data that you have, which actually are more valuable than you might think. If you would find somebody who could crunch your data for you, you probably have a paper.
Dr. Keith Sutton: (09:48):
Yeah, yeah. Right, now tell me a little bit about your kind of trajectory in your career and how you got interested in CBT and evidence-based work and research. I'd love to hear that story.
Dr. Jaqueline B. Persons: (10:03)
Well, I was trained as a clinical psychologist. I started my PhD program in 1975 at the University of Pennsylvania. In the Department of Psychology, Marty Seligman was on the faculty then. Oh, he still is actually. Also then I started to hear about a new treatment that was being developed over in the Department of Psychiatry. Dr. Beck, and Beck was in the Department of Psychiatry. In the Psychology Department, it was not very enthusiastically smiled upon for the students to go over to psychiatry and get training, but I figured out how to do it. And so I went over to Beck's, it was called the Depression Clinic then, the Mood Clinic, maybe I don't even remember now, which was in the Gerard Bank Building. And I got invited to participate in the practicum in the-I did a practicum over there. I got invited to have to purchase it in the didactic training that was being done for the therapists who were learning Cognitive Therapy for one of the first randomized trials. My teachers included Art Freeman. I saw some patients in Beck's Clinic but one of my very first clinical supervisors was David Burns.
Dr. Keith Sutton: (11:34):
So amazing training.
Dr. Jaqueline B. Persons: (11:36)
Oh my God. Later I met a local psychotherapist here in this local community who asked me, how did you get started? Why did you go over there? Cause I could have gone over to Lester Luborsky's psychodynamic Psychotherapy training, which was also at Penn. Lester Luborsky is an amazing person. I don't know. I went over to Beck's place. I think certainly Cognitive Behavior Therapy is more congenial to my own way of operating and thinking. But as I was telling my colleague here, once I said, "Oh, I think one of the reasons I did it is because I could see that they were focused on collecting data and developing a treatment that was supported by data." You know, they're doing these randomized trials to evaluate the efficacy of their treatment. I thought, "That is a kind of treatment that I want to learn."
Dr. Keith Sutton: (12:32)
Showing efficacy.
Dr. Jaqueline B. Persons: (12:34)
Yes. I want- I don't want to learn a treatment where we don't have efficacy data. I just don't want to do it. Which my colleague was surprised at, because I don't think many clinicians think about that when they decide what treatment they're going to learn. But part of why I'm saying this is if you're a young person trying to figure out what treatments you're going to learn, I would suggest think about what your values are. But to me, one of my values is science, evidence-based learning. Learning psychotherapy is extremely demanding. Don't learn therapies that do not have an efficacy database, please. Well, I shouldn't say that. Think about your values. Anyways, science and data was one of my values, and that's part of why I learned cognitive behavior therapies is what I'm saying.
Dr. Keith Sutton: (13:27)
Great. Great. And then yeah. Where did you go from there, from doing that kind of training with Beck.
Dr. Jaqueline B. Persons: (13:37)
So I got some training with Beck. Well, I attached myself to David and David was very generous with his time. So, even though after my practicum ended, he had a weekly group supervision that happened on Friday afternoons four o' clock. Most of us, we come in the room we're just exhausted. By the time we leave we're full of energy. I don't know if you've ever been to one of Dr. Burns's trainings.
Dr. Keith Sutton: (14:01)
I haven't actually, I've been wanting to go.
Dr. Jaqueline B. Persons: (14:05)
David Burns is one of the best teachers I have ever met, and he had a lot of energy. So we had a lot of fun. So I basically attached myself to David Burns and I went to his clinical supervision for pretty much the whole time I was in graduate school. Then I did my internship training at hospital and the University of Pennsylvania, which I did just because it was convenient. I didn't want to move out of town for my internship. By that time I was married. My husband was an economist on the faculty at Penn. So I want to just stay right at home. That was kind of a challenging experience, Department of Psychiatry, various psychodynamically oriented. But anyway, and then after that I had year postdoc training and I went over to Joseph Wallpain Clinic. Oh wow. I went to the Behavior Therapy Unit, Eastern Pennsylvania Psychiatric Institute. The director of the clinic was Joe Wallpain. And one of the core faculty was Edna FOA, and Gail Steketee was there, Jonathan Grayson was there. Can you imagine.
Dr. Keith Sutton: (15:14)
That's amazing training.
Dr. Jaqueline B. Persons: (15:17)
I thought I had died and gone to heaven. So I got all that fabulous clinical training and I was still interested in research. And so I was collecting different types of data. And then my husband, who's on the academic job market. I thought about going on the academic job market, but I wasn't really ready to go. I didn't know. So I came to California and started a private practice and started writing up some of my research and doing some of my research in my private practice. And I have a lot of fun.
Dr. Keith Sutton: (15:56)
And with the research that you were doing in the private practice, was that based on kind of, symptom measuring that you were doing, and kind of looking at outcomes and such and kind of have your own, accord?
Dr. Jaqueline B. Persons: (16:12)
Yeah. So as you pointed out, I started developing some ideas about individualized case formulation as a way of personalizing the treatments from the random protocols that were studied in the randomized trials. Part of that I learned to do when I was on the clinical faculty over at UCSF, when I worked with Ricardo, Ricardo ran the depression clinic over at San Francisco General Hospital. Those patients have a lot of diversity. They're lower-income patients, disadvantaged patients, minorities frequently, often from the Hispanic community in the area. All the patients that were seen in the depression clinic were medically ill.
Dr. Jaqueline B. Persons: (17:10)
So I started developing my ideas about personalizing the treatment, and how to use a case formulation to do that in a systematic way, and then monitor outcome. So I developed my approach to case formulation driven, Cognitive Behavior Therapy. And then after a number of years, I dunno, I guess a lot of years I had enough outcome data. I published a paper. You could think of it as a single trial, do patients who come into my office, and I think some of those patients were also treated by my colleagues in my group practice, do they have outcomes? And we're giving them case formulation driven, Cognitive Behavior Therapy. Do they have outcomes comparable to the depressed patients treated with a protocol in the randomized trials? I mean, it's not hard to do the data analysis. You look at the outcomes, and you just look at it and you know what, those patients did well. So, I published a nice paper. It was published in Behavior Research in Therapy. Two of the graduate students at UC Berkeley helped me with it.
Dr. Keith Sutton: (18:17)
Oh, great. Wonderful. And can you say more, can you describe your individualized case formulation approach?
Dr. Jaqueline B. Persons: (18:27)
I have to learn how to answer that question briefly. The formulation driven approach, first of all, focuses on the whole patient, not just a disorder. Notice the empirically supported treatments treat a disorder, right? Cognitive therapy for depression, cognitive processing therapy for PTSD. Usually the patient who's in your office, or my office has more than one disorder. So I want to know what all the disorders are. Often the patient also has a number of psychosocial problems. Like maybe there's a marital problem. Maybe the patient is underemployed. Maybe the patient has an outstanding tax bill from three years ago that he's avoiding dealing with IRS the on. Anyway, I want to know about all that stuff. So I want to be thinking about the whole case. I want to know about the medical problems. I want to know about all of the psychiatric disorders and problems. I want to know about all of the psychosocial problems. And then I want to develop a hypothesis about what are the disorders and problems and, or the psychological mechanisms, that are at the heart of the matter, and that are driving a lot of the symptoms. So I can focus my treatment on those.
