I avoid the “Self Check-Out” at Kroger for two reasons: 1. I have never been able to complete my transaction out without a “Please notify the attendant” malfunction. (Note, yet again, The Great Fallacy of Individualism.) 2. I need the time in the “Check-Out With Other People” lines to read OK!, Star, Us, and, People. Who doesn’t love a good controversy?
Controversy! might as well have been the name for our entire semester, not just tomorrow’s class. Tracking the fault lines of our discipline has provided an exciting and incredibly useful kind of map, one that will be an excellent tool for the rest of graduate school. One thing I’ve learned along the way is that I find some controversies juicier than others.
As far as I’m concerned, whether or not to use empirically supported treatments, scientific evidence, and actuarial judgments is one controversy that should be put to bed. Baker, McFall, and Shoham’s editorial in the Washington Post brings it home when they report that “the practice of psychology—which includes psychotherapy—is akin to medicine as it was practiced a century ago” (italics mine), largely because psychologists fail to collect and scrutinize evidence. Psychologist’s tendency “to use their own insights and experience” to treat patients, instead of using those that have been rigorously scientifically tested, seems to me like obvious malpractice. I’m hoping that there are enough people in the field who agree with me because this is not necessarily an argument I want to have. It’s boring. Look at the question being asked: should you use treatments that are known to help a lot of people when you’re trying to help people? It’s both rhetorical and tautological.
I much prefer questions like, “Can you implant repressed memories?” Or, one I’m working on: “Can teachers indirectly make friends for students?” These are non-obvious questions about people’s experience. They may be counter-intuitive, but they are not counter-logical (the way disagreements about scientific evidence may be). As Jim’s narrative illustrates, the kind of controversies these research questions can spark can be just as incendiary, but I feel these arguments can be more productive, if only after well-designed, well-executed scientific evidence comes to light. I would be absolutely thrilled if, one day, a study of mine evokes as much contempt as Jim’s and Dr. Loftus’ did. I’d know that I was really getting at something deeply ingrained in a culture. I’d much rather argue with somebody who was grappling with a deeply felt conviction, than somebody with an ego so big that they’d claim their own intuition and experience is superior to scientific evidence.
Tuesday, November 17, 2009
Sunday, November 8, 2009
I Love this Week's Readings!
Terrie Moffitt’s Adolescence-Limited and Life-Course-Persistent Antisocial Behavior and Marsha Linehan’s Borderline Personality Disorder have been two of the most lucid, illuminating, inspiring readings of the semester. They are both brilliant figure-ground compositions. Both say a lot (the figure); yet the negative space of the unsaid (the ground) tells just as rich a story. I’m not even talking about “subtext,” here. It’s more like a pulsating “simultext."
Carl Rogers’ unconditional positive regard is the simultext of Marsha Linehan’s article on BPD. My blog a few weeks back scoffed at unconditional positive regard: if psychologists need to operationalize compassion for their clients, I thought, they might be in the wrong profession. After reading Linehan, I embrace unconditional positive regard as both necessary and sufficient. A tell-tale sign of BPD: “The emotional state of both the patients and the therapists seemed to deteriorate when these individuals entered psychotherapy.” Linehan elucidates many mechanisms for maintaining or re-engaging a therapists’ unconditional positive regard for these clients who are so challenging. The first is forthright golden-rule empathy. People with BPD suffer “intense misery;” at another point Linehan likens both their pain and--critically--their basic human innocence, to that of burn victims and cancer patients. This points to another simultext of the article: psychologists have had real contempt for people with BPD. Secondly, the acceptance aspect of Dialectical Behavioral Therapy that is both prerequisite for and mechanism of change is fundamentally Rogerian. Also very Rogerian is Linehan’s emphasis on process over structure. Rogers and Linehan may both agree with the principal of the school for kids with LD I used to teach at: If the process is right, the outcome will be what it needs to be. Of course the “right” processes is often a matter of great debate, but simply (re)locating the emphasis on the process seems much more “right” than not.
[By the way, Borderline Personality is the most misleading term ever. It sounds like these patients are “on the fence” about having a clinical diagnosis or not. In fact what defines Borderline Personality disorder is that individuals don’t hover over a boundary, they continually breach various boundaries. 1. Of life and death (36% of people who meet all 8 DSM criteria for borderline personality disorder are suicidal). 2. Of expected outcomes (by definition, BPD are resistant to treatment). Of client-therapist boundaries (see above discussion of client-therapist emotional states.)]
