“Hypocritical Oath”

Lilienfeld, 2007

Of this week’s five articles, I found the by far the most compelling one to be (the always controversial) Scott Lilienfeld’s manifesto on Potentially Harmful Therapies (PHTs). Taking on quackery, DARE, and experiential therapies in one fell swoop, Lilienfeld sets forth a powerful argument for the real and present urgency of addressing PHTs in clinical psychology ­now – before, even, taking another step towards establishing firm ESTs. This is a powerful idea of which, I admit, I was quite skeptical at the outset. However, having walked Lilienfeld’s path of logic (sic) with him, I am largely compelled by his claim of importance in addressing PHTs

To catalogue the interesting and/or contentious ideas discussed in this article would be both overlong and boring. So, I will touch on some of what I see to be the most intriguing ideas:

-I have not before heard a more damning portrayal of the impact of the “file-drawer effect” and its brother, “Type III error” (p.57). That all finding should be somehow reported is, of course, prescriptively wonderful, but awfully hard to make happen, especially given the (necessary) rigors of the peer-review process. That the lack of reporting of Type III error may very well be masking a body of research demonstrating iatrogenic (at least) effects of various treatments is just downright scary. Though the International Journal of Non-Significant Results represents a step in the right direction towards resolving this mishap, the notion of “enrolling all intervention studies in a centralized data bank that is publicly accessible” (p. 57) is probably a better idea.

-I was particularly heartened to see Facilitated Communication (FC) listed on the provisional list of PHTs. Having seen firsthand the amount of false hope that such interventions can provide to families that are desperately seeking real hope, it is worrisome to me that its prevalence has not diminished at all over time. I find it telling, too, that, in additional to FC, several of therapies listed in the article are directed towards children with autism (chelation, hyperbaric chambers, etc). Perhaps this population is a good starting point from which to address this pressing concern, as most information-providing agencies for families are proscribed from providing preferential treatment information – except in the case of conclusive demonstration of harmful effects. To my knowledge, no treatment has been sufficiently widely accepted to meet this criterion.

-Most notably, there is a logical flaw in Lilienfeld’s paper when he claims, “the literature here suggests that it would be erroneous to presume that these [untested] treatments are safe prior to subjecting them to adequate tests.” (p. 62; italics mine) In contrast to the Dodo Verdict, Lilienfeld is proposing an “inverse treatment specificity” effect. As a result, he proclaims that we should indeed be wary of untested treatments, as they may, in fact, prove more harm than good. However, he may be committing a sort of Type I error, here, by too hastily rejecting his null hypothesis of treatment equivalence. Given this formulation, though, it seems we are stuck with trying to impose a 3-factor logic on a binary set of choices: though in principle we would like to presume a priori that a treatment is either efficacious, negligible, or iatrogenic, in practice one must either offer a treatment option to a patient or not.

As such, from a practical standpoint, it may behoove us to no longer view the large body of untested treatments as either “probably ok” or “maybe harmful,” but to use the existing body of research to make solid evidence for use in clinical practice prior to subjecting them to rigorous research. To wit: we have a body of literature speaking to “common factors” (such as positive treatment alliance) for efficacious treatments. It seems, then, that Lilienfeld’s list of potential “underlying principles of negative change, such as premature termination of exposure, vicarious exposure to negative role models, and induction of false traumatic memories, that cut across numerous specific techniques,” (p. 65) could be seen as “common factors” of PHTs (indeed, Lilienfeld calls them “mediators”). Of course, research would be needed to ensure that these are appropriately-defined constructs, but it seems that, as Lilienfeld notes, undertaking this line of research would be “more informative and parsimonious than a catalogue of PHTs” (p. 65). This, then, brings me to my point: using both sets of positive and negative “common factors,” one could evaluate an untested treatment as being at risk for being a PHT or as having a protective factor against such risk. Treatments, for instance, that hinge on the generation of “suppressed memories,” could be seen as at risk treatments, while those that adhered centrally to principles of exposure for phobia treatment could be seen as somewhat protected against the potential likelihood of being iatrogenic. This rather easy and straightforward process of evaluating the prima facie characteristics of treatments could provide the useful direction needed for those researchers hoping to heed the urgent call of this paper to begin to determine a more comprehensive list of PHTs.

Standing on Shaky Ground

Linehan, 1993

Marsha Linehan takes us through the first of our two (14 year old…) trips across the shaky ground of personality disorder. When Jim told us in class today that it is a “mess,” I figured the thicket of conflicting ideas, incomplete theories, and constructs that fell apart upon scrutiny. Though this may be the case broadly, I was actually fairly impressed with how Linehan was able to make a strong case for her position on one of the most contentious of disorders.

I should insert a bit of personal disclosure before I continue: I have, in recent years, had much direct contact with (and consequent from) an individual with BPD. Indeed, she was treated by the selfsame Dr. Gunderson -- using DBT -- who is cited throughout the article (e.g. p. 8) during the time I knew her. As such, many of the positions I hold on this matter are strongly influenced by this experience (as is the case, it seems, for many people who have had close relationships with people with BPD), and I may therefore make statements stemming from my n of 1 that may not otherwise generalize.

A quick note on the interpersonal relationships section (p. 9): yes, I know what they mean by the various criteria, but it seems these should be awfully difficult ideas to get good interrater reliability on, since almost everyone who has been in serious or complex relationships has experienced “intolerance of aloneness,” “stormy relationships,” “abandonment concerns,” or some confluence of them. The criterion I am most concerned about, though, is the “treatment regressions” one. I understanding this to be byproduct of BPD as we understand it now, but to include it as an inclusion criterion for the disorder seems to belie the whole notion of trying to come up with good treatments for it in the first place! What if DBT or its successors end up minimizing regression in the vast majority of cases? Does this mean they’ve “cures” a symptom of BPD?

One thing I appreciate about Marsh Linehan is her perspective on individuals with BPD. While many clinical psychologists view the disorders they treat or research through a clinical (in the sterile or… pejorative… sense) lens, it seems that this approach is a double-edged sword. On the one hand, you maintain scientific objectivity and appropriate distance. On the other hand, one may lose sight of the actual issues facing individuals with the disorder; to cite Allison’s quote in her Blog of the child who spoke at the Autism: the Musical Q&A “A person with autism can't tell you what it's like to not have autism and a person without autism can't tell you what it's like to have autism. It's part of me, I don't know what it's like.” This is problematic in a practical, and, perhaps, ethical sense. Linehan, however, seems to have no qualms playing the role of advocate and empath for her patients (and this is reflected in her treatment methodology). Her sympathy for them is particularly evident in her damning of the “pejorative” terminology that’s often associated with the diagnostic criteria for BPD (see pp. 17-18). Though I’m not sure all clinical researchers need hold such a sympathetic position (though, perhaps they do?), it does seem to be an important position to exist to keep us from going so far down the pure science route that we lose sight of who we’re working for in the first place.