Dr. Keith Sutton: (20:01)
Yeah, there's a particular quote, I'm forgetting the author, it's one of the Treatments That Work series on working with depression, and it sounds like they do a little bit of similar — they use the acronym "beast" to look at kind of the different factors. They came up with the term based on, they talk about the story about how Winston Churchill struggled with depression his whole life. And he used to call it as a "little black dog" that followed him around, and they took this acronym beast to kind of break it down. To look at the, the "B" the biological aspects, you know, health issues, medical issues, nutrition, sleep, drugs, and alcohol, that kind of stuff. "E" the emotions as a person, emotionally avoidant, or are they more ruminative, kind of obsessive, do they have emotional awareness, "A" which is actions, so kind of your behavioral interventions or kind of behavioral activation, you know, are you living a life that's worth living, in direction of values. "S" as a situation yeah.
Dr. Keith Sutton: (21:05)
Situation, financial taxes, or problems with a partner or family members what's kind of adding to, or even decreasing the likelihood for depression, like having strong friendships or so on. And then "T" are the thoughts, the cognition part of the cognitive behavioral therapy, because like you're saying, there's so much more and all these kinds of aspects interplay, and so really kind of being able to look at all those pieces is so important in really kind of understanding how it all kind of integrates together, and what's going on with that particular client. How do we address that?
Dr. Jaqueline B. Persons: (21:42)
I'm going to have to look that up. Yes, it does sound right up my alley.
Dr. Keith Sutton: (21:46)
Yeah, I'm sure they probably, they might even reference your work in there. Yeah, it's nice to kind of have that piece, and I think Lazarus also, I forget the acronym, it was like basic ID or something like that, also kind of multi-modal, you know, piece like you're talking about, you know, again, expanding it beyond just the pure cognition, and kind of bringing in those other pieces cause originally, right, it was really just cognitive therapy and that later on the "B" got brought into it, is that right? Cause I know
Dr. Jaqueline B. Persons: (22:18)
No, the "B" was always there, and Beck's cognitive therapy for depression. The "B" was always there. The "B" was subservient to the "C" in that the behavioral interventions were viewed as having the mission to change thoughts. But the first, the "B" was always there. And in fact, the behavioral activation treatment that was later developed by, I'll think of his name, but anyway, came directly out of Beck's cognitive therapy. They just grabbed the B part and grew it. And also they strengthened the behavioral functional on analytic way of thinking about the B's, but all that actually came out of Beck's cognitive therapy, which did have a "B" column, but part of the reason or B element, but the reason you think of it as cognitive is because it was called cognitive therapy. If you look at Beck's daily record of dysfunctional thoughts, which is the thought record from the treatment, there's no behavior column, which in my opinion is a mistake. So my thought record, I want to know, are what are the thoughts, but I also want to know what are the behaviors and Ben does talk about the triad, the cognitive behavioral mood triad, although maybe that's not what he uses the word triad to refer to, but certainly the cognitions were primary.
Dr. Keith Sutton: (24:05)
Definitely. Yeah. And yeah, I remember cause I did a training at the Cognitive Beck Institute and yeah. That kind of talking about that cognitive therapy aspect, and I know that right, the behavioral activation was kind of part of the depression treatment kind of right from the beginning, I think. And so it's always been kind of an interesting, you know, a history of CBT and how it's evolved and also too how I know now there's also kind of a focus on more of a trans diagnostic kind of approach. I know there's kind of, I think it's, Barlow's universal approach and I know Matt McKay is doing his mindfulness and emotions and this idea, like you're saying again, kind of treating, you know, dealing with the multiple kind of issues that the clients are bringing in because rarely are they coming in, like in a research study where they've only got depression, and there's not kind of other factors or only having panic disorder or something like that.
Dr. Keith Sutton: (25:02)
And I think part of what you're saying too is, you know, and again, in your approach of kind of creating an individualized plan, is all sort of looking at the social cultural aspects of both how the person is experiencing their environment, and the culture that they're living in and how that's interacting with their culture. And also how the therapist is thinking about how, what they're bringing to the therapy is also interacting with the client's experience and cultural experience. That's really important. Definitely, you know, tell me a little bit if that's something that you've been focusing on more in your research lately, or is that something that you've been thinking about, cause you were mentioning in a lot of folks in having a diverse kind of clients that they're working with in private practice and kind of all this kind of opportunity for data. Is that been something you've been thinking about more lately or writing about or is that kind of, yeah?
Dr. Jaqueline B. Persons: (25:55)
Well, I'm very aware of it just by reading the newspaper right. And seeing this shift that we hope our culture is going through. And of course, but I come from a very white privileged background, so I'm not actually very knowledgeable in this area, but I'm trying to learn. I also have a private practice that has very few people of color by way of patients in my office. So, that's not very satisfying. I'm talking about working with one of the graduate students in the clinical science program at UC Berkeley, where the clinic sees a more diverse range of patients in the community. So I'm talking about supervising her next year. She's particularly interested in these issues of diversity and equity and how the treatments developed by white people might or might not be helpful to other people of other races. So I'm hoping we can do a single case study in the clinic to think about some of these questions. I have to figure out what the questions are exactly, but I'm hoping Erica is going to know.
Dr. Keith Sutton: (27:17)
What I think too, so back, earlier in my training, I trained in motivational interviewing even way before graduate school and really loved that model, and I really kind of connected with it. And I think that oftentimes, you know, particularly with any, you know, when I actually started, so I had first gone into more kind of a more postmodern approach doing narrative therapy. I was really interested in family systems and I was working with families and then I got reading and working with couples, but I didn't have a good individual approach. So I ended up actually gravitating towards CBT, which kind of grew out of my, in undergraduate, my minor was in Eastern philosophy. And so I was really interested in the way that kind of our perceptions of the world color, our experience. And then I went and did training with Albert Ellis when he was alive, training at the bedrooms to which youth and Aaron Beck.
Dr. Keith Sutton: (28:08)
I did some training with Edna FOA, and Robin Waltzer and so on. And so in the beginning, when I was kind of doing CBT, I would say, you know, talking to my narrative friends, I'd be saying I'm doing CBT, but humanistic CBT. Because oftentimes I think there's an association with cognitive behavioral therapy as this kind of very rational, emotionless, kind of perfunctory type of approach. Whereas you know, really, and it's taken some years for me to even kind of grow into it, just really that it is very much about that human connection and particularly kind of more of these humanistic approaches, like motivational interviewing kind of more of a Rogerian kind of piece, these aspects kind of really mingled very well with the Cognitive Behavioral Therapy, because ultimately you can't get any movement in Cognitive Behavioral Therapy, unless you're able to make that connection with your client.
