Controversial Issues

I became extrememly frustrated yesterday as I was reading the Garb (1999) article. Essentially, the Rorschach sucks and any study claiming that it is an effective, valid assessment contains some sort of fatal flaw. The reason that I was so annoyed by these conclusions is because we have to learn how to administer and score the stupid thing next semester. As Garb (1999) points out it takes 2-3 hours to complete so one would hope (even expect) it to be useful. So if the available evidence says its not, then why are we still using it? Why is our department forcing us to learn an assessment that, according to Garb (1999), leads to a DECREASE in validity of judgements? With that said, however, after reading the Dawes et al. (1989) my guard was up everytime I read the words "clinical judgment". Garb (1999) says that "positive results have never been obtained for the Rorschach in studies on clnical judgement and incremental validity" and that "when judgments have been made by using statistical prediction rules, there is some evidence supporting the incremental validity" of certain Rorschach scales (pg. 315). So I wonder if more studies were conducted testing the usefulness of Rorschach scales based on statistics, would we find better results? I really hope so!

The Dawes et al. (1989) got me thinking about my experience last week administering an IQ test to an inpatient at Western State Hospital. Without getting into too many specifics since these blogs are open to the public, I was able to review the client's records before testing him and I must say I am definitely guilty of some of the extrememly dangerous biases related to clinical judgments. The chart indicated that the client had "flat affect", slurred speech, low intellectual functioning, among a host of other problems. We are instructed to record behavioral observations while administering the test that are supposed to be extrememly useful in making diagnoses after testing. Guess what most of my observations related to?--The information that I was previously given from his record. I pertained to information that confirmed by beliefs (such as making a notes in line with a low functioning individual) and didn't really take into account any disconfirming evidence that could question his diagnoses. I didn't even realize that iw as doing this either. I've pretty much questioned behavioral obserations since the beginning of the semester because they seem so subjective to me. I'd be interested to see how similar two observers behavioral ratings are for the same person. If theya re supposed to be so important in making inferences after performing assessments, shouldn't they be highly standardized and reliable just as the tests are? I liked Garb's (1999) comment that the ability of humans to observe does not necessarily mean we have the ability to accurately predict.

Personality Disorders

I've always found the personality disorders to be interesting, but we seem to know the least (or at least disagree the most) about thier etiology and classification. I worked as a research assistant in a Personality lab when I was an undergrad at Penn State--the lab, at the time, was attemping to find empirical support for the vulernable narcissism subtype (as opposed to the grandiose subtype which is currently the only one in the DSM, which I thought was really cool. Anyway, I'd like to comment on an aspect of the Moffitt (1993) article that I found particularly problematic. The author suggests that adolescence-limited delinquency is normative and adaptive, evidenced by its prevalence and flexibility. However, the author seems to be taking sort of a laid back attitude about adolescent delinquency. Just because its the norm doesn't mean its okay and it doesn't mean that its not problematic. Moffitt (1993) even does so far as to say that people who refrain from delinquency in adolescence are the ones that "warrant our scientific scrutiny" (pg. 689). She also outlines reasons for why some people fail to commit antisocial acts, which seems counterintuitive to me. Why should we be concentrating on explaining the processes underlying FAILURE to take part in delinquent behavior? Is there evidence that relates an abscence of delinquency in adolescence with negative outcomes? Moffitt (1993) cites a study by Shedler and Blcok (1990) that attempts to show that abstainers are linked with an "enduring personality configuration", marked by social isolation, poor interpersonal skills, etc. but I don't think the evidence is strong enough to assume that adolescence who do not engage in delinquent acts are worse off. Moffit (1993) makes an argument for why people who show no history of delinquent behavior become delinquent in adolescence namely through social mimicry and being trapped in the maturity gap. One thing I wondered though: Is such a small number of life course persistent teens really able to influence such a large number of people so strongly that people with no prior delinquency will mimic their behavior? The author states that the prevalence rate of persisters is 5% or roughly equivalent to one or two per classroom. This makes me think that there has to be substantially more teens who display prosocial behavior, so why aren't they being mimicked? The author suggests that the desirable resource that these adolescents are attempting to attain by mimicking antisocial youths is mature status. But I think that positive, prosocial behavior could bring about just as much power and prestige as delinquent acts. So why aren't more of them being mimicked? Of course, there are inevitably going to be teens who fall victim to (negative)social mimicry. However, this doesn't seem like to most compelling explanation to explain the substantial increase in delinquency in adolescence...I'd like to say I have an alternative but I don't...just intuitively, I think there are some flaws in Moffitt's reasoning.