Given Linehan’s position, I must say that my biggest concern stems from an unlikely source. Again, this is coming largely from my subjective experience with one individual who met criteria for BPD, but it seems that the goal of DBT doesn’t seem to address the underlying distress of individuals with the disorder. Indeed, this seems to be a natural position for many CBT-derived treatments to take (“we’re not trying to eliminate the unwanted thoughts you have, just how you react to them”). Though this makes sense functionally, I believe it is important to see it as a starting point, not a conclusion, for treatment targets. Even Linehan’s own studies bear out somewhat the phenomenon I’m addressing, when she finds “no differences between groups in self-reported depression” and that “DBT was not more effective… in raising subjects’ rating of their own success in accepting and tolerating both themselves and reality.” (p. 24) These self-report measures (read: subjective) haven’t changed much under treatment. This is precisely what I saw with my friend, whose dangerous behaviors declined, but still came home daily reporting on a slew of upsetting interpersonal interactions which where often based upon “unusual perceptual experiences” (DIB-R term). It was, of course, wonderful to see her living more safely; I also hoped that DBT might begin to help her intervene in her own head to decrease her distress. Though I know this is, of course, a latent construct I’m pointing to, it certainly isn’t one for her (and, I imagine, others with BPD). Is there any hope, when the research is populated by observational measures and practice is slowly being engulfed by EST-CBT, for treatment of these symptoms to emerge as a target – if only an incremental one?

Speaking of increments, the value of the “face” of DBT is perhaps an interesting one. By this, I am speaking of the Zen basis for DBT, and its consequent “hippie-dippy” and decidedly unscientific presentation when examined by a casual observer. It is evident after reading Linehan’s introduction that these facades are, for the most part, a mask for sound, integrative behavioral and cognitive-behavioral approaches. Even the purported exceptions to this -- e.g. “emphasis on the therapeutic relationship as essential to treatment” (p. 20) -- are dubious at best. How, then, do we reconcile this with the scientific goal of parsimony? Perhaps, it is on the grounds of what might be called incremental utility. While it may be that behavioral principles have tremendous therapeutic power, if people are typically wary of them (gasps of fear and horror!), is it not incumbent upon the purveyors of treatment technology to consider this in the design process? Perhaps Linehan is on to something when she couches DBT in her “Eastern” terms. If doing so will increase the willingness of individuals to enter treatment, and their receptivity once they get there, has she not then increased the value – the utility – of the treatment, even if it had already existed in some form before? This is an idea I’ve been batting about for some time now (Jim & Allison, my apologies if I unduly exposed you to it in several of our past interactions), but one about which I’m curious as to others’ thoughts.

Hello Muddah, Hello Faddah

Barlow, 2000

Barlow provides us a thorough examination of the state of the most prominent models of anxiety. Though his findings are, not surprisingly, quite compelling, it is interesting to think of them in light of our previous readings. For instance, his framing of the relationship of anxiety & depression (p. 1252) follows from the model presented in the Cuellar et al. article. Just as there is an intersecting track between depression & mania, it seems like, likewise, it may be the same for anxiety and depression. I’m not sure what the implications of this may be for diagnosis (is it useful to reframe our terminology to accept this, or can this model be effectively implemented under the current terminological paradigm?), it does seem useful for better approximating etiology and treatment.

Additionally, Barlow speaks frequently of the role of parenting and early development in contributing to anxiety. Specifically, he seems to allude to a uniquely important role in this case. Though he does this in the context of something like a largely interactional model of anxiety, I wonder of Coyne would consider this an example of what Coyne calls “neocryptopsychoanalytic” thinking? Inasmuch as early psychology blamed parents for quite nearly everything, I can sympathize with Coyne’s aversion to this kind of formulation. However, is it incumbent upon David Barlow to know and address this in his presentation of findings, or is it up to us – the academic readership – to take these findings with a historical grain of salt, and to translate them with care and caution to our … anxious… clients?

Mineka & Zinbarg, 2006

So, here we are again, deep in the throes of classical conditioning and its offspring. It seems to turn out that these principles may underlie – every major disorder thus far? I’m increasingly unsure of whether I am heartened by the flexibility inherent in each person’s psyche to be able to adapt, learn, and insulate himself or herself against disorder – or scared stiff by the notion that our innate biological defenses may be largely helpless against the unwavering assault of conditioning. Aside from some mildly-influential genetic predisposition to the contrary, it seems I could very easily – and unpredictably – find myself afflicted with an anxiety disorder. Perhaps only Tony Soprano knows my newfound fear more fully than I.

Be that as it may, there were some interesting – and not totally discouraging – parts of this article. Most notably, the sections on “vicarious conditioning of fears and phobias” (p. 11) under “specific phobia,” and “social learning and social phobia” (p. 14) seem to point to a neurological phenomenon about which I (admittedly) know little, but nonetheless find fascinating: mirror neurons. These little bundles of cells in our brains (examined, of late, for their role in the development of Theory of Mind and empathy) simulate the experience of doing or feeling whatever it is you are watching someone else do. Implicated in such dubious human activity as the vast success of the porn industry, it seems to me that they may prove to be the best place to look for the neurological proof vicariously acquired fears and phobias. If “simply observing others experiencing a trauma or behaving fearfully could be sufficient for some phobias to develop,” (p.11) and “simply observing another being ridiculed or humiliated… may be sufficient to make the observer develop social phobia,” (p. 14) then it seems a fruitful place to look for proof of concept may be the very part of our brain that may be responsible for vicarious sensation and emotion. Then again, in light of the anxiety that all this anxiety research has provoked in me … maybe I don’t want to know.

Isn't it neurotic? Don't you think?

Kendler, Kuhn, Prescott, 2004

This was a very powerful (experientially and statistically) analysis of the role of neuroticism, gender, and stressful events in predicting depressive episodes. I was impressed, frankly, that such analyses have been undertaken at all, and I couldn’t help but wonder what other goodies could be plumbed from the amazing data set (the Mid-Atlantic Twin Registry) that was used. I was also curious about the construct the authors used for “stressful life events.” It seems that their criteria (lasting more than 10-14 days, self-reported, recent relative to the interview date) are neither the most conservative nor the most exploratory of the options that could have been used. I guess that, given the size of the sample, one could argue for the normality of the distribution of adverse life events, leaving this middling choice to be at least representative enough to capture a real phenomenon – but still! What about acute life events NOT captured in the time window? What about more persistent life events? What about the possibility of cyclical or random emergence of depressive episodes and the possibility of those with more primarily neurochemically-induced depression (I now know better than to make a distinction between neurochemically- and non-neurochemically-based, though)? These are the types of questions one might expect to see (or at least see discussed) in an analysis such as this (especially given the advantages of having a large sample of MZ twins), but they were nowhere to be found.

