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.