ANXIETY!!!

For me, it was so absolutely appropriate that this week's readings were about anxiety because I am feeling the heat of first year this week! This actually got my thinking about "normal" or sort of everyday anxiety. The Mineka & Zinbarg (2206) did a good job highlighting individual differences in the development of pathological anxiety- for instance, why some poeple develop phobias after minor traumatic events whereas some never develop phobias after major trauma. What about people who are anxious about speaking in public, for example? Why do some poeple develop more anxiety about speaking in front of others? It's hard for me to imagine that this type of anxiety develops as a result of traumatic conditioning. I realize that this type of anxiety is not necessarily pathological, but when considering the characterististics of social phobia, namely "excessive fears of situations in which they might be evaluated or judged by others, and they either avoid such situations or endure them with marked distress" (Mineka & Zinbarg, 2006, pg. 14), public-speaking anxiety could very well fit into this conceptualization. This points to yet another short coming of the DSM. Just because certain symptoms aren't considered pathological by DSM standards doesn't mean they are not effecting a person't ability to function daily and its a shame that they can't technically be treated (or at least treatment for these "everyday" types of symptoms is difficult to get reimbursed through insurance). What happens to a person whose job demands that they take part in weekly presentations? As psychologists, are we just supposed to say oh wait, sorry, public-speaking anxiety is not a disorder in the DSM so you can't be treated for it?

It was really interesting to find out that there are implications in the development of anxiety related to whether a person learns to have a sense of control over their enviroment, and it was a common area of discussion in both articles this week. Particularly, Mineka & Zinbarg (2006) state that "infants and children raised in environments in which they gain a sense of control over their environment are less frightened by and better able to cope with novel and frightening events" (pg. 13). This relates almost directly to a major area of research in our lab- specifically, the importance of an adolescent to develop a sense of autonomy from their parents, meaning that they exhibit some independence from their parents. Adolescents who are successfully able to balance autonomy and relatedness with parents (which are two key developmental tasks) show more positive psychosocial outsomes, as well as a greater ability to engage in healthy freindships later on (which may be viewed as novel situations). Essentially, when parents allow the appropriate amount of freedom to their adolescents, the better adjusted the adolescent becomes and the better equipped they are to engage in other relationships in the future. It was exciting to see this idea play a role in anxiety as well.

Interpersonal Contexts and Depression

I experienced conflicting opinions about the Coyne article this week. On one hand, I was really excited to read something about the involvement and importance of the interpersonal environment in depression...this is generally what I want to research. In my opinion, close relationships are inextricably linked to one's ability to function, cope, regulate emotions, and to successfully handle life complications. Coyne made some interesting assertions about this idea. Specifically, I was intrigued by his emphasis on significant others involved in the lives of depressed people. I think alot of us tend to attribute the dysfunction in depressed people's relationships to the depressed individual themselves (i.e intrapsychic causes) and do not consider what the other people in their lives bring to the equation. We assume that there is something inherently wrong with the depressed person like having distorted cognitions that contribute to interpersonal problems, but we often fall short of really considering the role of the depressed person's environment, and Coyne did a nice job emphasizing the reciprocal nature of people and the enviroment. Back to the significant others piece though...the article really got me thinking about the impact that these people have on a depressed person's ability to recover vs. remain in a depressive episode. The recurrence factor in depression is important here. Because depression is a recurrent disorder, a spouse for instance could learn to be understanding, sympathetic and sensitive to their depressed partner which would likely contribute to recovery. On the other hand, I can see many spouses becoming fed up, impatient and irritated, especially after dealing with several recurrences which could exacerbate the depression. It's almost like a never ending cycle in this case--someone becomes depressed which decreases the quality of their relationships and social interactions which only makes them more depressed.