Even more perplexing was the lack of any meaningful discussion of the implication of the findings. The authors speak about the implications as they relate to the modification of a model depression of etiology (an important area of inquiry in its own right), but they say nothing about the implications for individuals who might be at risk for such disorders, and they make no effort to speculate as to why their unexpected findings might have occurs. Specifically, why are females (regardless of rates of neuroticism) so much more likely to have a major depressive episode following a “minor” stressful life event? Does the model of “minor” life events not map appropriately onto the stress-management systems of differing genders? Do women have defense mechanisms against depression that don’t “kick in” until higher levels of distress are experienced? What, if anything, are the implications for targeted treatments for women at risk for depression (e.g. with high neuroticism)? The lack of (apparent) interest in addressing these sorts of “real world” implications for findings seems to be the downside of doing research with an n of 7517.

Rabbit Holes, Rest, and Relapse: that was Groucho, this is Karl

Bootzin & Epstein, 2000, Stimulus Control

I must say, though I already knew that behavioral treatment for Insomnia were apparently effective, these findings still really wowed me. Seeing the incremental effectiveness Stimulus Control (both on its own and as part of a larger treatment package) has over pharmacological interventions (and, in some cases, even over combined behavioral/pharmacological treatments) makes me wonder about the already-suspect motives of drug companies in pushing these meds. Is the book essentially closed on treatments for sleep disorders – the problem already largely solved? Do articles in the journal SLEEP about treatments amount to the academic equivalent of the very Nick-at-Nite reruns their subjects were once ensnared by in the wee hours? I find it telling, though, that such strong effectiveness findings for behavioral treatments seem to present themselves in the arena of more unitary, nomothetic, reactive, and instrumental disorders, while they are more contentious (at best) with regard to more potentially complex, behaviorally aggregate, usually ipsatively-deduced disorders (such depression, autism, personality disorders, etc).

That said, there were a few areas of the Bootzin and Epstein paper that caught my interest and led to several questions:

-On the first page of the article, the authors note that in the 60’s and 70’s, “programs for weight reduction that focused on SC were found to be highly effective” (p. 168). What happened to these “highly effective” programs, though? Were they overtaken by more cognitively-based approaches, discarded for some methodological reason, or simply lost to history for no good reason?

-The authors note that their preferred method, the “small-group format,” (p.171) had some evidence for its specific effectiveness (although, near the end of the article, they seemed to note that there was some evidence to the contrary). I’m wondering, then, if there has been any mechanisms of change work examining the potential “common factor” in this condition. Specifically, what, if anything, might the role of normalizing sleep disturbances be in reducing the stigma (and consequent anxiety) surrounding them? I imagine there might be a differential effect (that could be easily testable with an intervention group, plus wait-list control and a support-group control conditions), though I’d be curious to find out if such a thing exists.

-On p. 177, the authors note that “older adults usually take longer to fall asleep than younger persons.” Though I’ve certainly seen this phenomenon in action, it seems counter-intuitive to me. Young, spry individuals seem more likely to have an excess of wakeful energy to keep them up at night. Is this not the case?

-Finally, among the treatment instructions, Bootzin & Epstein note that “SC should be followed at the time of the final awakening.” However, they don’t say what to do in the event of finding oneself very sick with a cold or flu. In these situations, staying in bed can be healthy and necessarily (not to mention medically indicated), and could certainly circumvent the effectiveness of a SC protocol. I imagine that the authors would allow for this as an exceptional circumstance, though I wonder what their preferred method of response might be (e.g. get up and be sick on the couch instead). Additionally, does this response change when a mental illness such as depression is involved? Are there intermediary interventions to break the cycle of exhaustion and depression that can be so self-reinforcing in depressed individuals?

Sleep Hygiene Handout

I guess my main reaction to the Sleep Hygiene handout was simple: how, if at all, does Sleep Hygiene (programmatically) differentiate itself from the Stimulus Control method outlined by Bootzin & Epstein? It seems to just incorporate it as the manualized component of a larger battery of recommendations around, well, healthy sleep. Is that all?

-Also, is the nightmare component of sleep Hygiene simply a variant on systematic desensitization? If so, I wonder if augmenting the “change” component of it with humor or absurdity (e.g. “put a bow on the snake,” or “you fall… into a big pile of tapioca pudding”) might increase its reliable effectiveness.

Witkiewitz & Marlatt, 2004, Relapse Prevention for Alcohol & Drug Problems: That was Zen, this is Tao

I found myself perplexed by my response to this article. Though the model and systems (and, importantly, the article’s subtitle) should have been fascinating to me, I had a lot of trouble getting into it. In any case, I came up with a couple of thoughts:

-After much ado, on p. 229-230, Witkiewitz & Marlatt present their Dynamic Model of Relapse. This model is fascinating in its complexity, modernity (it’s awfully hip), and comprehensiveness. Not being extremely well-versed in the literature, I don’t really feel qualified to take serious issue with any component of it, though, importantly, the authors themselves do note that the model “needs to be empirically tested and replicated across drug classes and with a variety of distinct substance-using populations” (p. 232). An interesting factor that they touch upon only briefly is the role of neural mechanisms & correlates of additions. Specifically, I’m curious as to whether the authors would conceptualize them as more “phasic” or “tonic,” as the implications for “hard-wiring” learning and thereby neurologically protecting relapse seem to be great.

-Also, I’m not entirely clear how the Dynamic Model of Relapse directly speaks to treatment. Though it “depends on clinicians’ ability to gather detailed information about an individual’s background, substance use history, personality, coping skills, self-efficacy, and affective states,” (p. 231) I’m not sure how, given the necessarily immense complexity of the relationship of these factors as they relate to the Dynamic Model, it can give direction to a clinician. Put simply: it’s just too much information to effectively synthesize; indeed, the comparison to chaos & catastrophe theories, whose models can only be analyzed and plotted using the most cutting-edge computing hardware, seems apt. If a clinician is to use the model, it should inform either a) how s/he should intervene, or b) when is the most optimal time to apply specific interventions. As it stands now, the Dynamic Model seems to provide meaningful direction for either of these questions, but it certainly does hold immense promise.

