361 Week 9
- The essence of psychotherapy/counseling
o In most general sense, psychotherapy is a social interaction in which a trained professional tries, primarily through language and other social influence measures, to help another person think, behave, and feel differently
o Basic assumption – language and social interactions can change people, that particular kinds of verbal and nonverbal exchanges in a trusting, professional relationship can achieve goals such as reducing anxiety and eliminating self-defeating or dangerous behavior
o Hypnosis a good example
§ Words matter
o Distinction in textbook between “psychotherapy” and “psychological treatment” is primarily semantic, how the words are defined
§ Critical issue is how well-grounded a given intervention is in scientific research. Textbook reserves term “psychological treatment” for scientifically-based intervention
- Key concepts in psychotherapy research
o Research and psychotherapy are extremely complex
o Efficacy versus effectiveness outcome research (current usage in the field)
§ Efficacy
· Research studies (usually randomized control trials) with random assignment, usually use of manuals, variety of controlled measures of outcome, usually non-professional therapists, carefully selected participants with exclusion criteria
§ Effectiveness
· Studies of therapy as actually conducted in the field with professional clinicians treating actual patients with a variety of problems. Usually only self-report measures and judgments by treating clinicians
o Process research examines mechanisms of change
o Outcome research examines outcomes without attending to process
o Cautionary notes:
§ Hard to draw conclusions, compare across studies or show influence of small-scale factors
§ Commercial/reputational aspects not to be overlooked. Money made in selling novel therapies to desperate patient and therapists
§ Since the 1980s, getting grants and getting published in the best journals required treatment manuals
§ “science-based practice” new term, scientific plausibility of the evidence
· Accounts for not only the outcome data considered in evidence-based practice but also the scientific plausibility of the rationale for a practice. One should avoid assertions that violate well-established principles drawn from other scientific domains and to proclaim dramatic paradigm shifts in the absence of convincing evidence
· The argument is that outcome data themselves are necessary but not sufficient to establish the scientific standing of why treatments work
· If the rationale blatantly contradicts well replicated findings drawn from basic science, its scientific status is weak
o Ageism in psychotherapy
o Older adults may be particularly open to existential therapy, life review and putting things in perspective
o A blend of the nomothetic (general principles) – the essence of any science – and the idiographic (the analysis of the single case) recall earlier discussion of meat on theoretical skeleton
o Meta-analysis: the differences among studies that are pooled and examined as a kind of “package”, seen by some as mixing apples and oranges
- General issues in evaluating psychotherapy research
o The use of therapy manuals in randomized clinical trials
§ The independent variables in experimental research
· What is a randomized clinical trial
§ Detailed manuals on how to conduct a particular therapy (specifying the independent variable), that is, stipulate specific procedures to be followed at different stages of treatment
§ Manuals have become the norm in psychotherapy research; funding agencies have been requiring them
§ Distinguish between ballistic or interactive: amount of flexibility a given manual gives the therapist:
· In research it is adhered to quite closely (ballistic). In real practice there are, however, changes depending on what S patient does (interactive)
· Trade-off between internal and external validity – therapy as practiced not the same as therapy in RCTs
· Goal of manual is to minimize the tailoring of intervention to individual patients, to operationally define the independent variable
· Very useful in earliest stages of training, like training students
· But there is a move to strategy-based rather than technique-based manuals. Increased focus on mechanisms of change rather than outcome studies
· Current controlled studies are limited in what they can tell us about the effectiveness of the psychotherapy available to patients who are not participants in research studies. But useful in where to place one’s bets
o The role of the therapist
§ The purpose of using treatment manuals is to minimize the role of the therapist in order to reduce differences among therapists and to define the independent variable
§ But, there is research showing that there is great variability among therapists even in RCTs
§ Research suggests that the differences between therapists are sometimes greater than the differences between treatments
· Must remember importance of therapist variables
o Some limitations of randomized clinical trials
§ Patients who volunteer and are accepted as participants in controlled studies are different from the vast majority of patients in real world psychotherapy. External validity an issue
§ Widespread use of a DSM diagnosis to define patients as homogenous, making idiographic analysis of a person impossible. Maybe functional analysis, cognitive-behavioral assessment better
§ To increase internal validity, researchers pretend that the controlling variables are the same for all people carrying the same diagnosis. This assumes the homogeneity necessary for randomization, which is questionable, e.g., people are depressed for different reasons (poor social skills leading to social isolation, Beckian cognitive errors, Ellis-type irrational assumptions)
§ Large numbers of participants are needed in psychotherapy research
· Assumption of the differences “randomizing out”, found in all human research, psychological or otherwise
§ Comparative research outcomes imply that improvements in experimental subjects are due to something particular about that condition vis-à-vis a control group
§ To complicate matters further, there is usually some deterioration among some subjects in experimental conditions (Bergin). How frequently do authors attribute this worsening to something special about the experimental condition?