Towards the end of the article, however, I was a alittle disappointed and confused. Actually, the summary pretty much sums this up. I found it kind of annoying that Coyne admitted to publishing an inadequate interactional model of depression in his 1976 article, but then basically used this model as the basis of his arguments. Additionally, the overall tone of the article stressed depression research to move beyond theoretical interpretations and assumptions, yet he supported an intervention-namely strategic therapy- that has not been empirically validated. Coyne states on pag 385: "Much of the strategic therapy literature consists of provocative case examples and transcripts; there are limited outcome data availalbe for the approach." In my opinion, if one is going to necessitate empirical support for the explanation of a disorder, he/she should be consistent and endorse treatments that have empirical support as well.

RP and SC

I enjoyed the readings this week because substance abuse and sleep problems are two interesting topics that I don't know much about and because I think they are going to be really relevant to our clinical work. I can imagine that a large percentage of people experiencing emotional distress, for instance, use drugs and alcohol as a coping mechanism AND have difficulty sleeping. However, I would venture to guess that are rarely the topics that are talked about in therapy, especially in the beginning. If someone comes to therapy because he/she is extrememly depressed, experiencing suicidal thoughts, and is drinking every night to deal with these horrible thoughts, the therapist probably won't target the person's drinking right away (maybe because drinking is the only thing keeping the person alive at the moment). However, I think there comes a point in therapy when they need to be addressed. In addition, I think it is important to evaluate a client's everyday habits and routines (i.e, how much sleep they get, how much caffeine/alcohol they drink, how much stress they are under at work) because these things could really be driving thier problem and probably get overlooked alot of the time.

I appreciated the acknowledgement by Witkiewitz & Marlett (2004) about the complexity of relapse and thought they did a great job reconceptualizing relapse as a dynamic process. I know that their model does not presume that one factor has more influence than another, but the whole time I was reading the article, I kept thinking about personal experiences and conversations that I've had with past substance abusers. A few of my uncles and cousins were involved with drugs and/or alcohol addictions and they've unanimously said that they attribute their ability to overcome the addiction to the support of family and friends. Granted, it is most likely not the sole factor in their recovery and it was probably most helpful AFTER they worked on other things like self regulation, fighting cravings, avoiding risky situations, etc. but I think interpersonal determinants (as the article calls them!) are more important than the article gives them credit for.

One final comment: I was laughing to myself when I read the SC article because I read it in my bed right before I went to sleep the other night... and I kept thinking that I should get up and read it in another room or else my bed would become a cue for arousal and not sleep! Then I rememebered that I've been reading in my bed for years and it hasn't been a problem since. But if I ever develop sleeping problems, I'll know why! Anyway, SC seems very practical, but as the article mentions, one main problem is compliance. I know I would have a tough time getting out of bed every night, especially in the winter time. The article gave some suggestions (such as setting up slippers and a robe next to your bed), but I'd be interested to know the percentage of clients who say they follow the instructions but actally don't, as well as strategies that a therapist could use to increase compliance.

The Importance of Context...