Voelker, 2006, Stress, Sleep Loss, and Substance Abuse Create Potent Recipe for College Depression

The findings reported in Voelker’s article are striking indeed! It is really quite amazing to see how mutable the brain and its structures are. That socially-activated adrenocorticotropic hormones “have the potential to remodel the brain” (p. 2177) at the genetic level says a tremendous amount about the importance of our ability to process and regulate social information – and about the fragility of the brain’s architecture in the first place. Though I don’t believe that anyone really thinks of humans as nothing more than walking bags of blood & neurons & hormones that just bump into different environmental factors (or, as Greenberg put it more eloquently in our first reading, we are beings “orchestrated by ion channels and neural pathways and axonal projections… deep in the grips of [our] chemicals”), the findings reported in this article are pretty persuasive in that direction. Though the finding the “brain change that defines addiction” may take us beyond the “metaphor of the frying pan,” I daresay that it may take is into the fire. If we find that all this neurobiological information is knowable, and all that we are is changeable, then the only field with more infinite promise than psycho(pharmaco)therapy is… bio-psycho-totalitarianism.

FIN

The New Behaviorism: Perfect Grammar or Poor Poetry?

Hayes, et. al 2004, DBT, FAP, and ACT: How Empirically Oriented are the New Behavior Therapy Technologies?

Several things excited me about this article. Specifically, it was very helpful to see how well-reasoned and promising some of the “new behavior therapies” may be, and how much they may, indeed, not just be “old wine in a new bottle,” due to a renewed focus on non-observable behaviors, in vivo practice/training methods, transportability methods, and clearer models of change. To wit:

-In the description of more comprehensive treatment packages such as DBT, it is exciting to hear about the sequential focus beginning with behavioral training and continuing through “living skills” such as employment and education. One of the biggest problems in the long-term effectiveness of any treatment is the lack of explicit tools to apply it to functional settings in an ongoing way. It seems to me that the addition of such functional modules to existing treatments would be an interesting imperative to put before practitioners of existing ESTs to see how their therapeutic principles apply.

-There were some interesting methods of ensuring agreeable treatment fidelity mentioned in this article. For instance, in comparing CBT to ACT, “the same primary therapist was trained both by Beck and Hayes in their particular form of intervention.” (p. 45) This is a good idea (to have the treatment originators of the competing treatments BOTH be involved in the training process), and, when feasible, can go a long way towards resolving some of the recursive arguing from both sides that can emerge in a comparison study.

-More personally, I was excited to see some of the principles employed in my Spotlight Program reflected (and deemed important) by these new behavior therapies. For instance, the value of in vivo examination (and reframing) because “it is easier to deal with actual relevant behavior within session than with a mere description of the behavior.” (p. 44) is a fundamental approach I’ve been espousing for years, and it is nice to see that others have been adopting it as well. In general, the notion that these approaches are “often more experiential than didactic,” (p. 36) is an exciting discovery for me in light of my experience with other purported behavioral approaches.

An important theme implicit in this article is the connection of the theoretical model of change in a given treatment to the specific disorder it is intend to treat and the consequent projected outcomes. In many of the meta-analyses we’ve read, there have been awfully impressive outcomes reported about effectiveness with a range of disorders. However, there is often not a clear picture of why the researchers figured their treatment might work with these disorders in the first place, and, concurrently, why certain specific outcome measures were chosen. A good instance of where this issue is addressed is Hayes’ et. al’s recount of how ACT was used for patients with positive psychotic symptoms. This particular treatment “targeted acceptance of the private experience of symptoms, defusion from these symptoms, the importance of distinguishing one’s self from the content of one’s thoughts, and the role of … action.” (p. 46) The authors then report that the best outcome in this case was lower levels of rehospitalization at follow-up, but say that, “paradoxically,” more ACT participants admitted to symptoms than TAU controls, and ACT participants showed lower levels of believability. In light of the purported goals of ACT in this case, this is not paradoxical at all. It seems that part of the proposed treatment mechanism is about accepting and owning up to such symptoms (while simultaneously disassociating from them personally), and, importantly, is not trying to extinguish them from existing altogether. As such, it is completely in line with the theory of change underlying ACT in this case that such patients would be happy to report their symptoms if asked, but would not be sufficiently perturbed by them to require subsequent hospitalization. Though the question remains as to whether extinguishing the underlying symptoms might be an important therapeutic adjunct (or alternative), it is important to note the clear relationship here between the theorized change mechanism in ACT, the chosen disordered population, and the subsequent measured (and, in this case, achieved) outcome. This seems a far superior (and more scientifically valid) method of approaching treatment research than that of haphazardly applying a treatment to a disorder and hoping that it sticks, somehow.

Jacobson, Martell, & Dimidjian, 2001, Behavioral Activation Treatment for Depression: Returning to Contextual Roots

It is also consistent with the very approach that, according to Jacobson et. al, 2001, led to the rise of Behavior Activation (in the second article we read) in the first place. This radical behavioral intervention is predicated on the notion that the cognitive components of cognitive therapy for depression are extraneous, and that comparable results can be obtained from focusing primarily on the adaptive behaviors that CT prescribes. Much is compelling to me about BA, despite myself. For instance, I am very partial to the notion of what Jacobson et. al call “focused activation.” Also known as “person-specific motivators” (as used in the Spotlight Program) this idea of using non-generic reinforces is – given its commonsense value -- surprisingly spare in much of the behavioral literature to which I’ve been exposed. That BA embraces it is further evidence of the evolution in thinking that the “new behavior therapies” demonstrate. The contextual approach (which is very much like an environmental or narrativist approach) is very much “old wine,” but is nonetheless compelling in its own right.

That said, I had a few problems with the sort of radical behaviorism espoused by the authors. First of all, the “distinctly behavioral model of depression” (p. 258) that is presented is somewhat problematic. Certainly, there are individuals and circumstances for whom contextual factors are a cause and support of depression. For such individuals (who, it could strongly be argued, may be the majority of those afflicted with major depressive disorder), getting at the events that have led to the particular episode(s) of depression can be fruitful, and doing so in the sophisticated way that BA employs can be valuable for many. However, there are those for whom even a diathesis-stress model of depression is tenuous – for whom a clear-cut cause of the specific depressive cycle is elusive at best. For these individuals, the notions upon which BA is predicated may be more frustrating than helpful – at least at first. This, indeed, may be the problem: for such people, the later steps of BA could be useful, but getting to them in the first place may be quite insurmountable.