§ Thus, there are limitations of what RCTs can tell us
§ Idiographic analyses always have to be blended with nomothetic analyses. Big challenge of science-based clinical work
o Efficacy vs. effectiveness
§ The efficacy of an intervention is what we determine from a controlled RCT (or any other experimental design, like single-subject research), typically conducted in an academic research setting
§ The effectiveness of an intervention refers to what is offered to and received by people in the everyday world
o Aligning practice with research
§ Perhaps it is the practice that needs changing, not the research
· Rather than trying to make scientific evaluations of treatment truer to the current activities of clinicians (improve the analogues), it can be argued that it tis the normal activities of therapists that should be changed to bring them more in line with the research
· Problem: there is great professional inertia and resistance to making such evidence-based changes in practice
o The challenge of managed care
§ How much control should insurance companies have over the nature and expense of psychotherapy?
· Managed care organizations (MCOs – basically insurance companies who control the nature and extent of healthcare) may have brought down the costs of care over the past few decades
· Demanded increased accountability from providers
o MCOs usually demand scientific evidence to warrant what health professionals do with their patients
o Stepped care
§ Stepped care refers to the practice of beginning one’s therapeutic efforts with the least expensive and least intrusive intervention possible and moving on to more expensive and/or more intrusive interventions only if necessary. Consistent with the “doing more with less” mantra of the 90s and beyond
§ Stepped care is consistent with the legal principle of least restrictive alternative, the principle in forensics that the patient’s liberty be restricted to the least possible degree while remaining workable and effective
§ However, are less intense/intrusive (and usually less expensive) interventions necessarily in the patient’s best interests? Maybe not
· Patients may drop out (or worse) if the intervention isn’t effective. Drop-outs hardly a sign of therapeutic success
· Risks associated with beginning with low-intensity treatments
§ Deterioration effect: the consequences of patients getting worse from harmful or ineffective treatments
· Some treatments or insufficient “doses” can have harmful, iatrogenic effects
§ Ineffective treatments do not bring about desired change (by definition); and may have a negative impact on the patient’s self-esteem and reduce his or her motivation to continue trying to change
§ Time spent with an ineffective treatment is time that could have been devoted to a more appropriate intervention
- A proposal for a different strategy for process research and the search for mechanisms of change
o Recall that CBT is very much concerned with change mechanisms – why therapies work, not just whether they work
o Moving from experimentally established principles of change to novel and effective clinical applications is an inadequately explored strategy for developing new therapeutic procedures. In other words, rather than compare existing treatments, why not move from established principles of change to the creation of treatments
§ If you do this, you already know what the mechanisms are because that is where you started
§ There are signs that the field is going this way
- Psychological tests – the big picture
o What is assessment?