I really enjoyed the Jacobson et al. (2001) article on Behavioral Activation, especially the section on "demedicalizing depression" (pg. 257). I completely agree with the general theme of BA that one has to take into account the environment and the context within which a disorder, especially depression, arises. Jacobsen et al (2001) presented some really powerful examples that make it hard for someone to deny the importance of individual life events as risk factors for depression. Models that focus exclusively on genes are flawed, as Jocobson et al (2001) point out. For example, a genetic predisposition to depression cannot comprehensively explain why so many people experience depression after traumtic events, such as the loss of a parent or spouse. Furthermore, I appreciate the idiographic approach that BA takes on and the emphasis on not making "a priori assumptions that an event is reinforcing until we have seen that it increases behavior or has a positive effect on mood" (pg. 257). This makes so much sense to me because what may be a positively reinforcing activity for one person may not be for another person (i.e, "focused activation"). I imagine that clients in BA therapy probably feel that the therapist takes a genuine interest in their specific problem and really tries to understand how they, as an individual, can improve. I also like that BA focuses on specific, goal-directed behaviors and does not assume that mood needs to change before behavior can. BA seems to be a very proactive, practical approach to positive change, and I really like that! However, I did find myself questioning the effectivess of the "attention to experience" part of BA. Jacobson et al (2001) readily points out the tendency for depressed people to ruminate, which is a type of negative thinking. However, because BA is strictly a behavioral model, the content of these negative thoughts is never addressed, only the context or the function of the thought. The BA therapist, therefore, trains clients to pay more attention to their environment as an exposure exercise inorder to attempt to decrease their rumination and increase their activation strategies. I don't know if there is efficacy literature on this particular BA component but in my opinion, it seems like targeting the negative thought itself might be more productive. This was one area of BA that I found to be pretty abstract as compared to other components of the model. Overall though, I really like the basis of Behavioral Activation and I'm interested to know the outcome of Jacobson et al's clinical trial that compares BA to CT!!

CBT

I thought the readings this week were a great overview of both CBT and RET (or I guess REBT, according to Ellis). I did, however, have some concerns about the Butler et al. (2006) article. The general theme seemed to be that CBT (or in some cases CT) was found to be superior than wait list, placebo or no treatment controls for most of the disorders that were discussed in the article. I'm still left wondering how well CBT does compared to other alternative treatments, such as IPT or psychodynamic therapy. Some people may be better off when they get treated with CBT than if they had not received treatment at all, but is it really the BEST, most effective treatment when compared to other therapies? I think there needs to be more research/evidence on this issue. We are doing a disservice (is that a word?) to clients if we are not confident that the treatment we are using is the best treatment out there for them. In addition, while CBT appears to work well for a subset of disorders like phobias, OCD, and PTSD, the article lacked a discussion of its effectiveness for other disorders, particularly personality disorders. The disorders within the internalizing realm (depression, anxiety, etc.) do make up a large portion of the types of clients in therapy, but by failing to address disorders or symptoms outside of that subset, we should not make the generalization that CBT is the best form of psychotherapy.

I also would like to comment on the issue of follow-up research. In general, I think there needs to be more of it and I think there needs to be a more systematic way to measure it. For instance, there was absolutely no follow up findings for CBT on chronic pain, bulimia, and PTSD in Butler et al.'s (2006) article. In my opinion, knowing the long term effects of a treatment for specific disorders are essential. For instance, if one treatment shows immediate effects but does not persist over time, then it might make sense to treat the client with an inital treatment and then provide "maintenance therapy" using another type of therapy that shows greater long term benefits (this may be unrealistic given all the insurance issues, but in an ideal world it makes sense!) In addition, when follow up studies are completed, I think it is necessary for researchers and clinicians to be extrememly clear about what exactly they are measuring, the outcome measures used, the length of time between end of treatment and folllow up evaluation, etc. When a treatment is shown to produce "clinically significant change", for instance, what does that mean? A slight reduction in symptoms or problematic behavior after 6 months of therapy might be life changing for a schizophrenic or an anti-social person, but may have much less impact on someone who is midly depressed. In such a case, are both treatments equally effective in producing "positive change" at follow up?

