Evidence-Based Practice in the Real World

Welcome to Sound Behavioral Health, an organization that strives to make evidence-based clinical work realistic and alive. Over the next few months we will be updating the site with training announcements and articles in our quest to empower clinicians with real-world application of the best that science and research has to offer.

A More Cost-Effective Tx for Depression?

We here at Sound are big fans of accessibility. One of the many things that attracted us to Salvador Minuchin’s work was his emphasis on community-based access to care. As director of the Philadelphia Child Guidance Clinic in the 60s and 70, Minuchin spearheaded “lay therapists,” community members with no formal degree who were trained to do family therapy. In addition to the benefits families received from working with persons who were from their same socio-cultural context, the treatment was more affordable and accessible for both the families and the clinic.

So our interest was piqued when we came across this Lancet article publishing the findings comparing behavioral activation treatment and cognitive behavioral treatment for depression for adults. Sure, it is interesting that behavioral activation, a treatment that focuses on helping people with depression to change the way they act (rather than change the way they think), did just as well regarding effectiveness than CBT. What’s really interesting is that the behavioral activation treatment cost twenty percent less.


Why, you may ask? Well, like the “lay therapists” at Minuchin’s PCGC, the behavioral activation treatment was provided by lay professionals. The CBT, on the other hand, was provided by licensed professionals.

The authors of the study, including David Richards of the University of Exeter in England, contend that these findings show that behavioral activation could increase the availability of effective therapy, as well as reduce the need for costly professional training.

Does everyone with a ‘mental disorder’ diagnosis need treatment?

A study that came out this past summer found that many people diagnosed with substance abuse, anxiety, or depressive disorders recover within a year of diagnosis without treatment. “This study further supports the argument that meeting diagnostic criteria for a mental disorder does not necessarily indicate a need for mental health treatment,” the researchers, led by Jitender Sareen from the University of Manitoba, writes.


This study, which reviewed data from the Netherlands Mental Health Survey and Incidence Study (NEMESIS, N=5,618), is consistent with past research that indicates that cases of mental distress can be temporary and remit without treatment.

Similar research conducted by some of the same authors of this study found that a substantial portion of individuals diagnosed with ‘severe mental disorders’ no longer met the criteria for their diagnosis one year later, whether they had treatment or not.

The data of this current study reveals that over half of the 5,618 no longer met the criteria for their disorder at follow-up without receiving any mental health services. However, these individuals had lower quality of life compared to healthy individuals.

This data point regarding the lower quality of life is a curious one. The authors portend that it indicates the negative impact on the presence of residual symptoms from the diagnosis. As firm believers in supporting people to pursue meaning and fulfillment in their lives alongside uncomfortable experiences (symptomatic or otherwise), we applaud this research for questioning the common assumption that a diagnosis is a signal for the need for treatment. We also would like to turn the question on its head: must a person need to qualify for a diagnosis in order to engage in therapy?

Diversity in Couple and Family Therapy

Hello and happy new year to all.

A quick post to announce that we, the founders of Sound Behavioral Health, Matt Wofsy and Brian Mundy, have a new publication out. We were honored to write a chapter on diverse couple and family forms (chapter 13) in the wonderful Shalonda Kelly, PhD’s edited tome Diversity in Couple and Family Therapy.



We had a lot of fun writing this chapter, which includes family structures such as kinship families, same sex surrogate families, and adoptive families. One of the pleasures of working in New York City is being able to learn about and work with many diverse family forms.

New Training: Mindfulness and Acceptance-based CBT for Anxiety

On Saturday, July 16th, we are offering a CE-accredited 7 hour training on Mindfulness and Acceptance-based CBT for Anxiety.

This one-day training is designed to help clinicians approach anxiety treatment with the psychological flexibility model underlying acceptance and commitment therapy, functional analytic psychotherapy, behavioral activation, and mindfulness-based cognitive therapy. Participants will learn case conceptualization, engage in experiential exercises designed to illustrate key components of mindfulness, present moment awareness, acceptance, values, and emotional deepening, and practice intervention skills in both group and dyad environments.

The training will combine theoretical and practical information at a beginner to intermediate level, with specific interventions from evidence-based protocols for anxiety. Participants should have, at minimum, basic familiarity with CBT concepts.

Brian Mundy, LCSW, SW CPE is recognized by the New York State Education Department’s State Board for Social Work as an approved provider of continuing education for licensed social workers #0362. 

Click here to register!

Ok, you have anxiety. Are you doing what you want?

Another study is making the rounds here at Sound Behavioral Health.

This systematic review by McKnight and company (Clinical Psychology Review, April 2016), attempts to investigate the empirical evidence for the relationship between anxiety symptom measures and functional impairment measures. It looks at levels of social, occupational, and physical functioning in relation to symptom levels.

For a long time, there has been an assumed corollary between reduction of anxiety symptoms and level of functioning — that if we experience less panic, for example, we function better. In truth, as this article points out, it’s not a relationship that has been scientifically tested to a sufficient degree.

So. The study raises the important question that sometimes creates divides in both the research and the clinical worlds: is therapy primarily about symptom reduction, or is it primarily about responding to such symptoms in order to live a valued life?

(Of course, these are not mutually exclusive aims, but you can see how the context of each question establishes very different clinical stances)

In other words, do we emphasize feeling GOOD or about FEELING good?