The simultext of Moffit is the critical importance of etiologies as a framing device or lens. Etiology is like a framing device because of its cropping function; it decides what should be considered as well as what is irrelevant. It’s like a lens because our understanding of one etiological model so easily influences how we evaluate others, making it easy to conflate or invalidate new information that may bear on our model. I entered grad school determined to come out an interventionist. I want to discover the tools for swooping in and changing behavior. More and more, though, I’ve come to realize how critical it is for intervention-oriented psychologists to really refine their understandings of etiologies. A fully realized etiology, like Terrie Moffit’s, does a whole lot of the interventionist’s work. By providing so much evidence about the mechanisms of life-course-persistent antisocial behavior (the kind society really needs to worry about), we interventionists can direct our behavior.
Carl Rogers’ unconditional positive regard is the simultext of Marsha Linehan’s article on BPD. My blog a few weeks back scoffed at unconditional positive regard: if psychologists need to operationalize compassion for their clients, I thought, they might be in the wrong profession. After reading Linehan, I embrace unconditional positive regard as both necessary and sufficient. A tell-tale sign of BPD: “The emotional state of both the patients and the therapists seemed to deteriorate when these individuals entered psychotherapy.” Linehan elucidates many mechanisms for maintaining or re-engaging a therapists’ unconditional positive regard for these clients who are so challenging. The first is forthright golden-rule empathy. People with BPD suffer “intense misery;” at another point Linehan likens both their pain and--critically--their basic human innocence, to that of burn victims and cancer patients. This points to another simultext of the article: psychologists have had real contempt for people with BPD. Secondly, the acceptance aspect of Dialectical Behavioral Therapy that is both prerequisite for and mechanism of change is fundamentally Rogerian. Also very Rogerian is Linehan’s emphasis on process over structure. Rogers and Linehan may both agree with the principal of the school for kids with LD I used to teach at: If the process is right, the outcome will be what it needs to be. Of course the “right” processes is often a matter of great debate, but simply (re)locating the emphasis on the process seems much more “right” than not.
[By the way, Borderline Personality is the most misleading term ever. It sounds like these patients are “on the fence” about having a clinical diagnosis or not. In fact what defines Borderline Personality disorder is that individuals don’t hover over a boundary, they continually breach various boundaries. 1. Of life and death (36% of people who meet all 8 DSM criteria for borderline personality disorder are suicidal). 2. Of expected outcomes (by definition, BPD are resistant to treatment). Of client-therapist boundaries (see above discussion of client-therapist emotional states.)]
The simultext of Moffit is the critical importance of etiologies as a framing device or lens. Etiology is like a framing device because of its cropping function; it decides what should be considered as well as what is irrelevant. It’s like a lens because our understanding of one etiological model so easily influences how we evaluate others, making it easy to conflate or invalidate new information that may bear on our model. I entered grad school determined to come out an interventionist. I want to discover the tools for swooping in and changing behavior. More and more, though, I’ve come to realize how critical it is for intervention-oriented psychologists to really refine their understandings of etiologies. A fully realized etiology, like Terrie Moffit’s, does a whole lot of the interventionist’s work. By providing so much evidence about the mechanisms of life-course-persistent antisocial behavior (the kind society really needs to worry about), we interventionists can direct our behavior.
Monday, November 2, 2009
Supermodels
Last week I was overwhelmed by the complexity of depression and how far we are from thoroughly understanding it. This week, on the other hand, I’m excited by how comprehensive and convincing our models for anxiety are. Compared to Coyne’s portrayal of the hyper-dimensional moving target that is depression, anxiety looks like, well, like a series of well-appointed flowcharts. (See Barlow’s figures 1 through 7.) There seems to be relative tranquility about the etiology of anxiety.
Barlow presents us with an “integrated” model. Mineka and Zinbarg lay out the “range of variables (that) can lead to a rich and nuanced understanding of the etiology and course of anxiety disorders.” B and M&Z have different theories as their points of departure, and M&Z address the six major anxiety disorders (and how principles of classical and operative conditioning apply), whereas Barlow basically addresses his “three vulnerabilities” separately. Barlow could have easily stated his same ideas about how life events become a “vulnerability” in the learning terms of M&Z. I don’t think these models are at all at odds.
The beauty of these thorough models (that the authors mention in passing) is their applicability to prevention (anxiety immunization is the coolest idea ever) and intervention. My hunch is that too few therapist apply these sophisticated models to their work with patients.
Why is such a harmoniously integrated model exceptional? (Please correct me if I’m wrong or overstating this.) Why are other areas of psychology still struggling to integrate perspectives in this way? Does that say more about the nature of anxiety or the nature of the discipline of psychology?
Barlow presents us with an “integrated” model. Mineka and Zinbarg lay out the “range of variables (that) can lead to a rich and nuanced understanding of the etiology and course of anxiety disorders.” B and M&Z have different theories as their points of departure, and M&Z address the six major anxiety disorders (and how principles of classical and operative conditioning apply), whereas Barlow basically addresses his “three vulnerabilities” separately. Barlow could have easily stated his same ideas about how life events become a “vulnerability” in the learning terms of M&Z. I don’t think these models are at all at odds.