The Therapeutic Relationship

When I finished the readings for this week, I was actually kind of disappointed. There wasn't much that I got really excited or fired up about. I thought the articles were a little boring and I was worried that I would have nothing to say in my blog! One thing that really bothered me in the Kirschenbaum & Jourdan (2005) artcile was that the authors partly based their evaluation of the status of Rogers' theories on a PsycInfo search! I thought the arguments using empirical research as a basis were pretty weak in both articles. Maybe I'm just primed to expect some serious empirical evidence as a result of the past two weeks, but I just didn't find either of the articles' theory and research support to be very compelling. I also felt like Castonguay et al. (2006) made alot of sweeping generalizations. It was a nice review paper, but I'm not too convinced that just because measures of the alliance exist, that all therapists should be using them, for instance (pg. 273). Or that there really is enough evidence to warrant the "forecasting" of patients that clinicians may have difficulty working with (pg. 272). This suggestion brings me back to Meehl's credentialed knowledge arguments.

However, the more I thought about it, the more I realized that even though the therapeutic alliance may not be an incredibly exciting topic and that it may not be firmly grounded in scientific research, I think there were some important points to consider, especially for us clinical folk who will most likely be putting these techniques to use next year! I mention "techniques" because this is what I would argue the alliance should be viewed as (which I'm sure people already have, I'm just not aware of the research in this area). Rather than a "school of thought" or a particular orientation, the alliance seems most valuable for teaching therapists about appropriate strategies that COULD foster a better, more positive working relationship during therapy, which in turn MAY contribute to client improvement. For instance, an "affective bond or positive attachment" (pg. 272) most likely will not hurt the chances of positive change, but the extent of its necessity is still debatable. Don't misunderstand me...I actually personally feel like the client-therapist relationship is extremely important and should not be taken lightly, I guess I would just be hesitant to place too much emphasis on it if it means that other important therapeutic techniques are ignored (expecially for those manualized treatments!)

EST's: Part Deux

Just when I thought the logic of EST's made total and complete sense...I guess being able to critically think about varying positions is what grad school is all about, but man, its making my head spin. I'm discovering that I can be swayed pretty easily by "the written word" which is probably a good and bad thing, depending on the situation! Anyway, I wanted to broadly touch on a few issues from the readings this week, mainly from the Weston et al.(2004) article, the first issue being about the "appropriate" sequence to test a treatment. From the Chambless and Holon (1998) article last week, we learned that the standard is to first prove that a treatment is efficacious in the lab and only after this has been accomplished can the treatment be brought out into the community (to be proven effective). However, as Weston et al. (2004) point out, starting with such "pure" samples in highly controlled environments may seriously limit the generalizability of a treatment. Along these lines, RCTs typically have pretty stringent inclusion criteria and may exclude people with more complex, co-occurring symtoms, particularly those that show some personality disturbances. I do not think it is reasonable for one to assume that because a treatment has been shown to be efficacious for highly specific sample with highly specific symptoms/conditions in a lab that it will necessarily fare just as well with all the variablity and comorbitity (which the article states is the norm rather than the exception) that appears in clinical settings and communities. Having said that, I think I need to re-evaluate what I said in my blog last week about the necessity of treatment specificity! I do think it is important to identify exactly how a particular treatment works for some specific disorders, but I'm starting to believe that there are conditions that will benefit more from integrative strategies that are able to address/treat several different aspects of a person's condition. I like the suggestion at the end of the Weston et al. (2004) article about "using practice as a natural laboratory" (pg. 657).

This idea takes me to my next thought about the integration of theory and practice, which is the basis of the Sehcrest & Smith (1994) article. My various mentors over the past few years have all reiterated to me the importance of guiding clinical practice on sound research. While I completely argree, the readings this week underscored the importance of a more "transactional philosophy of clinical science" (Weston et al., 2004) where both science and practice can inform eachother. Just as clinicians need to be aware of and up-to-date on current research, I think its fair set the same standards for researchers. In the words of Sechrest & Smith (1994), "...psychotherapy should become an integral part of all psychology" (pg. 4).

