Brad,

I'd be happy to chat sometime when you're back in Ohio.

I'll respond to your latest reply as best I can, but maybe we're in an "agree to disagree" situation.

You mentioned differentiating specific NARM questions from the larger points about evidence based research. NARM is simply an example for my larger points. To be sure, there are many other examples.

About the limits of scientific pursuits, I don't claim that there are no limitations. Nothing is perfect, but I've yet to see a better way of demonstrating whether and how things work.

You also stated you don't adhere to any camp that believes we shouldn't hold science in high regard. The comment I made that might have prompted that response was, as I mentioned, related to someone else who had commented on our exchange (just in case there was confusion about that). However, I do think there is a disconnect between what you say about research and what you do.  Below you say "There are times that I agree we need to nail an intervention/method down before disseminating it, and I believe there are other times we have to go with what is working and do the necessary research as we go." One of my main points has been that you need well designed studies to demonstrate that something "is working". You can't (shouldn't) just say it works and market it as such, explicitly or implicitly. You indicated that an initial efficacy study is only now underway. So what is the basis for saying that it works? I assume you mean you have anecdotal evidence. That's just not enough to warrant marketing and promoting it on a wide scale. You can't say that scientific research has limitations and then go on to rely on anecdotal evidence.  You also seem to be saying that there is urgent need to find what helps people. Although I agree that more work needs to be done, we DO have things that help people. I run a clinic that treats people with PTSD and other trauma-related problems (yes, including complex PTSD, etc.) every day. We use evidence-based practices and collect detailed outcome data that demonstrate treatment effects in various domains.

You also say "...I agree with your perspective, while adding my advocacy for openness to newer therapeutic approaches that for many different reasons may not be widely accepted yet, and therefore not taken seriously by the scientific community."  Again, you can be open to newer approaches but show restraint in promoting them until the evidence is in. And lack of scientific evidence is *exactly* a reason why something shouldn't be "widely accepted yet", and why it shouldn't be "taken seriously by the scientific community", specifically *as an evidence-based intervention worthy of dissemination*. Certainly it can be developed and studied scientifically, but that is not a step to be skipped in the process. I'm glad there is something underway now.

You also refer to that now underway efficacy trial as "the exciting next step of our journey in promoting this promising treatment model." Again, why is it a next step in *promoting* it? Shouldn't some efficacy be demonstrated before promoting it? Without efficacy, what is there to promote? It's the recurring theme here of the cart-before-the-horse analogy.

As we both have noted in some way, we probably could go back and forth forever on this and we may need to agree to disagree. I would be happy to discuss further, in this forum or backchannel, if you would like.

I have enjoyed the dialogue that my original blog stimulated.  Thank you all for your comments, both publicly here and in private.  I appreciate them.

Patrick, I appreciate your perspective and what you are bringing to this discussion.  As I mentioned in the email exchange we had earlier, I look forward to meeting some time when I’m in Ohio and learning more about your work and sharing more with you about mine.  I think these discussions are best had in person where we can sit face to face and truly dialogue. 

But in brief response your comments, I believe it’s important to differentiate your specific questions about NARM from the larger points you are making about the importance of evidence-based research.  I do not adhere to any camp that believes that we shouldn’t hold science in high regard.  I hold science in the highest regard, I have many close people in my life who are scientists, and I am in total agreement with what you are writing regarding using scientific research to promote innovation in any scientific field, including ours.  At the same time, it is important to recognize the limitations of such pursuits.  As I wrote earlier, it doesn’t have to viewed as an either/or scenario – I believe that innovation can fuel research and evidence can fuel further innovation.  There are times that I agree we need to nail an intervention/method down before disseminating it, and I believe there are other times we have to go with what is working and do the necessary research as we go.  Both directions have their pros and cons.  Yes, in an ideal world, we would scientifically validate everything before we apply it.  But we're not living in an ideal world.  And from my perspective, it is important to not let strong ideological beliefs get in our way of the urgent need to find what serves people, and to serve them. 