The beauty of these thorough models (that the authors mention in passing) is their applicability to prevention (anxiety immunization is the coolest idea ever) and intervention. My hunch is that too few therapist apply these sophisticated models to their work with patients.
Why is such a harmoniously integrated model exceptional? (Please correct me if I’m wrong or overstating this.) Why are other areas of psychology still struggling to integrate perspectives in this way? Does that say more about the nature of anxiety or the nature of the discipline of psychology?
Friday, October 23, 2009
Framing the River
When it was released in 1976, a music critic said of Steve Reich’s 54 minute composition Music for 18 Musicians:
“…try to impose a frame on a running river, making it a finite, enclosed work of art yet leaving its kinetic quality unsullied, leaving it flowing freely on all sides. It has been done. Steve Reich has framed the river.”
It’s clear from this week’s articles that depression researchers have at least as complex a task. Depressions’ fundamental “heterogeneity” is in part to blame. It’s a syndrome characterized by episodes, a long-term condition defined by ephemeral states. And these states or episodes may look the same but may be symptoms of different kinds of illnesses. Are mania and depression continuous? Or parallel and commonly comorbid? Are depressive or manic episodes sometimes non-discreet and cumulative, so that “scarring” from previous episodes muddles our understanding of subsequent ones?
That’s the river. Cueller, et. al and Coyne convince us that we definitely haven’t found the right frames. Apparently our methodologies for studying depression are kind of a mess, which, I think says more about depression than the state of the field of clinical science. The methodological problems actually teach us a lot about the elusiveness of depression. The nomenclature surrounding depression takes for granted what hasn’t been empirically supported. Our samples aren’t representative of the manic population because mania doesn’t normally bring people to treatment. Our measurements give us snapshots that crop out important background relationships and contexts. Self-report has been way overused, interview way underused, and questionnaires have been naïve. College kid samples may be biased. Coyne is very cogent about why an integrative approach is needed. Although he shows us to models of good interviewing techniques, I would have loved if Coyne detailed a design for an experiment that could capture the highly integrative phenomenon of depression he describes qualitatively. Interesting to note that in his “most recent work” he’s “drawing on the work of Bakhtin and Vygotsky, as well as feminist theoryists such as Dana Jack.” I think Vygotsky was pretty empirical but wasn’t Bakhtin a literary theorist? How interesting that Coyne has expanded the frame in this way, but tell us more, Coyne!
Gratefully, Cueller et suggest MAXCOV as “a natural technology” for exploring the continuity of uni- and bipolar depression. Kendler, Kuh, and Prescott model a method for parsing three variables involved in depression, and quantified the risk of being a female with high neuroticism. What would Coyne think about this? Yes, they left out all the relational, contextual variables he talks about, but, since Coyne has no proposal for the omnibus study on the river, taking the variables three at a time and subjecting them to the sophisticated models Kendler, Kuhn, and Prescott use (can we talk about the Cox and MAXCOV models in class?) seems like a promising start.
“…try to impose a frame on a running river, making it a finite, enclosed work of art yet leaving its kinetic quality unsullied, leaving it flowing freely on all sides. It has been done. Steve Reich has framed the river.”
It’s clear from this week’s articles that depression researchers have at least as complex a task. Depressions’ fundamental “heterogeneity” is in part to blame. It’s a syndrome characterized by episodes, a long-term condition defined by ephemeral states. And these states or episodes may look the same but may be symptoms of different kinds of illnesses. Are mania and depression continuous? Or parallel and commonly comorbid? Are depressive or manic episodes sometimes non-discreet and cumulative, so that “scarring” from previous episodes muddles our understanding of subsequent ones?
That’s the river. Cueller, et. al and Coyne convince us that we definitely haven’t found the right frames. Apparently our methodologies for studying depression are kind of a mess, which, I think says more about depression than the state of the field of clinical science. The methodological problems actually teach us a lot about the elusiveness of depression. The nomenclature surrounding depression takes for granted what hasn’t been empirically supported. Our samples aren’t representative of the manic population because mania doesn’t normally bring people to treatment. Our measurements give us snapshots that crop out important background relationships and contexts. Self-report has been way overused, interview way underused, and questionnaires have been naïve. College kid samples may be biased. Coyne is very cogent about why an integrative approach is needed. Although he shows us to models of good interviewing techniques, I would have loved if Coyne detailed a design for an experiment that could capture the highly integrative phenomenon of depression he describes qualitatively. Interesting to note that in his “most recent work” he’s “drawing on the work of Bakhtin and Vygotsky, as well as feminist theoryists such as Dana Jack.” I think Vygotsky was pretty empirical but wasn’t Bakhtin a literary theorist? How interesting that Coyne has expanded the frame in this way, but tell us more, Coyne!