Dr. Keith Sutton: (29:05)
You need to one, understand your client and your client needs to feel understood before you can even begin moving forward in the work. And I think particularly CBT, most protocols started out with the psycho-education and which is really about kind of connecting with our client, finding out their understanding of the problem, discussing our conceptualization of the problem, and collaborating and kind of bringing those together to come up with a solution or a treatment that we're going to do together. And I think that-that's the place kind of where, you know, also our, connection or kind of differences or experiences culturally, socioeconomically, socially, all kind of match up to be able to have a therapeutic relationship to begin moving forward, in whatever these treatments are, evidence-based or kind of order relational or whatever it might be. So that kind of foundation of that, therapeutic relationship I think is so significant.
Dr. Jaqueline B. Persons: (30:05)
Yeah, it reminds me of, I can tell you two little stories. One is, I ran an article in the New Yorker about 20 years ago. It was about George Balanchine. Is that how you say his name, the choreographer. And, he talked about how, the way he would choreograph a new dance is he would bring in the dancers and he would say to them, show me what you can do. And then he would use what he could see what their strengths were to guide him as he choreograph the dance that these people would do. So to me, part of what you're talking about and motivational interviewing, I think is particularly strong in this, you know, they view the patient as the best expert on his or her situation. Anyways, so what I try to do with my people is, you know, show me what you can do.
Dr. Jaqueline B. Persons: (31:01)
What are you already, like often I'll try to lay out the situation and offer a little bit of a conceptualization, but tell me, like, what are you already doing to solve this problem? And then I'll try to work with them to figure out, is it helping? Can I help you do more of it? Is it not quite right? Can I help you tune it up? But you know how to help people take what they're already bringing in, do more of it or switch it up, or maybe they need to learn new things. In which case I'm happy to teach them, but let's start with what you're already bringing. And each person is bringing his or her own things to the table. So that's one thing I always try to do in my therapy is that it has to do with being responsive to what the person is bringing. That was one story. What was my other story that I wanted to tell? This is the problem. I start with one story, and when I can't remember the other one, but I'll remember it. What are we talking about? I don't know.
Dr. Keith Sutton: (32:01)
So with the collaborative piece, I mean, I think part we're talking about, you know, kind of the work and you're thinking about kind of working with a diverse clientele and you know, about kind of that you know, collaboration and you know, moving forward.
Dr. Jaqueline B. Persons: (32:19)
Okay, so here, so I had a patient who was in my office, who did not get very much help. She had a big ticket OCD, and somehow I just wasn't able to help her very much. And I felt like she needed more intensive treatment. So I sent her off to an intensive treatment center, and then she came and she wasn't all that much better. Actually, even though she had gotten a lot more help, I should probably be offering a little more detailed conceptualization as to why I think she needed a more intensive treatment, but anyway, I'm going to skip that part. So then what happened was she did all this intensive treatment, but when she came back to me, she wasn't all that much better. So then I called the therapist, the provider, and I said, "Okay. So could I learn from you a little bit more about what happened in this intensive treatment?" And the therapist said to me, "Well, I delivered this intervention and I delivered this intervention. And then we did the exposure and then she learned mindfulness. And then she, this actually, she probably didn't say she learned, she said, I delivered this intervention. I delivered this." So that I hear you saying you deliver these, the question I have for you is did the patient learn anything?
Dr. Jaqueline B. Persons: (33:36)
What's the engagement, but also like, did the information get into her head and did she have anything changed in her way? She was thinking and behaving as a result of your delivering the intervention, and something you said about probably about feedback reminded me. Cause we want to not just deliver the intervention, we want to hear from the person. Okay. Does this make sense to you? Does it seem like something you could use? Do you want to try it, talk to me about what happens when you try it? Is it helpful? Is it not helpful? Is it harmful? Like give me some feedback because then the feedback which is data, I'm going to use the feedback to figure out what's my next move. Maybe that intervention isn't going to help you because it doesn't make sense to you and you can't really, I don't know, but using feedback. So there's kind of a back and forth dynamic process. It's not just that you're the person and I'm like giving you all these interventions and now you're fixed.
Dr. Keith Sutton: (34:40)
Yeah, exactly. What about feedback? So important? I know in the common factors research, especially with the Scott Miller Barry Dunkin work, Scott Miller talks about how they did one research project where the clients are filling out the feedback forms, but then they weren't giving that data to the therapist. And then after I think, five or six sessions, they gave that data. And then actually the therapist shifted. And just by getting the feedback, they were able to increase outcome by 60%, regardless of their theoretical orientation. Particularly I think I'm thinking too about like, especially with a client that I had with OCD that they never really kind of got on board with a work, they were doing an intensive program. So they were just kind of white knuckling it through their exposure. They were doing their exposures, but they hadn't gotten the sense of, I need to lean into this.
Dr. Keith Sutton: (35:35)
I need to release the anxiety and really feel this. Instead, they kind of sit there and sit long enough until the anxiety went down, but then they go, "Ooh, good. That's over with." Kind of that engaging with it. And I think sometimes when I was back in my pre doc, I was working with a family and I felt like I was just kind of dragging them along. And I realized, cause you know, even though we had kind of gotten on the same page in the first session that didn't just carry through every single session that we needed to be, re-contracting reconnecting to kind of what we're working on, the steps that we're taking and making sure that kind of we're walking side by side, rather than me getting ahead and kind of trying to pull the other person was dragging them along behind. Yeah. Cause that's not gonna, that does not have what therapy makes. You know, because it really is that partnership about kind of walking on that, that journey together. I was actually seeing you there was a reason article that you published also on kind of therapists and keeping up with kind of the recent research. Do you know what I'm referring to?
Dr. Jaqueline B. Persons: (36:41)
I believe it was the paper that Kim Wilson was the first author on and it was published in the Behavioral Therapist and it was article about how, if you're a clinician, what are the strategies that you can use to keep up to date with the literature, which is a hard task. It's hard to fit it into a busy clinical life.
Dr. Keith Sutton: (37:01)
And I actually, I didn't have a chance to read it. I actually saw it while I was just perusing your bio before our meeting. And I was wondering if you could speak a little bit about that, cause they know again for me and you know, I think the goal of this podcast is for therapists that are really interested in keeping up, but sometimes we have all the time to read all the papers in the new books and so on. What is your advice, or what are your thoughts on what would be helpful to clinicians wanting to stay kind of up to date?
Dr. Jaqueline B. Persons: (37:30)
Well, first of all, congratulations to you for being devoted, to trying to stay up to date. It's part of being an evidence-based practitioner, which attention to the evidence and the evidence changes. So then we're going to want to change what we're doing. So kudos to you for being motivated to do that Kim Wilson and I, and some of the others who worked on that article did so as a result of a project we were doing, and I'm still doing at the Society for a Science of Clinical Psychology, which is a fantastic group. And I head up a committee called The Committee on Science in Practice. So it's about how to get science into your practice and on the webpage, if you just go to Society for Science of Clinical Psychology, go to the webpage on resources, there's five interviews that I did with leading scientists describing their up-to-date work and its clinical implications, probably the best article article.