I agree with you that it’s too easy to throw around terms like “emerging” and “promising”, just as it’s too easy to throw around terms like “pseudoscience” (not that you used this, but it’s long been widely used by scientists to discount effective theories and treatments).  And I hope that all new models that are “promising”, in the sense of gaining wider notoriety surrounding their effectiveness – even if just anecdotally - would then be treated fairly by the scientific community and researched in a fair manner.  This is not how science always, or even most often works, based on the political, financial, moral and cultural influences of our society’s institutions.  It’s possible we could argue this forever but I just want to point out that I agree with your perspective, while adding my advocacy for openness to newer therapeutic approaches that for many different reasons may not be widely accepted yet, and therefore not taken seriously by the scientific community.

Patrick, you were asking specifically about one of the therapeutic models I practice and teach, the NeuroAffective Relational Model (NARM) - it is a theoretical and clinical model emerging out of earlier psychotherapeutic models such as Psychodynamic Psychotherapy, Cognitive Therapy, Humanistic-influenced approaches, Somatic-based approaches such as Gestalt Therapy and Somatic Experiencing, and mindfulness-based approaches.  It is heavily influenced by and integrates Object Relations Theory, Attachment Theory, Affective Neuroscience, Interpersonal Neurobiology, and other relational theories.  While Dr. Heller, founder of NARM (and my long-time teacher and mentor), has been practicing psychotherapy for over 40 years now, NARM as a model is very new – the book Healing Developmental Trauma in which he introduced NARM came out in 2012 and the NARM Practitioner Trainings started around that same time.  They have taken off in Europe very quickly and passionately, and we are working to train clinicians in the US now as well. 

As I have mentioned to you, we are in the early stages of conducting research, and as you well know, that research takes time (and money).  It is the exciting next step of our journey in promoting this promising treatment model.  And we are not going to slow down in sharing with interested clinicians who are working in a field that is just now being more clearly defined (thanks to websites like acesconnection), and who are actively seeking effective treatment options for addressing complex trauma.  They have clients who are in need, and if NARM can help serve their clients, we want to support their efforts.

Lastly, I will make another appeal to you Patrick, or any other interested member reading this forum who is experienced in research that would like to learn more about NARM, and the research possibilities of evaluating the effectiveness NARM has on working with ACEs - please contact me.  I look forward to further discussion and perhaps collaboration with members of this growing community. 

I'm glad there is active discussion on this topic. I only have time to respond briefly here now and then will be unavailable for a while, but I will return for further discussion when I can.

Brad, I view myself as a clinical scientist - so I'm not one to separate clinical and research knowledge and activities into separate silos. It is very helpful to have a solid grounding in both to do either of them well. At least at some level we seem to agree on that.

Regarding my cart before the horse comment, when you say "how can you research a clinical approach that doesn't exist yet?", you are, in my view, misinterpreting or misrepresenting my central message. I am very much pro-innovation and creating new knowledge, as any scientist is. Where we differ is how to go about doing it. My approach is to have a plausible theory underlying what is being developed and how it works (I am not saying you have none - but I don't know if you do or not), then to conduct a series of research studies that along the way refine the intervention and build up - or not - the evidence base supporting the intervention. This would be done in a research context where participants are informed about the intervention being experimental, the potential benefits and risks involved, etc. This program of research would start on a small scale and work its way up.  On the other hand, your approach (and NARM's marketing efforts) seems to suggest that such research cannot happen without first scaling up on a global level the # of NARM practitioners. This is simply not a pre-requisite for conducting the kind of research that is needed to establish at least some efficacy in an intervention. These were the cart and horse I was talking about. 

Another comment (that also touches on a few of the other comments made by others on this thread) is that if something doesn't have an "evidence base", we can't just call it "emerging" or "promising". My personal view is that all of these descriptors too often are too loosely defined and thus provide cover for all sorts of things. What is promising about NARM? And who says so and why do they say so? Is it okay for an intervention to be provided to clients and taught to providers if it is only emerging? If so, then shouldn't there be at least the beginnings of a peer-reviewed evidence base? NARM has been utilized and taught for years - for how long is it okay to continue doing that without a compelling scientific evidence base? Again, it is the widespread dissemination and promotion that is the "cart". I am not suggesting we should avoid innovation.  