Second, it seems ironic that an approach so grounded in visible behavioral processes can be so contingent upon a relational component. Specifically, the authors note that “establishing a collaborative foundation is a critical part of effectively presenting the model and conducting effective BA in general.” (260) This idea is present throughout much of the article, and is a circuitous way of saying: therapeutic alliance really matters here. That this is the case is fairly straightforward and evident: you can’t get a patient to buy into a model that requires so much of them (in terms of both belief and action) without getting them to trust you and want to work collaboratively with you as the therapist. However, this idea (very much relating to the content of the patients thoughts and feelings about the therapist) seems to run counter to the behavioral underpinnings of BA (that it is all context over content). This discrepancy is never reconciled through the article.

Finally, my largest concern emerges from the overall feeling I have about radical behavioral treatments in general. My position is this: they are not inherently wrong; there is certainly (and necessarily, a priori) a behavioral component to both disorders and the capacity to change them. This is true of the psychological condition in general. However, to borrow from my old mentor and esteemed colleague Dr. Karen Levine, to say this is much akin to saying that all sentences have grammar in them. It is definitely true, but it may be beside the point. I can write many sentences about old men in boats, lecherous gentlemen, and obscure neurological conditions, but this does not mean those sentences will be comparable to those written by Hemingway, Nabokov, or Sacks. Emotional content, form, artistry, word choice, and a host of other factors differentiate my sentences from theirs, even though one could properly say that both our form (grammatical structure) and content (topic) were identical. So it goes for behaviorism: I am not convinced that, in getting at the form that necessarily underlies psychological being and action, we have stumbled upon the best or even truest model of change, even if it is the most universal. This, I guess, is what comparative outcome and mechanism studies are all about: does one form of therapeutic prose outstrip another? Do the different forms of form perform differentially – just as Faulkner resonates more with some than Fitzgerald, does Rogers do likewise relative to Beck? Or, for that matter, is all we need the therapeutic equivalent of Strunk & White to cure what ails us?

cognitiverationalemotivebehaviorism -- and why it's so great.

What are CBT Psychotherapies?

This article highlights one of the greatest concerns I’ve had as we move through our review of the empirical foundations underlying clinical psychology at present: its disconnect with the views of so many practitioners in the field. While many of the academic articles we’ve read have tried to cautiously circumscribe their positions in terms of support for specific interventions, clearly the British Association for Behavioural and Cognitive Psychotherapies has no such imperative. Bald-faced claims such as CBT being “based on concepts and principles derived from psychological models of human emotion and behaviour,” and involving therapists who only work “once a therapeutic alliance has been formed,” ‘treatment interventions are predicated on a robust evidence base derived from studies utilising randomised controlled and single-case methodologies that have demonstrated the efficacy and effectiveness of cognitive and behavioural psychotherapies” are proudly put forth with little or no citation. Such claims, of course, and ones much worse, are the norm amongst organizations like this one, much to the detriment of a field desperately clamoring to come out from the pall of practices like phrenology and tarot cards.

Though organizational self-promotion is a fact of life in a free market society, it occurs to me that even bare-bones regulations could reasonably be put in place for psychotherapy organizations mandating a more balanced perspective. In particular, the BABCP site espouses the various strengths of CBT (populations it’s been proved effective for, skills CBT therapists apparent must possess), but nowhere does it make mention of its limitations. I know of few who would advocate that symptoms of MR could be effectively addressed by CBT, and, as mentioned in class, CBT could certainly be shown to be nominally effective at best as a unitary treatment for severe schizophrenia, though such disclaimers (necessary in medicine as regulated by the FDA) are nowhere to be found in this field. Perhaps this would be a good role for a new APA task force.

Butler, et. al, 2006, Empirical status of CBT: review of meta-analyses

Where the BABCP article/site was unapologetically overzealous, the Butler et. al article is surprisingly evenhanded. Though clearly written by proponents of the CBT model (Beck himself is a co-author), this meta-meta analysis (a it is proudly defined in Kazrin, 1978) does an impressive job of delineating the limitations of its findings by being very careful to not compare apples-to-oranges in review of meta-analytic design, and to address such effects as researcher allegiance on outcomes. More importantly, the authors expressly address the critical issue of the persistence of treatment effects after treatment cessation. Some of these efforts seem to come up a bit short -- for instance, I’m not sure I buy the “possible explanation for the difference in findings… that researcher allegiance influences study outcomes when a new treatment is first tested, but its influence fades over time” (p. 20) – but, on the whole the findings are impressive. Most impressive, I thought, was the comparisons with psychopharmacological conditions, in which CBT (or its variant) outperformed pharmacological treatment and combination treatment for panic disorder, and outperformed medication for Bulimia. This seems to be powerful supporting evidence for treatment specificity for these disorders.

The one caveat I might offer is one the authors attempt to address. Specifically, I’m speaking of the differential effects offered by the unfortunately wide array of heterogeneous treatments being offered under the title of “CBT.” Though Butler, et. al attempt valiantly to address this (they clarify differences in modality, such as CT, CBT, Cognitive-behavioral Marital Therapy, Trauma-focused CBT, etc), for there to be truly sufficient internal validity (not my favorite axe to grind, but so be it) to ensure real equivalence, it might behoove the authors to ensure that similar methodologies (in additional to similar modality) are being appropriately compared.

Engels, et. al, 1993, Efficacy of RET: a Quant. Analysis

… and just when I thought that such an approach to treatment research might be hard to find, along comes an article from 1993 that is up to the task. In painstaking detail, Engels, Garnefski, and Diekstra provide a useful meta-analysis of RET that (in my mind) more than adequately breaks down the treatments being aggregated using a useful coding system which accounts for methodological treatment variance (i.e. types of interventions “said to be used”), allegiance effects, and other relevant variables. That such a system was devised more than 15 years ago (with little follow-up as far as I can see) is a little disheartening, but I digress. Addressing all these relevant variables, Engels et. al tentatively conclude that RET does, in fact, seem to demonstrate effects above and beyond wait-list control and placebo. Interestingly, though, it seems that a major theme of the findings in this article is that these effects are “mainly due to the therapeutic effects of rational thinking” (p. 1086). That is, rational thinking seems to have a differential effect above and beyond behavioral components – a very different finding than many studies on CBT-related interventions. I would be curious to find out more about follow-ups in RET meta-analyses since 1993 to see if such findings (as well as findings for non-YAVIS populations, as Engels et. al ask for) bear out.

Ellis, 1999, Why RET to REBT?