What did this impressive and exhaustively researched review reveal? In short, the correlations are there, but are identified as “somewhat weak,” and the authors state, “Combined, these studies counter the assumption that symptom severity is strongly positively correlated with impaired functioning and suggest that a more complicated relationship exists.”

Abstract link: http://www.ncbi.nlm.nih.gov/pubmed/?term=Anxiety+Symptoms+and+Functional+Impairment%3A+A+Systematic+Review+of+the+Correlation+between+the+Two+Measures

Concurrent Documentation

It’s been a while since we here at SBH have shared or posted anything, and this one is too important NOT to share.

First, here’s the link, go see for yourself: http://psycnet.apa.org/psycinfo/2015-34225-001/

As many of us know, Article 31 clinics in New York state are having a hard time. The transition to managed care has raised a lot of questions regarding treatment length, paperwork, and scheduling. Concurrent documentation, the process of creating documentation in real time with the client, has been both upheld as an effective form of treatment collaboration and time-saving, as well as reviled as a cheap(er) way to schedule more billable sessions.

Here’s the rub: there isn’t much research to back up either argument. However, an important addition has been added to this debate.

Rosen, Nakash, and Alegria video recorded 104 intakes in the northeast and measured (coded) the therapeutic alliance as documented in the video. The quality of the observer-rated working alliance and client’s continuance in care were significantly lower in intakes in which the therapist used a computer during the session.

We’ll continue to watch as this body of research grows.

Why the Dodo Bird Argument is Important (and why it’s not)


Are all forms of therapy effective? Saul Rosenzweig concluded in the 1930s, that yes, all modes are effective as long as the clinician is a skilled listener and the patient has a certain degree of readiness.

This argument, called the Dodo Bird Verdict — named after the famed dodo bird in Alice in Wonderland who determined that everyone who raced wins all the prizes — has experienced prevalence in the behavioral health community. Research labs across the world where modalities such as DBT, CBT, and psychoanalysis are measured for effectiveness, frequently find the Dodo Bird appearing in discussions.

Scott Miller’s work takes a different spin on the Dodo Bird Verdict, claiming that, yes, specific intervention techniques may be effective for a given presenting problem, but common factors such as therapist empathy, incorporating client feedback, and the nature of the therapist-patient relationship trump such theoretical constructs to a high degree.

In our co-authored book, Therapy in the Real World, we argue that joining and engagement comprises just one of six core meditational processes that are critical to effective, evidence-informed, real-world practice. The other five are motivational interviewing, cognitive behavioral strategies, acceptance and mindfulness strategies, multi-systemic collaboration, and relapse prevention.

This sets the stage to ponder a fascinating (and impressively executed) bulimia study conducted by Stig Poulsen and Susanne Lunn in Denmark that compared the effectiveness of CBT vs psychoanalysis. To quote this Guardian article:

Even though the participants in the Danish trial received vastly unequal amounts of treatment over an extended timespan – with those given psychoanalysis seeing their therapist far more than those allocated CBT – it was CBT that proved more effective. After five months, 42% of the CBT group had stopped binge eating and purging; for those receiving psychoanalysis the figure was just 6%. After two years, the proportion of the psychoanalysis group who were free from bulimia had risen to 15%. But this was still a long way short of the success of the CBT group after two years (44%), despite the fact that by then it was 19 months since the end of their course of treatment.

Impressive results, yes? Here’s the ringer: the primary researchers were psychoanalysts.

One of the main reasons that the Dodo Bird Verdict has experienced such lasting power is the understandable and important argument that bias toward the orientation of the particular lab conducting the study skews results. That’s why we here at Sound Behavioral Health think that studies like Poulsen and Lunn’s are hugely important, and that the researchers should be applauded for their commitment to science.

Medication, Families, Choice, and Empowerment


We’ve been absorbing this article from the New York Times lately.

At Sound Behavioral Health, we believe that people with serious mental illness ought to have informed choice and family and institutional support in their care. We’ve worked too long in the system, seen too much punishment for “noncompliance,” and have seen too many people slip through the cracks to not wonder if there is another way.

The more coercive paradigm described in this article often leaves folks with serious mental illness with what feels like a double bind: either get with the program or go it alone. This paradigm is not just coercive to patients — it is coercive to psychiatrists and other providers, who bear some risk and liability in straying from established standards of care that are represented by medication and ‘swift discharges,’ even if those standards do not really work in the long term.

As Kelly Wilson points out: “Major organizations like the British Psychiatric Association are beginning to endorse real choice and real informed consent about the risks and benefits of medications. We are beginning to see clinical trials of no medication and minimal medication approaches to psychosis. And there are some very promising data out there showing that some, not all, but some, can thrive on alternatives to coerced high dose meds.”

What is deictic framing? And why is it important to good health?

file_101560_0_Baby_MirrorDeictic framing is framing events from different relational perspectives. For example, we can ask a client, “How can you-here-now reflect on the experiences of you-there-then?” When humans utilize this kind of perspective-taking, we can experience events, thoughts, feelings, and sensations differently than we usually do. This reinforces psychological flexibility.

We here at Sound Behavioral Health are digging on the new book “Mastering the Clinical Conversation: Language as Intervention” by Villatte, Villatte, and Hayes. Its breakdown of relational frame theory can get knotty at times, but our experience so far is that it’s worth the journey. (you can find the book here)

As part of the the book, the Villattes have created a very handy website with videos and blog posts. Here you’ll find three simple and immediately applicable methods to employ deictic framing in session with your clients.