Dr. Jaqueline B. Persons: (38:35)
And it's focused on an article. The one that's gotten the most attention is an interview I did with Michelle Crass in which she talks about inhibitory learning, which is her model or theory about what goes on during successful exposure based treatment. So learning these ideas from Michelle Crass about inhibitory learning is really important, but that's separate. Anyway, if you go to my interviews at the SSEP that it might help you keep up with a few things. I also did an interview with Michael Lambert about progress monitoring, and I did an interview with, Ed Watkins, rumination focused treatment. And I did a fantastic interview with Emily Holmes on use of imagery in therapy. Anyway, so you can listen to my interviews. What else? Well, I think it's a good idea to belong to a professional association in your fields, which then you can be part of their list serve.
Dr. Jaqueline B. Persons: (39:41)
If the association, which many do publish a journal, then you could get the journal. You could, you could get the journal alerts. You could go to the American Psychological Association, look at the journals. Probably the number one journal for clinical psychologists is, Journal of Consulting and Clinical Psychology sign up, sign up to get the alerts. Then every time a new issue of the journal is published. They'll send you an alert, they'll send you a list of all the articles you could read the abstracts, and you could get a sense of where the field is going and what are some of the findings, and then you could figure out if you want to learn more about it, go to the conference, attend the sessions. I think participating in a (unclear). I'm sorry. I hope it's not a problem at my end, but we're having some connectivity problems.
Dr. Keith Sutton: (40:40)
Yeah. I don't know what happened. It just dropped. But yeah, so you were talking about, you know, being involved with national you know, organizations, attending conferences, all these pieces around, staying up to date. I think that as I'm hearing you saying this, it's really about that community and kind of being connected to that community of, you know, whether it be your local organizations. Like I know I'm part of the Northern California CBT Network, or there's the national associations. You know, all these kinds of pieces are a great way to keep up to date and connected. I was wondering too, do you have any recommendations of are there any books out there that are good for talking about doing research in your private practice, or is that a book that you are going to be writing soon at some point? I think that would be really great.
Dr. Jaqueline B. Persons: (41:35)
Well, as I told you, I'm working on my article, here's a book.
Dr. Keith Sutton: (41:38)
Okay, "Practice-based Research and Guide for Clinicians." Wonderful. And that's by Trent Codd, perfect.
Dr. Jaqueline B. Persons: (41:47)
I have a chapter in this book, it's an edited book. So a bunch of different clinicians who do research in their practice, describe some of the ways they structure their business to support research. So that's an idea.
Dr. Keith Sutton: (42:06)
Well, wonderful. Well, Jackie, it's always wonderful, it's always great to catch up with you and hear about what you're doing and kind of what the latest is. Thank you so much for taking the time today. Really appreciate it.
Dr. Jaqueline B. Persons: (42:18)
Completely. My pleasure. I had fun. Thanks you Keith.
Dr. Keith Sutton: (42:21)
Okay, great. Take care.
Dr. Jaqueline B. Persons: (42:23)
You take care of yourself. Okay. Bye-bye
Dr. Keith Sutton: (42:25)
And actually, hold on. I love you. So now we'll cut the tape. It's great. Thank you so much. I appreciate it. How was that?
Dr. Jaqueline B. Persons: (42:33)
You are totally welcome. I enjoy doing it. So good luck to you with your project.
Dr. Keith Sutton: (42:38)
Definitely. I really appreciate it. And I'll have to look up those interviews. And so on that you're mentioning that sounds like you're also doing some cool interviews. It is. It's great. It's good to connect with people and kind of hear what's going on. Okay, well, thank you so much. I appreciate it. My pleasure. Okay. Take care. Have a good one.
Dr. Jaqueline B. Persons: (42:59)
Bye.
Dr. Keith Sutton: (43:01)
Thank you for joining us. If you're wanting to use this podcast to earn continuing education credits, please go to our website at therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay Area. IAP provides screening for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to sfiap.com or call 415-617-5932. Also, we really appreciate feedback. And if you have something you're interested in something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to the Therapy on the Cutting Edge podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the director of the Institute for the Advancement of Psychotherapy. Today, I'll be interviewing Jackie Persons Ph.D, who is a psychologist in private practice in Oakland, California providing Cognitive Behavioral Therapy (CBT). She is the director of the Oakland Cognitive Behavioral Therapy Center and has published numerous research articles and books, including, "The Case Formulation Approach to Cognitive Behavioral Therapy." Dr. Persons is the past President of the Association of Cognitive Behavioral Therapists is a professor at the University of California Berkeley and create a video series for training clinicians through the American Psychological Association on the treatment of depression, using cognitive behavioral therapy. Let's listen to the interview. Well, welcome, Jackie.
Dr. Jaqueline B. Persons: (01:18)
I appreciate the invitation.
Dr. Keith Sutton: (01:20)
Thanks for joining us today. So Jackie, I'm in the Bay Area and you're also in the Bay Area. You're one of the big CBT folks, and I've gotten some consultation from you on some of the CBT teachings that I've done. I know you have a consult group that some of my interns, who are associated non-profit, had gone to. It really had a great success and really enjoyed all of your work. I was also involved in one of the research projects you were doing, looking at outcomes and so on, and feedback monitoring in the sessions some time ago. So we'd love to hear a little bit about kind of what you're doing and how you got to where you're working and what you're working now.
Dr. Jaqueline B. Persons: (02:02)
Well thank you. I appreciate your interest. The thing I'm especially passionate about right now, and I'm devoting more time to is helping clinicians think about whether they might have interest in, and want to conduct some research in their private practice setting, which is something I have done all my life. Fortunately I was trained to do research, so I have some research skills. Although after so many years after my training, my skills at data analysis, for example, are weak. Also I'm learning I'm not very good at managing databases, so I always need help. But one of the things about research is you can always get help and people who have the skills you don't can help. But the thing about clinicians and practices, they see a lot of patients of a wide range of types and of psychopathology, especially in these days when we're very attentive to these issues of race, culture, diversity stigma, with the fact that clinicians in the community are taking care of these patients.
Dr. Jaqueline B. Persons: (03:31)
And if they're doing evidence-based practice, they're collecting data to monitor their patients progress and treatment, and they may be doing, we could hope they're doing, evidence-based treatments. If they're doing that, even a single case, they are collecting data that is useful to the larger research community. Because if you think about it, some people who are especially attentive to these issues of race and diversity and equity are aware that most of the empirically supported treatments that are currently available in our field, were developed by white people, and the randomized trials that were conducted involve a lot of white people. And so we don't have very much data. Do Black and Brown and other diverse populations benefit from these treatments? Do they find the treatments, meet their needs?