Gratefully, Cueller et suggest MAXCOV as “a natural technology” for exploring the continuity of uni- and bipolar depression. Kendler, Kuh, and Prescott model a method for parsing three variables involved in depression, and quantified the risk of being a female with high neuroticism. What would Coyne think about this? Yes, they left out all the relational, contextual variables he talks about, but, since Coyne has no proposal for the omnibus study on the river, taking the variables three at a time and subjecting them to the sophisticated models Kendler, Kuhn, and Prescott use (can we talk about the Cox and MAXCOV models in class?) seems like a promising start.
Sunday, October 18, 2009
The Human Animal
Most of the time, the phrase, “like an animal,” (as in “She ate like an animal.”) evokes disgust, filth, depravity, even contempt. I’d wager to say that Skinner’s bad reputation has to do with his animal studies, and people’s resistance to compare themselves to pigeons and rats. People find it really threatening to think of themselves as animals. We (myself included) love to speak loftily about “what makes us human, whereas we eat animals for dinner. We are most complex; however, it is sometimes a better survival strategy to embrace our simple side. Our discussion of behavioral treatments last week and this week’s readings on a cure for insomnia, relapse prevention, and the “recipe” for college kid depression show us that closing the space we impose between humans and animals opens up a range of incredibly effective therapeutic possibilities. When we admit that we’re subject to the same rules of operant and classical conditioning, we can really evolve.
Bootzin & Epstein’s Stimulus control instructions are an air-tight example of this. Synch bedroom cues for falling asleep (cues we may not even notice are cueing our wakefulness) and they’ll stimulate our slumber. Yes, in addition to sometimes working in bed, it may be the distinctly human ruminations that keep us awake. But what human can perfect their life so that they never ruminate in bed? It’s cheaper, more efficient, and productive to deal with insomnia at the surface level of stimulus control. Bootzin and Epstein have offered us a perfect example of self-help without the self.
I shudder to write that the other two articles on the Dynamic Model of Relapse and the risk-factors of college campuses convincingly let humans off the hook for their vices and largely implicate the environment. This implied scoff at free will threatens both religious senses of free will and our vaunted American individualism. But these articles show us how in confirming these basic human urges affirms our basic human innocence. Bogey the black lab mix who’s been staying with us for the last three weeks sometimes lunges at food garbage on the sidewalk. I pull her back and yell “No!” because an old sandwich could make her sick, but can I blame her? An old sandwich is probably a lot tastier than her normal food. And sex and drugs are like old cheese sandwiches for college kids, with sex doubling dopamine levels and cocaine increasing dopamine release 400-500%!!! Stress, sleep deprivation, and social pressure all diminish self-control, which is why the psychiatrist in the article says that “we can’t separate these things out.” The Dynamic Model of Relapse knits these things together with a great deal of complexity and says the future of relapse prevention should be based on these complex interacting “urges, cues, and automatic thoughts.” Their model is a wonderful example of how humans should use their big smart human frontal lobes to leverage their animal nature.
Monday, October 12, 2009
Pragmatic psychology
This year’s Nobel Peace Prize was recently awarded to a pragmatist.* How perfect that some of the functional models of treatment we learned about in this week’s readings seem to represent psychology at its most pragmatic. The readings succeed in reconciling the frequent strain between theory and practice. Reading these papers, I was as satisfied with the authors’ tidy, coherent theories as I was convinced of their real-world utility.
Based on the treatments presented, I thought it would be pragmatic to come up with some principles some principles of the pragmatic psychologist. They are:
(1.) Treatment should take a global perspective—i.e., the functionalist’s view of the individual interacting with her contexts.
(2.) Treatment should be outcomes based. Outcomes must conform to what Jacobson et al. (2001) call a “pragmatic truth criterion,” based on whether what they did in therapy actually “reverses the depression. Not whether the therapist conformed to a theory, but whether the patient attained the therapeutic goal. That’s how you know you’ve “correctly identified functional relationships;” that’s how you know whether to keep working like you’ve been working or to try something new (see #3).
(3.) Treatment should be customized. Behavioral Activation Therapy (BA) and Dialectical Behavioral Therapy (DBT) are paradigms. They’re not blanket therapies, they’re designed to fit a certain set of symptoms.
(4.) Treatment should be flexible. Jacobson et al.: “we emphasize the importance of finding which behaviors and activities will be positively reinforcing and will help disrupt the spiral of depression for each individual client.” Mind the nomothetic ideographic gap!