§ An evaluation of an individual’s or family's [or any group’s and even an organization’s] strengths and weaknesses, a conceptualization of the problem at hand (as well as possible etiological factors), and some prescription for alleviating the problem
o Psychological assessment – interviews, standardized tests, projective tests, observations. Many purposes
o Other than in behavioral assessment, all these tests assume traits, stable and enduring ways of behaving, thinking, and feeling across situations and time. Traditional assessment concentrates on measuring underlying personality structures and traits, such as obsessiveness, paranoia, coldness, aggressiveness, intelligence, and so on. Thus, most tests measure traits like DSM disorders, test anxiety, social anxiety, depression, impulsiveness, honesty, shyness, etc.
o Tests can go beyond interviews, usually being more structured and validated by testing many people in a standardized way and then comparing people to each other and standardized norms
o So-called “objective tests”, also called "personality inventories” – standardized self-report questionnaires to which person chooses from a set of fixed options
o Projective tests
§ a psychological assessment device in which a set of standard stimuli—inkblots or drawings—ambiguous to enough to allow variation in responses is presented to the individual
§ the assumption is that because the stimulus materials are unstructured, the patient’s responses will be determined primarily by unconscious processes that seep through ego defense mechanisms and result in the person revealing his or her “true” attitudes, motivations, and modes of behavior, undistorted by defense mechanisms. This notion is referred to as the projective hypothesis
· if a patient reports seeing eyes in a Rorschach inkblot, for example, the projective hypothesis might be that the patient tends toward paranoia
§ projective tests are derived from the psychoanalytic paradigm
· the use of projective tests assumes that the respondent would be either unable or unwilling to express his or her true feelings if asked directly
· psychoanalytically oriented clinicians often favor such tests, a tendency that is consistent with the psychoanalytic assumption that people defend against unpleasant thoughts and feelings by repressing them into the unconscious
· thus, to bypass the defense mechanism of repression and get to the basic causes of distress, the real purpose of a test is best left unclear to the patient
o this has to be the case for psychoanalytic theory asserts that the factors of greatest importance are unconscious
§ the use of projective hypothesis is not limited to formal tests
· a psychoanalytically oriented colleague of ours uses it to form hypotheses about the client during the very first meeting
o he sees the client in an office that contains a wide variety and large number of places to sit
o when he brings a person into the office for the first time, he makes a point not to tell the client where to sit
o the therapist’s belief is that he can learn something useful about the new client from their choice of seating
o being less psychoanalytic in approach, we rejected his strategy outright—until one day a new client entered the office and before being shown where to sit, strode resolutely to the therapist’s desk chair. As it turned out, this person was highly resistant to being in therapy and made continual efforts to dominate and control the early sessions
§ there is considerable inference involved in most Rorschach scoring even though a psychologist named Exner claims that his system makes for somewhat greater inter-rater reliability
· this has been contested as have his and others’ claims of various forms of validity, including incremental
· at the very least, projectives like Rorschach are very time-consuming and therefore expensive, and their link to effective treatment is weak
o objective personality tests
§ the MMPI
· first, many clinicians provided statements that they considered indicative of various mental problems
· second, these items were rated as self-descriptive or not by patients already diagnosed as having particular disorders and by a large group of individuals considered normal
· items that discriminated among the patients were retained; items were selected if patients in one clinical group responded to them more often in a certain way than did those in other groups
o as long as an item discriminated between different groups of people, it was regarded as a sign of a given disorder
o there was no theory guiding the choice of test items. This is called “empirical criterion keying”
· with additional refinements, sets of these items were established as scales for determining whether a respondent should be diagnosed in a particular way
o if an individual answered a large number of the items in a scale in the same way as had a certain diagnostic group, his or her behavior was expected to resemble that of the particular diagnostic group
§ comments on the MMPI
· there is widespread sentiment that the MMPI provides little in the way of treatment planning
o consistent with its atheoretical nature, it eschews formulations that can mesh with treatment models, that is, it provides little information on how to structure treatment beyond providing general trait descriptions of people via the countless schemes for analyzing the data from the test
o and it rests on the validity of the DSM, so any questions about the DSM raise questions about the MMPI
· as long as an item discriminates between different groups of people, it is regarded as a sign of a given disorder or, in MMPI-3, particular problems like poor impulse control or undercontrolled behavior
o for example, “I grew up in a house that had three steps on the front porch” might discriminate people diagnosed as OCD as compared to undiagnosed people
o this example is intentionally flippant but is an accurate reflection of the process
o also keep in mind that these “empirical criterion keying” personality tests – most especially famous MMPI – are constructed around the DSM so clearly their validity cannot be better than the validity of the DSM