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.