One caveat: I laughed a bit when I read in Jacobson that “simply activating depressed people” accounts for therapeutic benefits. I buy BA as empirically supported, “parsimonious,” and potentially really helpful; but what about reversing the course of depression could be simple? This highlights a danger in pragmatism: a simplification of very complex ideas, belied by a tone of obviousness or common sense.
*What his "pragmatism" means is a fairly interesting debate.
Based on the treatments presented, I thought it would be pragmatic to come up with some principles some principles of the pragmatic psychologist. They are:
(1.) Treatment should take a global perspective—i.e., the functionalist’s view of the individual interacting with her contexts.
(2.) Treatment should be outcomes based. Outcomes must conform to what Jacobson et al. (2001) call a “pragmatic truth criterion,” based on whether what they did in therapy actually “reverses the depression. Not whether the therapist conformed to a theory, but whether the patient attained the therapeutic goal. That’s how you know you’ve “correctly identified functional relationships;” that’s how you know whether to keep working like you’ve been working or to try something new (see #3).
(3.) Treatment should be customized. Behavioral Activation Therapy (BA) and Dialectical Behavioral Therapy (DBT) are paradigms. They’re not blanket therapies, they’re designed to fit a certain set of symptoms.
(4.) Treatment should be flexible. Jacobson et al.: “we emphasize the importance of finding which behaviors and activities will be positively reinforcing and will help disrupt the spiral of depression for each individual client.” Mind the nomothetic ideographic gap!
One caveat: I laughed a bit when I read in Jacobson that “simply activating depressed people” accounts for therapeutic benefits. I buy BA as empirically supported, “parsimonious,” and potentially really helpful; but what about reversing the course of depression could be simple? This highlights a danger in pragmatism: a simplification of very complex ideas, belied by a tone of obviousness or common sense.
*What his "pragmatism" means is a fairly interesting debate.
Saturday, October 3, 2009
CBT, Surface and Depth
I wish I had this week’s readings around when I first heard of CBT. It was described to me in direct contrast to psychodynamic approaches. Whereas in psychodynamic therapy, the therapist may probe into the past for explanations of behaviors, in CBT, the therapist addresses the present tense with a problem solving approach. “The way to change a behavior is to change the behavior,” I heard. Psychotherapy:Depth::CBT:Surface. Even this simplistic conception of CBT is really compelling. Leave moms alone! ¡Viva the superficial!
I now see that there’s nothing superficial about CBT. After reading Alfred Ellis’ 1999 description of Rational Emotive Behavior Therapy, I’m convinced that this guy has to be one of the most underappreciated wonderful thinkers. I think he created not just an effective and efficacious therapeutic program but also a comprehensive theory of human nature at least as compelling as Freud’s and much more accurate. To summarize, people generally move towards happiness and self-realization, but “three major absolutistic musts frequently plague the human race:” the demand for success; the demand for good treatment by others; and the demand for easy life circumstances. When these “musts” don’t happen people get unhappy and behave badly. Quip revision: the only way to change the behavior is to change the belief. The only way to change the belief is through experience, so help your clients “experiment” with their self-defeating beliefs, and reckon with real world evidence that challenges them to change at the level of belief systems. And so when behavior change comes, the belief is in place to sustain it.
I’m not sure why Ellis isn’t as mainstream popular as Freud, or at least as famous as Buddha (their views on demands/attachments actually seem quite similar). Is Ellis (1913-2007) still too new? I wonder if Ellis’s ideas suffer from a marketing problem. The Freud brand has that iceberg, The Unconscious; the complexes with sexy Greek names; and phalluses everywhere. What are the punchy names and imagery for Ellis and Rational Emotive Behavior Therapy? In vivo desensitization? Unless I missed a nuanced difference, I think he should have stuck with calling it “exposure.” The best icon for REBT seems, for now, Ellis’s picture, late in life, smiling genuinely, pants pulled way up over his Buddha belly.
Saturday, September 19, 2009
Therapist as Neighbor
I’m sure I’m not the first to draw a parallel between Fred and Carl Rogers. Both men have captivated millions. Both men prized warmth, empathy, safety, and inter-personal engagement. And in both Mr. Rogers’ show and Mr. Rogers’ session, everybody feels good, but not much happens.
I am no expert in the history of clinical psychology, but it seems like Carl Rogers deserves credit for the meme “therapist as paid friend,”—i.e., the therapists who are sufficiently nice to you, but don’t help you set goals and learn strategies to accomplish those goals. This week’s two articles Kirschenbaum and Jourdan’s article “Current Status of Carl Rogers and the Person-Centered Approach,” and Castonguay, Constantino, and Holtforth’s “The Working Alliance” offer no consolation—but they may offer explanation—to those of us who feel that they’ve paid about $100 an hour for a lot of really great eye contact.