Our readings this week conclude with a funny little article from Ellis that, at first, seems to cast his RE(B)T as an aspiring also-ran in the emergent world of empirically-supported behavior therapies. This initially struck me as rather odd, and I wasn’t entirely dissuaded of this conception as the article progressed. However, I was certainly struck by the astonishing amount of versatility Ellis packs into (his conception of) RE(B)T. In particular, I found his framing of the empowerment of human agency (and its consequent relating of human choice to human behavior) rather compelling as a therapeutic foundation – though, admittedly, it certainly seems well-tailored to the YAVIS set. By and large, though, I had trouble distinguishing the characteristics Ellis describes as endemic to good RE(B)T specifically, from those qualities one might use to describe good therapy in general.

The Rumble in the Relationship

Castonguay, Constantino, Holtforth, 2006, Working Alliance

The Castonguay, Constantino, and Holtforth article cast the atmosphere of disarray that seems to pervade the area of psychotherapy research in a slightly more hopeful light. In particular, it seems that – though the authors may proclaim its promise a bit too zealously for my taste – the therapeutic working alliance between client and therapist may indeed provide a fruitful avenue for exploration for effective differential treatment and training. Though I was, on the whole, interested in this article, my ears perked up in a few places, namely:

-The finding that “when faced with alliance ruptures or therapeutic impasses, therapists’ increased or rigid adherence to prescribed techniques or the therapeutic rationale may fail to repair such ruptures and may even exacerbate them.” (p. 272) This seems to fly in the face of the position of pure treatment manual acolytes, who go around knocking on doors when hard-core CBT therapists deviate from their scripts. It also seems to echo one of the themes of the article: that therapists (either via training, formal measures, or both) need to become actively aware of the therapeutic alliance, in the same way that Freudians used to command that psychoanalysts attend to their transference and counter-transference processes – though with a bit less pressure this time.

-The authors note on page 273 that “the alliance can no longer be viewed as a ‘nonspecific’ variable, i.e. a variable for which the nature and impact is not yet understood.” Faced with the cacophony of naysayers who claim that therapeutic effects can almost ENTIRELY be ascribed to nonspecific effects, it is a fairly large and significant finding that alliance – which, one way or another, is present in all therapeutic relationships – can be differential, quantifiable, and capable of being manipulated. This leads logically, later, to the promising point that attempting to “match specific interventions to significant in-session events such as anger… is likely to enhance significantly our understanding of the process of change, as well as to make research efforts more meaningful and relevant to practitioners.” (p. 275) So, not only can the alliance help us understand change processes as researchers, it can help clinicians to directly impact those processes for the better – which seems to be what we’re all hoping to get at in the first place.

-An interesting point that I don’t think was satisfactorily addressed in this article is the question of whether the alliance needs to be made explicit, or remain in some meaningful way implicit – or even elusive – for the client. Though there seems to be some evidence presented in the article to support the claim that bringing the status of the alliance to bear is helpful for the therapist, it’s not immediately clear that the same is true for the client. In fact, one could make the argument that such a thing might be detrimental – that part of the alliance (and its attendant change processes) hinges on the sense in the client’s head that the therapist “just gets me.” Though many clinical researchers scoff at the “mystical” claims of some forms of therapy, I’m not sure what the empirical status of therapeutic mystique is; do we know that the sense that many clients have that their therapist has privileged knowledge – even privileged power -- isn’t valuable? I, even, wonder if some of the more powerful alliance effects might even come from this, and, just as importantly, if the dissolving of this presumed insight (through alliance measures with very high face validity, for instance) might serve to undo those very effects.

Kirschenbaum & Jourdan, 2005, Current Status of Person-Centered Approach

If the therapeutic alliance and Rogers’ 3 core conditions got into a fight, who would win? First of all, no matter what, it would be an awfully nice fight, filled with lots of subtle smiles, brief head nods, and appreciation of each other’s position. There would be all kinds of potential processes involved -- a jab of engagement mediating an existing relationship, countered by a right hook of unconditional positive regard moderating the alliance before it can have much impact. Most of all, there would be empathy – lots and lots of empathy. There might be so much, in fact, that the specific effects of each of the sides (the heavily-gloved fists that would be the prime moves in this battle royale) might just be subsumed by this… common factor… that pervades them both. In the end, it would be incredibly hard to determine a winner – what with all the Dodo birds flying around, obscuring the view and handing out trinkets of unimaginable value – and the language gap between them (sans interpreter, of course) would make it impossible to comprehend any announced results. One thing is for sure, though: everyone sure would feel good.

More on Clinicians (sic), and the researchers who care about them

Meehl, 1997, Credentialed Knowledge

Oh, to be venerable and curmudgeonly! As a not-even “fresh-baked Ph.D.” (Meehl, p.93), I confess that I am rather envious of a person who is so well-established that he can get 7 pages of personal musings published in a top-tier Journal like Clinical Psychology: Science and Practice, while mine remain more ephemerally ensconced in this online blog. Meehl himself, clearly a conceptual bosom-buddy of our old friend Dr. Dawes, spends the better part of his 7 pages musing about just how silly anyone is who claims to have special knowledge (or the ability to make special conjecture) by virtue of his Doctoral credential. Never mind that he spends the balance of those pages inserting his own pet theories (which, we are to assume, he presents by way of establishing prime evidence of such silliness) and concludes with seven items of largely unsubstantiated speculation; his mission is clear: to advance the notion that practitioners of clinical psychology may very well be no better than witch-hunters and 17^th century surgeons.

For all the fanfare, though, the fact remains: many people seek out clinicians, whose provided services is (empirically) at least as good as common factors can attest to, though is sometimes better (discounting, for the moment, the subset of iatrogenic treatments). That this is the case and, barring financial or natural catastrophe, it is likely to remain so for quite some time, there is one pragmatic inference that I can draw from Dr. Meehl’s article: we should tap these clinicians as an observational resource.

Meehl says on page 93, “I was convinced that many of Freud’s theoretical notions were unsound inferences from clinical correlations that were valid.” This is a good and important point! Though Meehl claims repeatedly that he and other clinicians are “lazy” about making good observations, this (the generation of consistent, documented observational clinical correlations that can contribute meaningfully to research findings) is an imperative one can put before the hoards (sic) of APA-accredited clinicians and actually find some footing. The clinical throng is not, one imagines, allergic to research as such – they just need to be pointed in the direction of utility and, as Westen et. al claim, be enlisted for their valuable (yes, valuable) services. Asking researchers to begin to document their “pet correlational theories” (after all, as much as we grapple with his legacy, who doesn’t want the latitude of creative freedom to be a Freud?) and then doing large-scale analyses of these potential correlations could be an unimaginably rich source of relevant and useful research direction. Factor analyses (given what I know of them) of these data could point towards clusters of representative, applicable findings that could be confirmed (or, just as importantly, disconfirmed) by researchers and embraced by clinicians. Incidentally, this would also go a great ways toward solving the “my dad can beat [up] your dad” standoff that Meehl helpfully calls attention to on page 94. Thanks, Dr. Meehl, for your text, which has thoroughly inspired in me a deeper respect for the role of practicing clinicians in the advancement of clinical science.