Dr. Keith Sutton: (04:40)
Hi, Jackie,
Dr. Keith Sutton: (04:46)
Hi, Jackie, I'm sorry. It froze up there for a moment. Apologies, can we go back to your saying, "I'm not really sure if these treatments meet those needs for people to,"
Dr. Jaqueline B. Persons: (04:59)
Yes. And for these people from other races cultures, do these treatments meet their needs? Do they seem culture friendly? Do they seem like they're the kind of treatments the person would want to, or feel comfortable engaging in? We don't have that information. We do know that dropout rates for minorities is higher than for white people. So maybe the treatments aren't very culturally, what's the term, relevant, so then talented clinicians are probably modifying these treatments to make them more suitable for these patients. If they would want to collect some data, showing a beautiful successful outcome in response to some adaptations the clinician made, that would be a contribution to the science. And so I'm just trying to say to clinicians, you have many contributions that you can make to science, that is just one example.
Dr. Keith Sutton: (06:07)
And I know for you, and originally one of the significant books that you wrote was, well they're all significant, but the [one] around kind of the treatment planning, because you know that in evidence-based treatment, often times it's very kind of focused on a particular diagnosis, and the clients that are being seen for that treatment model or that research, are kind of narrowed down. In the real world, we're seeing a lot of clients that have a lot of co-morbidities, both co-morbidities with different mental health issues. But like, again, as you're also saying, there's a lot of diversity in clients around culture, around race, around sexual orientation, gender identity, socioeconomic status, religion, ability, and all these kinds of things. Tell me a little bit about you, cause I know that you're really big on doing research in private practice and kind of, you know, that's always been an aspiration of mine. At grad school, I was like, doing all this research, and it takes a lot to do it. You know, it's a lot of organization and keeping track and kind of managing all these things. Yeah, I would love to hear kind of what you're doing around that.
Dr. Jaqueline B. Persons: (07:26)
Well, the kind of research I like- and I'm working on a paper on this topic right now. I have a plan to submit it to the American Psychologist. It's titled, "How to Do Research in Your Private Practice."
Dr. Jaqueline B. Persons: (07:39)
The kind of thing I would encourage clinicians to approach is related to the point you made, which is research can involve a lot of organizational details and cumbersome things. We would like to try to minimize that. And my thought about the best way to minimize that, is to base your research on data that you are already collecting to guide your treatment. And I'm sure you, Keith, are teaching your young people and yourself, you know, to collect progress monitoring data, to monitor progress at every session. And if you do that for long enough, and it doesn't even have to be very long, after a while you have a lot of gorgeous data.
Dr. Keith Sutton: (08:28)
Yeah. We use the outcome rating scales and the session rating scales from Scott Miller and Barry Duncan for next session outcome as well as feedback. And so a lot of data that's just not necessarily crunched.
Dr. Jaqueline B. Persons: (08:42)
Exactly. And you have data, you have both processed data related to the Alliance, I think, and outcome data. And of course our field would predict that the one is related to the other, and we might expect that there's a paper published in the JCCP recently showing that improved Alliance in one session, leads to reduced symptoms in the following session. You have the data to test that hypothesis because you have session by session by session data, and in the randomized trials, which of course are designed to answer different questions, but these trials, they're bringing these patients in to do these empirically supported treatments. They're typically not measuring progress on a weekly basis, so they don't have the intensive data that you have, which actually are more valuable than you might think. If you would find somebody who could crunch your data for you, you probably have a paper.
Dr. Keith Sutton: (09:48):
Yeah, yeah. Right, now tell me a little bit about your kind of trajectory in your career and how you got interested in CBT and evidence-based work and research. I'd love to hear that story.
Dr. Jaqueline B. Persons: (10:03)
Well, I was trained as a clinical psychologist. I started my PhD program in 1975 at the University of Pennsylvania. In the Department of Psychology, Marty Seligman was on the faculty then. Oh, he still is actually. Also then I started to hear about a new treatment that was being developed over in the Department of Psychiatry. Dr. Beck, and Beck was in the Department of Psychiatry. In the Psychology Department, it was not very enthusiastically smiled upon for the students to go over to psychiatry and get training, but I figured out how to do it. And so I went over to Beck's, it was called the Depression Clinic then, the Mood Clinic, maybe I don't even remember now, which was in the Gerard Bank Building. And I got invited to participate in the practicum in the-I did a practicum over there. I got invited to have to purchase it in the didactic training that was being done for the therapists who were learning Cognitive Therapy for one of the first randomized trials. My teachers included Art Freeman. I saw some patients in Beck's Clinic but one of my very first clinical supervisors was David Burns.
Dr. Keith Sutton: (11:34):
So amazing training.
Dr. Jaqueline B. Persons: (11:36)
Oh my God. Later I met a local psychotherapist here in this local community who asked me, how did you get started? Why did you go over there? Cause I could have gone over to Lester Luborsky's psychodynamic Psychotherapy training, which was also at Penn. Lester Luborsky is an amazing person. I don't know. I went over to Beck's place. I think certainly Cognitive Behavior Therapy is more congenial to my own way of operating and thinking. But as I was telling my colleague here, once I said, "Oh, I think one of the reasons I did it is because I could see that they were focused on collecting data and developing a treatment that was supported by data." You know, they're doing these randomized trials to evaluate the efficacy of their treatment. I thought, "That is a kind of treatment that I want to learn."
Dr. Keith Sutton: (12:32)
Showing efficacy.
Dr. Jaqueline B. Persons: (12:34)
Yes. I want- I don't want to learn a treatment where we don't have efficacy data. I just don't want to do it. Which my colleague was surprised at, because I don't think many clinicians think about that when they decide what treatment they're going to learn. But part of why I'm saying this is if you're a young person trying to figure out what treatments you're going to learn, I would suggest think about what your values are. But to me, one of my values is science, evidence-based learning. Learning psychotherapy is extremely demanding. Don't learn therapies that do not have an efficacy database, please. Well, I shouldn't say that. Think about your values. Anyways, science and data was one of my values, and that's part of why I learned cognitive behavior therapies is what I'm saying.
Dr. Keith Sutton: (13:27)
Great. Great. And then yeah. Where did you go from there, from doing that kind of training with Beck.
Dr. Jaqueline B. Persons: (13:37)
So I got some training with Beck. Well, I attached myself to David and David was very generous with his time. So, even though after my practicum ended, he had a weekly group supervision that happened on Friday afternoons four o' clock. Most of us, we come in the room we're just exhausted. By the time we leave we're full of energy. I don't know if you've ever been to one of Dr. Burns's trainings.
Dr. Keith Sutton: (14:01)
I haven't actually, I've been wanting to go.
Dr. Jaqueline B. Persons: (14:05)
David Burns is one of the best teachers I have ever met, and he had a lot of energy. So we had a lot of fun. So I basically attached myself to David Burns and I went to his clinical supervision for pretty much the whole time I was in graduate school. Then I did my internship training at hospital and the University of Pennsylvania, which I did just because it was convenient. I didn't want to move out of town for my internship. By that time I was married. My husband was an economist on the faculty at Penn. So I want to just stay right at home. That was kind of a challenging experience, Department of Psychiatry, various psychodynamically oriented. But anyway, and then after that I had year postdoc training and I went over to Joseph Wallpain Clinic. Oh wow. I went to the Behavior Therapy Unit, Eastern Pennsylvania Psychiatric Institute. The director of the clinic was Joe Wallpain. And one of the core faculty was Edna FOA, and Gail Steketee was there, Jonathan Grayson was there. Can you imagine.