Do not get me wrong, I wholeheartedly embrace the primacy of the therapeutic relationship and Rogers’ trio of core conditions: empathy, positive regard, and congruence. However, they seem more like prerequisite personality traits of clinicians. Can you even train empathy and warmth? Can you manualize it? I also wholeheartedly agree with Rogers and his followers that not one, not two, but all three conditions must be present for therapy to be “sufficient.” But sufficiently what? Yes, sitting on a comfy couch in the presence of a lovely therapist may be sufficiently, uh, pleasant? But how about raising the bar a little from “sufficient” to helpful. Could we even try, where needed, to be transformative?
Though many significant effects of Rogerian sufficiency are reported, few effect sizes are. Empathy, positive regard, and congruence, while clearly a necessary foundation for therapy, seem quite insufficient as a therapeutic technique or method. C, C, and H admit that while preliminary findings about the effectiveness of techniques designed to foster alliance are promising, “we need more convincing evidence… that such techniques have direct, unique, and causal effects on improvement.” Any mention of psychological mechanisms responsible for clients’ improvements in person-centered therapy is similarly murky. Again, my harshness may be due to not knowing enough about person-centered therapy, but it actually seems more about the therapist’s behaviors, how she should act. What are the strategies offered to the client?
I am no expert in the history of clinical psychology, but it seems like Carl Rogers deserves credit for the meme “therapist as paid friend,”—i.e., the therapists who are sufficiently nice to you, but don’t help you set goals and learn strategies to accomplish those goals. This week’s two articles Kirschenbaum and Jourdan’s article “Current Status of Carl Rogers and the Person-Centered Approach,” and Castonguay, Constantino, and Holtforth’s “The Working Alliance” offer no consolation—but they may offer explanation—to those of us who feel that they’ve paid about $100 an hour for a lot of really great eye contact.
Do not get me wrong, I wholeheartedly embrace the primacy of the therapeutic relationship and Rogers’ trio of core conditions: empathy, positive regard, and congruence. However, they seem more like prerequisite personality traits of clinicians. Can you even train empathy and warmth? Can you manualize it? I also wholeheartedly agree with Rogers and his followers that not one, not two, but all three conditions must be present for therapy to be “sufficient.” But sufficiently what? Yes, sitting on a comfy couch in the presence of a lovely therapist may be sufficiently, uh, pleasant? But how about raising the bar a little from “sufficient” to helpful. Could we even try, where needed, to be transformative?
Though many significant effects of Rogerian sufficiency are reported, few effect sizes are. Empathy, positive regard, and congruence, while clearly a necessary foundation for therapy, seem quite insufficient as a therapeutic technique or method. C, C, and H admit that while preliminary findings about the effectiveness of techniques designed to foster alliance are promising, “we need more convincing evidence… that such techniques have direct, unique, and causal effects on improvement.” Any mention of psychological mechanisms responsible for clients’ improvements in person-centered therapy is similarly murky. Again, my harshness may be due to not knowing enough about person-centered therapy, but it actually seems more about the therapist’s behaviors, how she should act. What are the strategies offered to the client?
Monday, September 14, 2009
Is it just me, or are this week's readings really Pomo?
This week’s authors seem as captivated by Postmodernism as contemporary artists, writers, and movie makers who may more readily garner the term. Perhaps I’m just stuck in a bygone undergraduate art history major way of reading articles and thinking about things. Or perhaps I shouldn’t at all be surprised that Postmodernism has seeped into psychology. Or, to be Postmodern about it, perhaps both.
Questioning assumptions; dissolving stark dichotomies; converting accepted facts into narrative “texts;” weaving together appropriations; getting “meta-” about things: Westen, Novotny & Thompson-Brenner (2004) and Smith (1999) traffic in all of these. W, N, & T begin by proposing (per Robert Abelson, 1995) that “the function of statistics is not to display ‘the facts’ but to tell a coherent story.” The authors then parody the rise of Empirically Supported Therapies (ESTs) in a pseudo-Arthurian tale starring the “Knights of the Contingency Table,” and ending in the qualified success of empirically supported therapies. Then, the authors revise the parody, writing in a more troubling ending involving oversights, untested assumptions, client relapses, biased funding, and “invoking the name of Empirical Validation” in vain. The two narratives merge into a palimpsest.
W, N, & T send the vaunted notion of “empirical support” through the wringer, emphasizing the validity of properly designed meta-analyses over blockbuster studies funded by drug companies. “Empirical support is not a dichotomous variable,” is W, N, & T’s concise entrée into the deconstruction treatment outcome studies that neglect the long-term view of patients’ struggles, which often include relapse. W, N & T also advocate consumer access to “details essential for assessing the internal and external validity of even high-quality studies.” This shrinking space between those with information/power and those without invoked for me the Postmodernist practice of collapsing the space between artist and viewer, or “breaking the fourth wall” in theater.