Westen, Novotny, Thompson-Brenner, 2004, Empirical Status of ESTs*

This week, we were more deeply exposed to the debate on what (if anything) the focus on empirically supported therapies has done to the field of clinical psychology and where the field should go next. I have quite a bit to say about the lengthy article by Westen, et. al, but I will keep to one main point in the interest of time:

A point that Westen et. al mention (which is also of concern to me) is that psychotherapy research & practice (even cutting-edge technique) is still so focused on behaviors without much attention to underlying or concomitant causes. For instance, on page 636, Westen et al. describe how dialectical behavioral therapy for borderline personality disorder has been found to lead to “substantial behavioral change in parasuicidal behavior … [but] personality variables such as feelings of emptiness showed little decline.” In some of my past contact with individuals who have undergone this treatment, I found it remarkable how effective it was in eliminating dangerous behavior, but was frustrated by little it did to affect the skewed perceptions that seemed to be causing it. These perceptions can have enduring consequences in an individual’s personal life, and it was striking to me that they didn’t seem to be addressed. In this reading, there appeared real hope for augmentation of such therapy that may become more comprehensive.

In initiating the published debate to which we are privy, Westen Novotny and Thompson-Brenner touch on some of the key limitations to the practice, advancement, and research of evidence-supported therapy, specifically as they pertain to a limited view of psychopathology and a consequent linear (and similarly limited) view of treatment (632-633). In the past, I have often found myself citing a Stanley Greenspan quote about traditional methodologies for treating autism. Specifically, Greenspan notes that such “approaches tend to mistakenly view autism as a unitary disorder made up of maladaptive behavior without consideration of the complex underlying processes that are responsible for the overt symptoms.” (Greenspan, 1998) It is extremely heartening to see that a similar perspective is advanced in the larger field of psychotherapy research. As discussed in previous readings for this class (e.g. Persons et. al, and Widiger & Clark), issues such as complexity of disorder (and, indeed, that a disorder may not have particularly well-defined parameters), the underlying causes of such disorders, or even the geographic and socio-economic location and distribution of patients seem to have gone under-addresses. Such approaches to both treatment and research seem to be simply indicative of the youth of the field. They are slow to accumulate and slower still to inform practice. Their advantage, though, is their careful systematic use of precedent. In general, I am inclined to embrace wholeheartedly the empirically informed treatment model that Westen and company endorse (especially with its revitalization of the relationship between the researcher and clinical practitioner). Conversely, I wonder whether its presumably more haphazard method of generating hypotheses (as opposed to the incremental, cumulative method that has been used traditionally) is as likely to yield more fruitful research.

Greenspan, S.I. (1998). Guidance for Constructing Clinical Practice Guidelines for Developmental and Learning Disorders: Knowledge-based vs. Evidence-based Approaches. The Journal of Developmental and Learning Disorders. Madison, CT: International Universities Press, Inc.

*NOTE: Portions of my thoughts on this reading are adapted or excerpted from my previous writings in reference to the same article for Journal entries assigned in a Psychotherapy Research course taught by Professor Matthew Nock.

Sechrest & Smith, 1994, Psychotherapy is the Practice of Psychology

As I have gone on too long already, I will reserve my comments on this article for class. However, I would like to briefly note (in writing) that the position advanced in this paper (that clinical psychologists should, first and foremost, be trained as psychologists) is almost identical to the mission put forth by the Clinical Psychology area of the UVA Psychology Department. This was, suffice to say, nice to see.

ESTs, Dodo birds, eyebrows, and flies

Chambless & Hollon, 1998 Defining ESTs

The Chambless and Hollon article provided a firm foundation for considering the issue of Empirically Supported Therapies (ESTs). In it, they provide a summary of their (fairly commonsense and relatively liberal) recommendations for how a therapy might achieve the much-vaunted status of becoming an EST. Though I largely agree with many of the points addressed in the article, the following are some issues that raised my eyebrows a bit:

-Several times, Chambless and Hollon refer to the fact that they “have more confidence in inferences derived from controlled experimentation than those derived from purely correlational analyses,” (p. 8) and that such controlled inferences merit the greater balance of subsequent study. Though this is a very sensible – and, indeed, necessary – foundation for considering the development of the empirical base for ESTs, it seems to belie an important element in the process of treatment design: that they may (and, perhaps, should) be developed, initially, “in the field” by practicing clinicians. For the reasons mentioned by Chambless and Hollon (e.g. lack of clinical sample representativeness, lack of replicability, cost-effectiveness), many lab-derived treatments have come under fire by practitioners. Even those that are thoroughly vetted for their effectiveness (as opposed to efficacy) are often not easily disseminated. However, there remain a large number of practitioners of clinical psychology in various settings who attempt to create novel, targeted (read: “specific” in the Chambless and Hollon sense) treatments quite frequently. It seems both good and proper to have clinical researchers survey these treatments and use them as the basis for future study (that they do not more readily do so already could be construed as a sort of chicken-and-egg “starting point error” in the pursuit of achieving treatment uniformity). Though they are not derived from controlled experimentation, they do have the advantage of – upon rigorous examination, of course -- having a distinct likelihood of achieving the lofty aim of getting ESTs into clinical practice more readily.

-Chambless and Hollon note that “any given therapy tends to do better in comparison with other interventions when it is conducted by people who are expert in its use than when it is not.” (p. 12) I found this interesting, as this could be the result of competence/”mastery,” bias, or some combination of the two. The result of this, then, has implications for both research design and staffing. Perhaps another bit of research methodology that psychology should borrow from medicine is some variation on the “double-blind” study. For clinical psychology, this iteration might involve bringing in “non-expert treaters” (culled, perhaps, from 1^st year students in terminal Master’s degree programs in Counseling Psych, Clinical Psych., or Social Work) to be trained as “blinded” therapists, administering more controlled treatment in psychotherapy research studies. Another option, of course, would be to have “researchers with differing orientations collaborate on comparative outcome research,” as suggested by Hunsley & DiGiulio.