A comment was made by someone else that seemed to imply that we shouldn't hold science in such high regard. In my view that is a dangerous position to take. I certainly don't see a better alternative for making substantive progress.  Does it always happen perfectly? Of course not (What does?)! Are there influences such as money, power, politics (as someone mentioned in a comment below)? Yes. But those are reasons for the peer review process, so that there are opportunities to cut through potential biases. I fail to see why those named potential biases are a reason to discount thoroughly vetted research findings but are not a reason to be wary of anyone's "inner wisdom" or of anecdotal or other evidence that is not peer reviewed and that is put forward by individuals or companies with commercial interests in what they are promoting and disseminating.

I think this discussion is spot on... In my career as a speech and language pathologist  I have been ethically committed to scientifically proven treatments, and now evidence-based.  Now I look back and realize that trauma and brain development and the impact of toxic stress was not mentioned in those studies.  I don't believe science can keep up with the need to nurture those suffering, and heal the trauma that is happening and has happened.  

This is logic... I don't believe that building relationships with others can be harmful as long as they are healthy relationships.  The problem with "programs" is that people interpret them differently.  I think we have to make sure we are focused on healthy loving and long-standing traditions such as yoga, and therapy.  We also need to keep helping others to understand the subtle impact of unhealthy relationships amongst family members and education and childcare providers and children.  

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Mind & Life XXXIII - Reimagining Human Flourishing

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Brad Kammer posted:

Thanks Karen, my background is also in grassroots advocacy – before I was a psychotherapist I worked internationally in humanitarian aid, and then early in my career as a therapist I worked in community mental health.  In both arenas, so many discussions centered around just wanting to use what worked to help people in need; and recognizing the reality that some of the accepted models simply weren’t working, despite what the evidence suggested.  This discussion has a long, and at times adversarial history.

Patrick, I appreciate you taking the time to share your thoughts on this, I value the clarity and strength with which you are sharing your perspective.  It is an important discussion to continue having.  I do have a somewhat different perspective.  In terms of the analogy you used about putting the cart before the horse, one could argue in the other direction too – that how can you research a clinical approach that doesn’t yet exist?  I don’t believe we can create therapeutic models in the laboratory.  When reviewing the history of psychotherapeutic models, nearly all of them have pre-dated any efficacy studies.  If we allowed scientific evidence to dictate the development of psychotherapy, we wouldn’t have gotten very far in evolving the field of psychotherapy.

The reality is that there are master clinicians (starting with Freud in our textbooks, but even before him with those that he studied under) who over the course of their careers expanded the prior models, evolving the work in new directions and teaching this to their students.  As these new models emerged, the necessary scientific evaluation took place to assess the efficacy of these models.  The cart has most often come before the horse in our field, and that is not necessarily a bad thing.  I believe that this has fueled the creativity and evolution in our field.

I could list countless therapeutic models that have been well established, promoted, and benefitted many people, well before scientific evidence came on board.  Just in my own personal experience, it so hopeful to observe what has occurred over the past decade with mindfulness meditation and yoga.  I was first introduced to meditation and yoga some 30 years ago.  Now of course these healing practices have been around for thousands of years, but up until very recently in our society, people discounted or even mocked them; and there are still those that refer to these approaches as “pseudoscience”.  Yet, over the past decade or so, there are now many research studies which have led to mindfulness and yoga being validated as "evidence-based practice".  

I really could go on and on with examples.  These examples aren’t a justification for not focusing on the necessary research to demonstrate efficacy for these emerging models.  I am all for that.  But it does help us balance the rigidity that may limit new, helpful models from getting the exposure and support they need to reach more people.  I agree with what you said about focusing on the models that already have a strong evidence base.  But I hope you would also agree that this doesn’t mean that we should shy away from focusing on emerging models that are demonstrating promising results, even if only anecdotally at this point. 