Cherished classifications of theoretical orientation are Smith’s target in “The End of Theoretical Orientations?” He proposes “a new kind of meta-theory of therapy.” This meta-theory isn’t a static code but more of a process, or, as Smith puts it, “a creative act.” When faced with patients who elude easy diagnostic categorization, “one must abstract pertinent change principles from the empirically supported procedure for a different condition, and then through a creative act, translate that principle into a plan for the situation in which the procedure is untested.” Certainly this “activity” is best performed by the Super Clinicians that W, N & T describe at the end of their article: “clinically competent decision makers (rather than paraprofessionals trained to stay faithful to a validated manual) who have the competence to read and understand the relevant applied and basic research, as well as the competence to read people.
Saturday, September 5, 2009
Mining Meta-anaylses, Hunting Dodos: Why We Love 771
I have to admit that during my reading of Chambles and Hollon, I suppressed urges to email old friends and go eat ice cream, but succumbed to cutting my toenails. Perhaps in part because I read it at the end of the day when I was a little drained, I found this article difficult follow and kind of a downer. I think it was a dizzying downer for me, however, because it’s a rigorous survey of the seemingly infinite number of pitfalls of something I think is infinitely important: testing whether therapies that sound good really help people. C and H are critically skeptical and highly conservative in their unpacking of therapies outcome research. C and H have us thinking, wow. That’s really hard to do right. ("No one definition of sound methodology suffices for all areas of psychological treatment research.") But C and H fueled my determination to attain methodological sophistication and not repeat others’ mistakes when testing my own interventions (which I sincerely hope to do for my own dissertation). I especially love the Appendix, “Summary of Criteria for Empirically Supported Psychological Therapies”— i.e., The Five Commandments for evaluating empirical support. Good to keep close at hand.
Hunsley and DiGiulio provided my first exposure to “the well-known ‘Dodo bird effect.’” The Dodo stars in a cautionary tale straight out of Chambles and Hollon: a few spurious arguments and some badly designed meta-analyses deemed therapeutic treatments to be equivalent, and that idea really caught on. Once the statistical errors in these meta-analyses were corrected, the Dodo effect turned out to be entirely inaccurate, and cognitive and behavioral treatments reign supreme. One wonders what other fallacies permeate psychology today, fallacies without colorful names, or even names at all.
Thursday, August 27, 2009
Classification
Poring over Persons’ appeal for turning most experimental paradigms on their heads, and Widiger and Clark’s extensive critique of the current DSM (which Widiger himself had a hand in composing), it is easy to become disillusioned with the many formidable shortcomings in the field we’ve all just committed to. An unassuming parenthetical in Widiger and Clark gave me hope, however: “(American Psychiatric Association, 1952).” The DSM is only 57 years old! That’s younger than my parents! Of course mustering the audacity to codify the infinite range of human psychological experience took civilization this long. And of course in only IV iterations, we haven’t gotten it right yet.
I’m not letting psychology off the hook here. With so many great minds working in the field today (e.g., Jam Jr!!!), and with technological advances refining methods and measurements daily, the onus is as formidable as ever to be better at what we do. Widiger and Clark give us good starting points for doing so. The first DSMs were composed by what seems to have been an arbitrarily appointed minority via an undocumented, inaccessible process. W and C oppose an entirely “democratic” process because a consensus opinion may still not be a valid one. I understand the urge to protect psychology from politics, but how many times have the politics that were in play emerged only in retrospect? Psychology does not and cannot exist in a vacuum. I oppose appointing a small group of DSM authors with some monopoly on validity. If psychologists can’t agree with some reasonable degree of consensus on scientific validity by the time they’re ready to contribute to the DSM, I think this is more a problem with training than with bias.
The Laboratory Findings section of W and C underestimate the potential of lab methods for increasing the precision of diagnoses when they say, “laboratory assessment instruments are useful in exploring and perhaps documenting neuropsychological correlates but not necessarily in validating a neuropsychological model for their etiology or perhaps even their pathology” (Citations elided, but let me know if you want them). Here I looked at the publication date of this article: 2000. I think this description of lab limitations is dated. DSM-V will be forced to reckon with reams of neuropsychological correlate research, and I hope—not naively, right?—that by DSM-VI EEG and imaging will have become valid, economical and precise ways of diagnosing.
W and C’s sections “Boundary with Normality,” and “Differentiation among Disorders,” are very much in dialogue with Persons, who totally succeeded in convincing me to design research targeting psychological phenomena and not diagnoses. (Thank you so much Amori Mikami and Lab for collecting a community sample for the school study!) I hope that Persons has published or is working on a parallel paper on discussing psychological phenomena versus psychiatric diagnoses in clinical practice.