EST's

With so much variability in symptoms and behaviors within particular psychological disorders, it makes sense that researchers and clinicians are identifying more specific treatments that target specific behaviors. However, standards for evaluating the effectiveness of these treatments are necessary and the Chambless & Hollon (1998) article attempts to provide structure for us in doing so. The authors acknowledge the complexity and magnitude of this task and point out that many disagreements will likely arise. Therefore, I'd like to point out a few of my concerns with their guidelines. First, the authors deviate from guidelines set forth by the Division 12 Task Force and state that "...if a treatment works, for whatever reason, and if this effect can be replicated by multiple independent groups, then the treatment is likely to be of value clinically..."(pg. 8). I do not think its enough to know simply that a treatment works. In fact, merely proving that a treatment is more beneficial than no treatment at all seems to be assuming psychotherapy equivalence, which is a questionable theory discussed in the Hunsley & DiGiulio (2002) article. Researchers should be able to identify a treatments' specific nature and the mechanisms underlying the particular treatment's success in improvement. Because there could be so many external factors for a client's improvment other than the treatment itself, evidence of treatment specificity seems essential to me.

Another concern I had involves the specification of a treatment population. While I agree with the authors that it is necessary to show that a treatment is efficacious for a particular group of poeple, I had some issues with their emphasis on the diagnostic criteria in the DSM as the means for defining a population. As we talked about last week, people with the same diagnoses could manifest very different symptoms (or at least the degree of the manifestation of certain symptoms could be different) and thus respond very differently (or not at all) to the same treatment. For instance, people with social skills problems could be exhibiting social problems because of an actual social skill deficit and would respond well to social skills training, wheras others may be experiencing soical problems due to social anxiety and would respond well to both systematic desensitization or social skills training (Trower, 1978)--this was actually an example put forth in an article for our assessment class called "The Treatment Utility of Assessment" (Hayes, Nelson, & Jarrett, 1987) which fits pretty nicely into this week's topic. In any case, while Chambless & Hollon (1998) do acknowledge other factors that should also be considered such as comorbidity and the age range of a population, I'd like to see more emphasis placed on defining treatment samples based on symptom homogeneity, not just diagnoses.

Comment on the DSM readings

Because I found the Widiger & Clark (2000) article to be the most interesting and controversial of the three readings, I will mostly comment on a few points raised by the authors. The article detailed several areas that need improvement or change in DSM-V, and while it may not have been authors' intent to comment on exactly how these changes should be accomplished, it left many questions unanswered for me. For instance, in the discussion about determining what is meant by a clinically significant impairment, the diagnosis of mental retardation is used to illistrate the possibility of using points of demarcation along continuous distributions of functioning. However, as the article points out, a question then arises about how to come to a consensus about exactly where the point of demarcation should be for specific disorders. In regards to an IQ of below 70 being necessary to diagnose MR, the whole idea of IQ itself is relatively controversial- what does IQ really measure, predict, and mean? (Neisser, 1996).
In somewhat relation to this, I found the discussion about including laboratory findings in diagnostic criterion sets interesting, but also puzzling. It certainly does not make much sense to include autonomic functioning in the diagnostic criteria for some disorders, yet require no physiological tests be done to prove that they exist. For instance, the article mentions panic attacks as an example-if a client tells a clinician that he/she feels nauseous, sweats, gets dizzy, etc. when nervous, is the clinician supposed to take their word for it? In addition, the article points out there is no reference in DSM-IV about standardized assessment instruments, such as brain imaging techniques, to use in making diagnoses, which seem necessary to me if the DSM is going to reference neurophysiological factors involved in certian mental disorders, such as references to neurotransmitters in depression. However, the article also brings up valid points about the availablity and costs of using laboratory data. Theoretically as a scientist, it makes sense to me to incorporate lab tests and findings into the dignostic criteria, but I'm not sure how practical or realistic it is to require for all diagnoses. This is a problem that I think needs to be addressed- just because it may not be practical and may be hard to implement doesn't mean its not necessary.