“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.