When I taught teenagers with ADHD and learning disabilities, I struggled to have helpful conversations with my students about their diagnoses. There was a movement at my school to familiarize students with the names and symptoms associated with their diagnosis, and it had many good intentions: externalizing the shame that comes with being different and being at a “special school” for kids with learning disabilities; engaging the body of intervention research associated with a specific diagnosis; and a general ethic of being open and honest with students to model being open and honest with self. These are all merited in their own way and certainly well intentioned, but I found that asking a 15-year-old to talk with their teacher about his existential feelings associated with having ADHD was more than either of us handle. ADHD, even to somebody who experiences it everyday, is still an abstraction, a dozen pages in the DSM, that is very hard to link to the chaotic state of your backpack, or the forgotten commitments, or lost iPod. How can that conversation not be reductive, overwhelming, depersonalizing? More than anything, though, it just felt so impractical, like it was taking time from devising and practicing strategies for organizing your backpack, reminding yourself of commitments, and hanging on to your iPod.
Also, getting diagnosed with anything still seems like the privilege of a minority lucky enough to have access to affordable mental heath care. Research that emphasizes symptoms and real problems people have (with or without psychopathology: see continuum discussions in both articles) will find a larger and more receptive audience. Dissemination of research is beyond the scope of this entry, but Persons, Widiger, and Clark all offer a beginner psychologist great tips for thinking about and doing research that expands our field’s sphere of influence with relevance, integrity and purpose.
I’m not letting psychology off the hook here. With so many great minds working in the field today (e.g., Jam Jr!!!), and with technological advances refining methods and measurements daily, the onus is as formidable as ever to be better at what we do. Widiger and Clark give us good starting points for doing so. The first DSMs were composed by what seems to have been an arbitrarily appointed minority via an undocumented, inaccessible process. W and C oppose an entirely “democratic” process because a consensus opinion may still not be a valid one. I understand the urge to protect psychology from politics, but how many times have the politics that were in play emerged only in retrospect? Psychology does not and cannot exist in a vacuum. I oppose appointing a small group of DSM authors with some monopoly on validity. If psychologists can’t agree with some reasonable degree of consensus on scientific validity by the time they’re ready to contribute to the DSM, I think this is more a problem with training than with bias.
The Laboratory Findings section of W and C underestimate the potential of lab methods for increasing the precision of diagnoses when they say, “laboratory assessment instruments are useful in exploring and perhaps documenting neuropsychological correlates but not necessarily in validating a neuropsychological model for their etiology or perhaps even their pathology” (Citations elided, but let me know if you want them). Here I looked at the publication date of this article: 2000. I think this description of lab limitations is dated. DSM-V will be forced to reckon with reams of neuropsychological correlate research, and I hope—not naively, right?—that by DSM-VI EEG and imaging will have become valid, economical and precise ways of diagnosing.
W and C’s sections “Boundary with Normality,” and “Differentiation among Disorders,” are very much in dialogue with Persons, who totally succeeded in convincing me to design research targeting psychological phenomena and not diagnoses. (Thank you so much Amori Mikami and Lab for collecting a community sample for the school study!) I hope that Persons has published or is working on a parallel paper on discussing psychological phenomena versus psychiatric diagnoses in clinical practice.
When I taught teenagers with ADHD and learning disabilities, I struggled to have helpful conversations with my students about their diagnoses. There was a movement at my school to familiarize students with the names and symptoms associated with their diagnosis, and it had many good intentions: externalizing the shame that comes with being different and being at a “special school” for kids with learning disabilities; engaging the body of intervention research associated with a specific diagnosis; and a general ethic of being open and honest with students to model being open and honest with self. These are all merited in their own way and certainly well intentioned, but I found that asking a 15-year-old to talk with their teacher about his existential feelings associated with having ADHD was more than either of us handle. ADHD, even to somebody who experiences it everyday, is still an abstraction, a dozen pages in the DSM, that is very hard to link to the chaotic state of your backpack, or the forgotten commitments, or lost iPod. How can that conversation not be reductive, overwhelming, depersonalizing? More than anything, though, it just felt so impractical, like it was taking time from devising and practicing strategies for organizing your backpack, reminding yourself of commitments, and hanging on to your iPod.
Also, getting diagnosed with anything still seems like the privilege of a minority lucky enough to have access to affordable mental heath care. Research that emphasizes symptoms and real problems people have (with or without psychopathology: see continuum discussions in both articles) will find a larger and more receptive audience. Dissemination of research is beyond the scope of this entry, but Persons, Widiger, and Clark all offer a beginner psychologist great tips for thinking about and doing research that expands our field’s sphere of influence with relevance, integrity and purpose.
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