Lastly, I just want to point out that this is larger than any one approach (whether NARM or any other promising model out there).  We are in the early process of exploring what models out there might be beneficial in treating ACEs/early trauma.  We are doing so in an online forum that is designed to “help heal and develop resilience rather than to continue to traumatize already traumatized people…The network achieves this by creating a safe place and a trusted source where members share information, explore resources and access tools that help them work together to create resilient families, systems and communities.”  In the spirit of this network, I would hope that all of us – whether clinician, educator, researcher or consumer – could continue to share resources respectfully, and work together to become an even more trusted source to provide effective treatment that will help heal and develop resilience.  I welcome and look forward to continued collaboration with anyone sharing this same intention. 

In my opinion, and I am a nerd that has studied a lot, evidence-based practice and the scientific method, in general, are way overrated.  We rely on science for ALL the answers - assuming scientific findings aren’t biased by power, money, and politics  - but ofcourse they are!  Even the FDA is funded by pharmaceutical monies more than public funds.  

How did our forefathers - native and indigenous tribal ancestors - understand so much about healing in the absence of controlled or discreet trials?  

Anyway, carry on with NARM - I actually rely far more on my own inner wisdom and knowing and less on anything that claims to be “evidenced-based.”  We need to continue to innovate and pioneer new ways of healing and cultivating community in this modern age.

Thanks Karen, my background is also in grassroots advocacy – before I was a psychotherapist I worked internationally in humanitarian aid, and then early in my career as a therapist I worked in community mental health.  In both arenas, so many discussions centered around just wanting to use what worked to help people in need; and recognizing the reality that some of the accepted models simply weren’t working, despite what the evidence suggested.  This discussion has a long, and at times adversarial history.

Patrick, I appreciate you taking the time to share your thoughts on this, I value the clarity and strength with which you are sharing your perspective.  It is an important discussion to continue having.  I do have a somewhat different perspective.  In terms of the analogy you used about putting the cart before the horse, one could argue in the other direction too – that how can you research a clinical approach that doesn’t yet exist?  I don’t believe we can create therapeutic models in the laboratory.  When reviewing the history of psychotherapeutic models, nearly all of them have pre-dated any efficacy studies.  If we allowed scientific evidence to dictate the development of psychotherapy, we wouldn’t have gotten very far in evolving the field of psychotherapy.

The reality is that there are master clinicians (starting with Freud in our textbooks, but even before him with those that he studied under) who over the course of their careers expanded the prior models, evolving the work in new directions and teaching this to their students.  As these new models emerged, the necessary scientific evaluation took place to assess the efficacy of these models.  The cart has most often come before the horse in our field, and that is not necessarily a bad thing.  I believe that this has fueled the creativity and evolution in our field.

I could list countless therapeutic models that have been well established, promoted, and benefitted many people, well before scientific evidence came on board.  Just in my own personal experience, it so hopeful to observe what has occurred over the past decade with mindfulness meditation and yoga.  I was first introduced to meditation and yoga some 30 years ago.  Now of course these healing practices have been around for thousands of years, but up until very recently in our society, people discounted or even mocked them; and there are still those that refer to these approaches as “pseudoscience”.  Yet, over the past decade or so, there are now many research studies which have led to mindfulness and yoga being validated as "evidence-based practice".  

I really could go on and on with examples.  These examples aren’t a justification for not focusing on the necessary research to demonstrate efficacy for these emerging models.  I am all for that.  But it does help us balance the rigidity that may limit new, helpful models from getting the exposure and support they need to reach more people.  I agree with what you said about focusing on the models that already have a strong evidence base.  But I hope you would also agree that this doesn’t mean that we should shy away from focusing on emerging models that are demonstrating promising results, even if only anecdotally at this point. 

Lastly, I just want to point out that this is larger than any one approach (whether NARM or any other promising model out there).  We are in the early process of exploring what models out there might be beneficial in treating ACEs/early trauma.  We are doing so in an online forum that is designed to “help heal and develop resilience rather than to continue to traumatize already traumatized people…The network achieves this by creating a safe place and a trusted source where members share information, explore resources and access tools that help them work together to create resilient families, systems and communities.”  In the spirit of this network, I would hope that all of us – whether clinician, educator, researcher or consumer – could continue to share resources respectfully, and work together to become an even more trusted source to provide effective tools and treatment that will help heal and develop resilience.  I welcome and look forward to continued collaboration with anyone sharing this same intention. 