Dr. Keith Sutton: (15:14)
That's amazing training.
Dr. Jaqueline B. Persons: (15:17)
I thought I had died and gone to heaven. So I got all that fabulous clinical training and I was still interested in research. And so I was collecting different types of data. And then my husband, who's on the academic job market. I thought about going on the academic job market, but I wasn't really ready to go. I didn't know. So I came to California and started a private practice and started writing up some of my research and doing some of my research in my private practice. And I have a lot of fun.
Dr. Keith Sutton: (15:56)
And with the research that you were doing in the private practice, was that based on kind of, symptom measuring that you were doing, and kind of looking at outcomes and such and kind of have your own, accord?
Dr. Jaqueline B. Persons: (16:12)
Yeah. So as you pointed out, I started developing some ideas about individualized case formulation as a way of personalizing the treatments from the random protocols that were studied in the randomized trials. Part of that I learned to do when I was on the clinical faculty over at UCSF, when I worked with Ricardo, Ricardo ran the depression clinic over at San Francisco General Hospital. Those patients have a lot of diversity. They're lower-income patients, disadvantaged patients, minorities frequently, often from the Hispanic community in the area. All the patients that were seen in the depression clinic were medically ill.
Dr. Jaqueline B. Persons: (17:10)
So I started developing my ideas about personalizing the treatment, and how to use a case formulation to do that in a systematic way, and then monitor outcome. So I developed my approach to case formulation driven, Cognitive Behavior Therapy. And then after a number of years, I dunno, I guess a lot of years I had enough outcome data. I published a paper. You could think of it as a single trial, do patients who come into my office, and I think some of those patients were also treated by my colleagues in my group practice, do they have outcomes? And we're giving them case formulation driven, Cognitive Behavior Therapy. Do they have outcomes comparable to the depressed patients treated with a protocol in the randomized trials? I mean, it's not hard to do the data analysis. You look at the outcomes, and you just look at it and you know what, those patients did well. So, I published a nice paper. It was published in Behavior Research in Therapy. Two of the graduate students at UC Berkeley helped me with it.
Dr. Keith Sutton: (18:17)
Oh, great. Wonderful. And can you say more, can you describe your individualized case formulation approach?
Dr. Jaqueline B. Persons: (18:27)
I have to learn how to answer that question briefly. The formulation driven approach, first of all, focuses on the whole patient, not just a disorder. Notice the empirically supported treatments treat a disorder, right? Cognitive therapy for depression, cognitive processing therapy for PTSD. Usually the patient who's in your office, or my office has more than one disorder. So I want to know what all the disorders are. Often the patient also has a number of psychosocial problems. Like maybe there's a marital problem. Maybe the patient is underemployed. Maybe the patient has an outstanding tax bill from three years ago that he's avoiding dealing with IRS the on. Anyway, I want to know about all that stuff. So I want to be thinking about the whole case. I want to know about the medical problems. I want to know about all of the psychiatric disorders and problems. I want to know about all of the psychosocial problems. And then I want to develop a hypothesis about what are the disorders and problems and, or the psychological mechanisms, that are at the heart of the matter, and that are driving a lot of the symptoms. So I can focus my treatment on those.
Dr. Keith Sutton: (20:01)
Yeah, there's a particular quote, I'm forgetting the author, it's one of the Treatments That Work series on working with depression, and it sounds like they do a little bit of similar — they use the acronym "beast" to look at kind of the different factors. They came up with the term based on, they talk about the story about how Winston Churchill struggled with depression his whole life. And he used to call it as a "little black dog" that followed him around, and they took this acronym beast to kind of break it down. To look at the, the "B" the biological aspects, you know, health issues, medical issues, nutrition, sleep, drugs, and alcohol, that kind of stuff. "E" the emotions as a person, emotionally avoidant, or are they more ruminative, kind of obsessive, do they have emotional awareness, "A" which is actions, so kind of your behavioral interventions or kind of behavioral activation, you know, are you living a life that's worth living, in direction of values. "S" as a situation yeah.
Dr. Keith Sutton: (21:05)
Situation, financial taxes, or problems with a partner or family members what's kind of adding to, or even decreasing the likelihood for depression, like having strong friendships or so on. And then "T" are the thoughts, the cognition part of the cognitive behavioral therapy, because like you're saying, there's so much more and all these kinds of aspects interplay, and so really kind of being able to look at all those pieces is so important in really kind of understanding how it all kind of integrates together, and what's going on with that particular client. How do we address that?
Dr. Jaqueline B. Persons: (21:42)
I'm going to have to look that up. Yes, it does sound right up my alley.
Dr. Keith Sutton: (21:46)
Yeah, I'm sure they probably, they might even reference your work in there. Yeah, it's nice to kind of have that piece, and I think Lazarus also, I forget the acronym, it was like basic ID or something like that, also kind of multi-modal, you know, piece like you're talking about, you know, again, expanding it beyond just the pure cognition, and kind of bringing in those other pieces cause originally, right, it was really just cognitive therapy and that later on the "B" got brought into it, is that right? Cause I know
Dr. Jaqueline B. Persons: (22:18)
No, the "B" was always there, and Beck's cognitive therapy for depression. The "B" was always there. The "B" was subservient to the "C" in that the behavioral interventions were viewed as having the mission to change thoughts. But the first, the "B" was always there. And in fact, the behavioral activation treatment that was later developed by, I'll think of his name, but anyway, came directly out of Beck's cognitive therapy. They just grabbed the B part and grew it. And also they strengthened the behavioral functional on analytic way of thinking about the B's, but all that actually came out of Beck's cognitive therapy, which did have a "B" column, but part of the reason or B element, but the reason you think of it as cognitive is because it was called cognitive therapy. If you look at Beck's daily record of dysfunctional thoughts, which is the thought record from the treatment, there's no behavior column, which in my opinion is a mistake. So my thought record, I want to know, are what are the thoughts, but I also want to know what are the behaviors and Ben does talk about the triad, the cognitive behavioral mood triad, although maybe that's not what he uses the word triad to refer to, but certainly the cognitions were primary.
Dr. Keith Sutton: (24:05)
Definitely. Yeah. And yeah, I remember cause I did a training at the Cognitive Beck Institute and yeah. That kind of talking about that cognitive therapy aspect, and I know that right, the behavioral activation was kind of part of the depression treatment kind of right from the beginning, I think. And so it's always been kind of an interesting, you know, a history of CBT and how it's evolved and also too how I know now there's also kind of a focus on more of a trans diagnostic kind of approach. I know there's kind of, I think it's, Barlow's universal approach and I know Matt McKay is doing his mindfulness and emotions and this idea, like you're saying again, kind of treating, you know, dealing with the multiple kind of issues that the clients are bringing in because rarely are they coming in, like in a research study where they've only got depression, and there's not kind of other factors or only having panic disorder or something like that.