Hunsley & DiGiulio, 2002 Dodo, Phoenix, or Urban Legend

I was very heartened to read the Hunsley & DiGiulio article. I find myself in strong agreement (both clinically and scientifically) with their exposure of the living Dodo and his absurd verdict as the hoax that it is, and I certainly hope the field of psychotherapy research has since taken note of the obsolescence of the prevailing notion of psychotherapeutic equivalence. That said, there is a small fly I’d like to throw in the CBT-flavored ointment that is the implicitly-prescribed salve smeared throughout the article. As I see it, there are two substantial problems precluding the trumpeting of behaviorisms final triumph in the kingdom of psychotherapy:

1) The issue of therapy “classes” (e.g. the problematic ones that Hunsley & DiGiulio cite in the Smith, et. al (1980) article) remains complex for behavioral interventions. It could be argued (and, indeed, often is argued) that any intervention is ultimately trying to change behavior, and so there is a strong magnetic pull towards calling almost anything behavioral. Indeed, in our post-Beck and post-Linehan era, it sometimes looks like almost any prefix could be affixed to “BT” to create a new treatment. This, then, could confound any attempt at future meta-analysis even further, leading to the same types of categorization errors that seem to have cropped up in the past, and thus causing the Dodo to again rise, Phoenix-like, from its own ashes – yet more resilient than before, due to our own best intentions.

2) Behavioral intervention, at its core, is an inherently “quantitative-analysis-friendly” sort of treatment. With its inclusion of explicit data points, observable change, and largely manualized approaches, it is an easy fit for the science of a field that strongly relies on statistically analysis as the coin of the realm for legitimacy. However, this fit may, in fact, beg the question: just because behaviorism lends itself to a quantitative analytic paradigm does not mean it is a) the best potential option within the paradigm, b) that the paradigm cannot accommodate other alternative, or c) that the paradigm is indeed optimal for the phenomena under examination. The first of these points is largely addressed by the meta-analyses cited by Hunsley & DiGiulio, but the second two are more problematic.

In terms of accommodating other alternatives: it may be that we have yet to develop effective tools of measuring change according to the mechanisms proposed to be involved in such interventions. Self-report surveys are often a crude measure of internal change processes, but they are (at present) the best method we have. That they will be less capable of measuring their target processes than direct behavioral observation or report is evident; that this should be a real problem in getting at reliably comparable treatment effects in comparative psychotherapy research is apparently less so. It is the responsibility, therefore, of psychotherapy researchers to remain ably abreast of current assessment tools, and to re-assess potentially “debunked” clinical therapeutic methods of superior tools for their assessment emerge.

In terms of the question of quantitative analysis as the best method for analyzing psychological phenomena: this is clearly a larger issue for another time. However, it remains important to take note and remember that such analysis cannot be taken a priori to be the best and only determinant of effectiveness and success in a field that is, by definition, fraught with qualitative assessment and subjective response.

Experimental Psychopathology - week 2

This week's readings addressed a variety of issues related to diagnosis, diagnostic criteria, and diagnostic methods, primarily via a review and critique of the methods existing in past and present iterations of the DSM. Below are some of my thoughts on parts of these readings:

Allen, 1998 DSM-IV

Allen notes early in his article that mental disorders include “risk of… losing an important freedom.” (Allen, p. 29)

This is a very interesting twist on the idea of diagnosis that I hadn’t considered. Most restrictively, this stipulation seems to involve inclusion of those who may engage in conduct that would lead, explicitly, to the loss of such a freedom (e.g. pathological lewd behavior in public leads to arrest, so this is a characteristic of a disorder). However, what of the other interpretations of this language? Did Rosa Parks qualify for a mental disorder because refusing to move from the front of a bus was considered illegal at the time (and would therefore lead to the same consequence as the purveyor of public profanity)? Would a man who chooses to move from America to an Islamic society (e.g. Saudi Arabia, Egypt, Afghanistan) with more restrictive social laws be considered potentially disordered by virtue of putting himself at risk for losing some of his freedom of speech? Is an advocate of gun control at risk for being disordered because he is advocating the abdication of his Second Amendment rights? Can the American populace of late, subjected to more intrusive scrutiny by way of large-scale Executive wiretapping, be said to qualify for potential diagnosis because of the cessation from its “important freedom” from warrantless search?

I bring up these questions (the latter of which I recognize to be more a vehicle for political flashpoint than true conjecture) by way of hypothetical inquiry, but the underlying point remains: many diagnostic criteria, as pointed out by Szaz, are broadly culturally enmeshed. The implications, then, for extensive, world-wide reliability for DSM diagnoses, seem rather sticky. Though mental disorders are to “reside within an individual,” a “caveat [which] is supposed to prevent … applying them to individuals whose values or beliefs differ from those of the majority,” (Allen, p. 30) some of the above circumstances could be argued to exist as “internal problems.” It seems, then, that a more consistent system of validity verification (either via increased understand of etiology through pathological mechanism, as argued in the Persons article) would be of utmost value to future iterations of the DSM. Understandably, this could splinter the DSM even further into many (many) more monothetic diagnostic categories. However, it could be argued that this level of breakdown (augmented somewhat by the clear value of the multiaxial approach) would more closely approximate the wide variety of mental disorders that actually exist, as supported by the notation by Widiger and Clark (p.951) that “the not-otherwise-specified category is the most frequently provided diagnosis in general clinical practice, perhaps because the nomenclature is currently inadequate in its coverage.”

Persons, 1986, Psychological Phenomena vs. Psychiatric Disorders

Given the question presented (psychological phenomena vs. classified disorders), it seems that the natural follow-up question lies in the practical functional utility of either. It is true that, as Persons argues, Psychological phenomena are both more descriptive and more precise than psychiatric disorders. However, I would imagine that a strong reason for doing research into Psychiatric Disorders is the prevalence of their use (i.e. their representativeness of the actual classifications of actual patients who show up for evaluation or treatment). Though it would be very interesting (academically) to learn more about the nature of underlying phenomena, applying these finding would be uniquely difficult given that (as Allen mentions) we do not have a dimensional approach to diagnosis; further, changing the diagnostic paradigm such that we do focus more on dimensions (e.g. psychiatric phenomena as diagnostic dimensions) would put an undue burden on clinicians to administer even (and ever) more extensive and intricate evaluation batteries to capture the nuances of these dimensions.

It seems, then, that the real utility would lie in the fusion of the two: research into psychological phenomena as they present in individuals given Psychiatric diagnoses. It is fascinating that, for instance, “patients with nonschizophrenic diagnoses may have overt thought disorders,” (Persons, p. 1253) but a more useful examination (for those diagnosing and treating those labeled “schizophrenics”) would look at the nature and presence of thought disorders in the schizophrenic population and how to more easily assess their impact. This, then, could lead to the kind of improved diagnostic classification that Persons talks about (p. 1257), while at the same time addressing the real and present needs and concerns endemic to the population as we currently understand it.