Working in public health for many years, we could see clear evidence of the benefit of public health nurse home visits - but at that time there was no recognized evidence based model.  During this time we were looked at promising practices and emerging models and found this resource useful:  National Registry of Evidence-based Programs and Practices (NREPP)  If folks haven't found it already, this is also a useful reference:  SAMHSA Clinical Practice Trauma Informed I hope this is helpful context as Brad shares the emerging NARM model.  This is really cutting edge work!  Karen 

Thanks for your reply, Brad.  There still remains a cart-before-the-horse situation. There is an intervention without demonstrated efficacy being promoted, and paid trainings are being promoted for it.  Being "in the early stages of the first efficacy study on NARM" is hardly the place to be when promoting widespread dissemination of an intervention and charging providers to become trained in it. Furthermore, the promotion of it has been happening for years, so it pre-dates the mentioned efficacy study that is underway . What if the study fails to show any efficacy? Would refunds be offered to clients who paid for NARM services? Would refunds be offered to practitioners who paid for NARM training?

As you said, "there is need for training clinicians in models that can address the real suffering that so many of us are seeing day to day with our clients." I agree with that whole-heartedly and would add that models/interventions with a very strong evidence base exist and help many people and should be more widely disseminated. Like anything else, they are not perfect and additional work certainly remains to be done, but that fact isn't a justification for widespread dissemination of other solutions that have no established evidence base. The cart needs to come after the horse. 

Patrick Palmieri, Ph.D. posted:

Brad, I'm going to echo an exchange we had via email some time ago. Before promoting NARM and promoting trainings for it, there should be some peer-reviewed evidence of its efficacy. Is there? I still don't see any.

Speaking generally, the increasing interest in recent years in trauma informed care is a welcome development. It has, however, brought with it a surge in highly touted though untested solutions for trauma-related distress and other outcomes. As interest and understanding about trauma and the role it plays in people's lives increases, it is especially important that our practices be based in scientific evidence.

Thanks Patrick for sharing your perspective.  As we discussed, I am in full agreement that these new models emerging for Trauma Informed Care must be evaluated and scientifically assessed.  The NARM Training Institute is currently in the early stages of the first efficacy study on NARM and is developing a second study that will be launched soon.  At the same time, there is need for training clinicians in models that can address the real suffering that so many of us are seeing day to day with our clients.  I would hope that the clinical and research sides can come together to support one another to improve our capacity for addressing the trauma-related suffering we are seeing.

And as I wrote to you previously, I would welcome you or anyone in our field with a research background to collaborate with NARM or any of the other trauma-informed emerging models so that we can expedite getting evidence-based models in place to support so many in need.  This is an exciting and important time in our field - and as you well know, we need to be tackling this worldwide epidemic on many fronts.  So I, as a clinician and educator, would welcome partnership with those skilled in research, including yourself.  You (or anyone else who may be reading this) are always welcome to contact me and I would look forward to brainstorming ways to collaborate in furthering our research into this rapidly expanding field of trauma treatment.

Brad, I'm going to echo an exchange we had via email some time ago. Before promoting NARM and promoting trainings for it, there should be some peer-reviewed evidence of its efficacy. Is there? I still don't see any.

Speaking generally, the increasing interest in recent years in trauma informed care is a welcome development. It has, however, brought with it a surge in highly touted though untested solutions for trauma-related distress and other outcomes. As interest and understanding about trauma and the role it plays in people's lives increases, it is especially important that our practices be based in scientific evidence.

Thank you for discussing the different types of Trauma... so important for improved understanding!

Thank you for your post, Brad!  I really appreciate the distinction you make between PTSD and developmental trauma.  I think that distinction is not well clarified in a lot of literature and training (and it's a very important one).

I am interested in NARM and I intend to check it out...Thank you!  Emily

P.S.  No wonder I liked what you were writing...I checked out the website.  I am "SE" girl myself (Intermediate I currently).  So funny when you recognize the language others are speaking...