Dr. Keith Sutton: (25:02)
And I think part of what you're saying too is, you know, and again, in your approach of kind of creating an individualized plan, is all sort of looking at the social cultural aspects of both how the person is experiencing their environment, and the culture that they're living in and how that's interacting with their culture. And also how the therapist is thinking about how, what they're bringing to the therapy is also interacting with the client's experience and cultural experience. That's really important. Definitely, you know, tell me a little bit if that's something that you've been focusing on more in your research lately, or is that something that you've been thinking about, cause you were mentioning in a lot of folks in having a diverse kind of clients that they're working with in private practice and kind of all this kind of opportunity for data. Is that been something you've been thinking about more lately or writing about or is that kind of, yeah?
Dr. Jaqueline B. Persons: (25:55)
Well, I'm very aware of it just by reading the newspaper right. And seeing this shift that we hope our culture is going through. And of course, but I come from a very white privileged background, so I'm not actually very knowledgeable in this area, but I'm trying to learn. I also have a private practice that has very few people of color by way of patients in my office. So, that's not very satisfying. I'm talking about working with one of the graduate students in the clinical science program at UC Berkeley, where the clinic sees a more diverse range of patients in the community. So I'm talking about supervising her next year. She's particularly interested in these issues of diversity and equity and how the treatments developed by white people might or might not be helpful to other people of other races. So I'm hoping we can do a single case study in the clinic to think about some of these questions. I have to figure out what the questions are exactly, but I'm hoping Erica is going to know.
Dr. Keith Sutton: (27:17)
What I think too, so back, earlier in my training, I trained in motivational interviewing even way before graduate school and really loved that model, and I really kind of connected with it. And I think that oftentimes, you know, particularly with any, you know, when I actually started, so I had first gone into more kind of a more postmodern approach doing narrative therapy. I was really interested in family systems and I was working with families and then I got reading and working with couples, but I didn't have a good individual approach. So I ended up actually gravitating towards CBT, which kind of grew out of my, in undergraduate, my minor was in Eastern philosophy. And so I was really interested in the way that kind of our perceptions of the world color, our experience. And then I went and did training with Albert Ellis when he was alive, training at the bedrooms to which youth and Aaron Beck.
Dr. Keith Sutton: (28:08)
I did some training with Edna FOA, and Robin Waltzer and so on. And so in the beginning, when I was kind of doing CBT, I would say, you know, talking to my narrative friends, I'd be saying I'm doing CBT, but humanistic CBT. Because oftentimes I think there's an association with cognitive behavioral therapy as this kind of very rational, emotionless, kind of perfunctory type of approach. Whereas you know, really, and it's taken some years for me to even kind of grow into it, just really that it is very much about that human connection and particularly kind of more of these humanistic approaches, like motivational interviewing kind of more of a Rogerian kind of piece, these aspects kind of really mingled very well with the Cognitive Behavioral Therapy, because ultimately you can't get any movement in Cognitive Behavioral Therapy, unless you're able to make that connection with your client.
Dr. Keith Sutton: (29:05)
You need to one, understand your client and your client needs to feel understood before you can even begin moving forward in the work. And I think particularly CBT, most protocols started out with the psycho-education and which is really about kind of connecting with our client, finding out their understanding of the problem, discussing our conceptualization of the problem, and collaborating and kind of bringing those together to come up with a solution or a treatment that we're going to do together. And I think that-that's the place kind of where, you know, also our, connection or kind of differences or experiences culturally, socioeconomically, socially, all kind of match up to be able to have a therapeutic relationship to begin moving forward, in whatever these treatments are, evidence-based or kind of order relational or whatever it might be. So that kind of foundation of that, therapeutic relationship I think is so significant.
Dr. Jaqueline B. Persons: (30:05)
Yeah, it reminds me of, I can tell you two little stories. One is, I ran an article in the New Yorker about 20 years ago. It was about George Balanchine. Is that how you say his name, the choreographer. And, he talked about how, the way he would choreograph a new dance is he would bring in the dancers and he would say to them, show me what you can do. And then he would use what he could see what their strengths were to guide him as he choreograph the dance that these people would do. So to me, part of what you're talking about and motivational interviewing, I think is particularly strong in this, you know, they view the patient as the best expert on his or her situation. Anyways, so what I try to do with my people is, you know, show me what you can do.
Dr. Jaqueline B. Persons: (31:01)
What are you already, like often I'll try to lay out the situation and offer a little bit of a conceptualization, but tell me, like, what are you already doing to solve this problem? And then I'll try to work with them to figure out, is it helping? Can I help you do more of it? Is it not quite right? Can I help you tune it up? But you know how to help people take what they're already bringing in, do more of it or switch it up, or maybe they need to learn new things. In which case I'm happy to teach them, but let's start with what you're already bringing. And each person is bringing his or her own things to the table. So that's one thing I always try to do in my therapy is that it has to do with being responsive to what the person is bringing. That was one story. What was my other story that I wanted to tell? This is the problem. I start with one story, and when I can't remember the other one, but I'll remember it. What are we talking about? I don't know.
Dr. Keith Sutton: (32:01)
So with the collaborative piece, I mean, I think part we're talking about, you know, kind of the work and you're thinking about kind of working with a diverse clientele and you know, about kind of that you know, collaboration and you know, moving forward.
Dr. Jaqueline B. Persons: (32:19)
Okay, so here, so I had a patient who was in my office, who did not get very much help. She had a big ticket OCD, and somehow I just wasn't able to help her very much. And I felt like she needed more intensive treatment. So I sent her off to an intensive treatment center, and then she came and she wasn't all that much better. Actually, even though she had gotten a lot more help, I should probably be offering a little more detailed conceptualization as to why I think she needed a more intensive treatment, but anyway, I'm going to skip that part. So then what happened was she did all this intensive treatment, but when she came back to me, she wasn't all that much better. So then I called the therapist, the provider, and I said, "Okay. So could I learn from you a little bit more about what happened in this intensive treatment?" And the therapist said to me, "Well, I delivered this intervention and I delivered this intervention. And then we did the exposure and then she learned mindfulness. And then she, this actually, she probably didn't say she learned, she said, I delivered this intervention. I delivered this." So that I hear you saying you deliver these, the question I have for you is did the patient learn anything?
Dr. Jaqueline B. Persons: (33:36)
What's the engagement, but also like, did the information get into her head and did she have anything changed in her way? She was thinking and behaving as a result of your delivering the intervention, and something you said about probably about feedback reminded me. Cause we want to not just deliver the intervention, we want to hear from the person. Okay. Does this make sense to you? Does it seem like something you could use? Do you want to try it, talk to me about what happens when you try it? Is it helpful? Is it not helpful? Is it harmful? Like give me some feedback because then the feedback which is data, I'm going to use the feedback to figure out what's my next move. Maybe that intervention isn't going to help you because it doesn't make sense to you and you can't really, I don't know, but using feedback. So there's kind of a back and forth dynamic process. It's not just that you're the person and I'm like giving you all these interventions and now you're fixed.
Dr. Keith Sutton: (34:40)
Yeah, exactly. What about feedback? So important? I know in the common factors research, especially with the Scott Miller Barry Dunkin work, Scott Miller talks about how they did one research project where the clients are filling out the feedback forms, but then they weren't giving that data to the therapist. And then after I think, five or six sessions, they gave that data. And then actually the therapist shifted. And just by getting the feedback, they were able to increase outcome by 60%, regardless of their theoretical orientation. Particularly I think I'm thinking too about like, especially with a client that I had with OCD that they never really kind of got on board with a work, they were doing an intensive program. So they were just kind of white knuckling it through their exposure. They were doing their exposures, but they hadn't gotten the sense of, I need to lean into this.
Dr. Keith Sutton: (35:35)
I need to release the anxiety and really feel this. Instead, they kind of sit there and sit long enough until the anxiety went down, but then they go, "Ooh, good. That's over with." Kind of that engaging with it. And I think sometimes when I was back in my pre doc, I was working with a family and I felt like I was just kind of dragging them along. And I realized, cause you know, even though we had kind of gotten on the same page in the first session that didn't just carry through every single session that we needed to be, re-contracting reconnecting to kind of what we're working on, the steps that we're taking and making sure that kind of we're walking side by side, rather than me getting ahead and kind of trying to pull the other person was dragging them along behind. Yeah. Cause that's not gonna, that does not have what therapy makes. You know, because it really is that partnership about kind of walking on that, that journey together. I was actually seeing you there was a reason article that you published also on kind of therapists and keeping up with kind of the recent research. Do you know what I'm referring to?
Dr. Jaqueline B. Persons: (36:41)
I believe it was the paper that Kim Wilson was the first author on and it was published in the Behavioral Therapist and it was article about how, if you're a clinician, what are the strategies that you can use to keep up to date with the literature, which is a hard task. It's hard to fit it into a busy clinical life.
Dr. Keith Sutton: (37:01)
And I actually, I didn't have a chance to read it. I actually saw it while I was just perusing your bio before our meeting. And I was wondering if you could speak a little bit about that, cause they know again for me and you know, I think the goal of this podcast is for therapists that are really interested in keeping up, but sometimes we have all the time to read all the papers in the new books and so on. What is your advice, or what are your thoughts on what would be helpful to clinicians wanting to stay kind of up to date?
Dr. Jaqueline B. Persons: (37:30)
Well, first of all, congratulations to you for being devoted, to trying to stay up to date. It's part of being an evidence-based practitioner, which attention to the evidence and the evidence changes. So then we're going to want to change what we're doing. So kudos to you for being motivated to do that Kim Wilson and I, and some of the others who worked on that article did so as a result of a project we were doing, and I'm still doing at the Society for a Science of Clinical Psychology, which is a fantastic group. And I head up a committee called The Committee on Science in Practice. So it's about how to get science into your practice and on the webpage, if you just go to Society for Science of Clinical Psychology, go to the webpage on resources, there's five interviews that I did with leading scientists describing their up-to-date work and its clinical implications, probably the best article article.
Dr. Jaqueline B. Persons: (38:35)
And it's focused on an article. The one that's gotten the most attention is an interview I did with Michelle Crass in which she talks about inhibitory learning, which is her model or theory about what goes on during successful exposure based treatment. So learning these ideas from Michelle Crass about inhibitory learning is really important, but that's separate. Anyway, if you go to my interviews at the SSEP that it might help you keep up with a few things. I also did an interview with Michael Lambert about progress monitoring, and I did an interview with, Ed Watkins, rumination focused treatment. And I did a fantastic interview with Emily Holmes on use of imagery in therapy. Anyway, so you can listen to my interviews. What else? Well, I think it's a good idea to belong to a professional association in your fields, which then you can be part of their list serve.
Dr. Jaqueline B. Persons: (39:41)
If the association, which many do publish a journal, then you could get the journal. You could, you could get the journal alerts. You could go to the American Psychological Association, look at the journals. Probably the number one journal for clinical psychologists is, Journal of Consulting and Clinical Psychology sign up, sign up to get the alerts. Then every time a new issue of the journal is published. They'll send you an alert, they'll send you a list of all the articles you could read the abstracts, and you could get a sense of where the field is going and what are some of the findings, and then you could figure out if you want to learn more about it, go to the conference, attend the sessions. I think participating in a (unclear). I'm sorry. I hope it's not a problem at my end, but we're having some connectivity problems.
Dr. Keith Sutton: (40:40)
Yeah. I don't know what happened. It just dropped. But yeah, so you were talking about, you know, being involved with national you know, organizations, attending conferences, all these pieces around, staying up to date. I think that as I'm hearing you saying this, it's really about that community and kind of being connected to that community of, you know, whether it be your local organizations. Like I know I'm part of the Northern California CBT Network, or there's the national associations. You know, all these kinds of pieces are a great way to keep up to date and connected. I was wondering too, do you have any recommendations of are there any books out there that are good for talking about doing research in your private practice, or is that a book that you are going to be writing soon at some point? I think that would be really great.
Dr. Jaqueline B. Persons: (41:35)
Well, as I told you, I'm working on my article, here's a book.
Dr. Keith Sutton: (41:38)
Okay, "Practice-based Research and Guide for Clinicians." Wonderful. And that's by Trent Codd, perfect.
Dr. Jaqueline B. Persons: (41:47)
I have a chapter in this book, it's an edited book. So a bunch of different clinicians who do research in their practice, describe some of the ways they structure their business to support research. So that's an idea.
Dr. Keith Sutton: (42:06)
Well, wonderful. Well, Jackie, it's always wonderful, it's always great to catch up with you and hear about what you're doing and kind of what the latest is. Thank you so much for taking the time today. Really appreciate it.
Dr. Jaqueline B. Persons: (42:18)
Completely. My pleasure. I had fun. Thanks you Keith.
Dr. Keith Sutton: (42:21)
Okay, great. Take care.
Dr. Jaqueline B. Persons: (42:23)
You take care of yourself. Okay. Bye-bye
Dr. Keith Sutton: (42:25)
And actually, hold on. I love you. So now we'll cut the tape. It's great. Thank you so much. I appreciate it. How was that?
Dr. Jaqueline B. Persons: (42:33)
You are totally welcome. I enjoy doing it. So good luck to you with your project.
Dr. Keith Sutton: (42:38)
Definitely. I really appreciate it. And I'll have to look up those interviews. And so on that you're mentioning that sounds like you're also doing some cool interviews. It is. It's great. It's good to connect with people and kind of hear what's going on. Okay, well, thank you so much. I appreciate it. My pleasure. Okay. Take care. Have a good one.
Dr. Jaqueline B. Persons: (42:59)
Bye.
Dr. Keith Sutton: (43:01)
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