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The implicit Contract by Therapist and Patient in Psychotherapy

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Idea for an experiment:

I proposed to prime therapists with the case of a patient that could easily be identified as one disorder (for example depression or dementia) and then present another case in which the information is ambiguous and thus allowing the possibility for both disorders to be present. Having read the articles by Chadwick, Williams and Mackenzie (2003) I wonder if disorder specific information is the “big thing” about case formulation. Rather it could be seen as a contract between the therapist and the client in which the therapist can prove his knowledge and skill to the client by structuring the clients’ life history, behaviour and cognitions in a meaningful way. A case formulation is like the therapist saying: “I know what is wrong with you, I have decided to help you and that is how were are going to do it!”. For the patient this might raise hope and contribute to remoralization. For the therapist the case formulation might be an important step-by-step guideline on what to concentrate on in therapy and how to do it. I stick with my experiment, but I would like to include another sub experiment. The case formulations by the novice and the expert are shown to the patient and he or she rates them in on their affective impact. As a control condition the patient could receive either personal case formulations that structure behaviour, life story and cognition in parsimonious ways, but do not reference to specific disorders. As an alternative, standard case formulations could be used.

Written by Martin Metzmacher

October 20, 2008 at 5:19 pm

More on the Topic of Experience in Psychotherapy

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In one of the last posts I summarized three articles that all came to the conclusion that there was no big difference between novice and expert therapists. I came to the conclusion that the tasks used were presenting ready-to-judge material, which was in no way ecological valid. I hypothesised that the true merit of expertise would rather lay in the skill of information gathering and a vast network of knowledge including contra-indications and possible developmental pathways that need to be taken into account. The article by Kuyken, Fothergill, Musa and Chadwick (2005) The reliability and quality of cognitive case information further elaborates on the process that take place in therapy and focuses mainly on the stage of information gathering. The authors had participants of different experience levels make case formulations using the J. Beck Case Conceptualization Diagram (CCD). 115 mental health practitioners were given extensive information about a hypothetical case (Anna), which included an account of the presenting problem, a psychosocial history, observation of the client during the assessment, standardized psychological assessments and a multi-axial diagnosis. Quality of the case formulation was rated with the Cognitive Case Formulation Scale and was defined as a ‘parsimonious, coherent and meaningful account of a client’s presenting problems in cognitive therapy terms. Interrater reliability for the judges who rated the CCD was good, although the rating of dysfunctional assumptions (in subcategories) only reached a kappa of 0,63. The case formulations of the participants were rated against a benchmark formulation provided by J. Beck and ranged from very poor to good. Only 44,2% of the formulations were found to be at least “good enough”. Such benchmarking by an allegedly expert must be interpreted with caution, because the agreement with the systematic approach of the CCD is measured and not validity of the case formulation. Chi-square analysis revealed that the quality of the formulations did differ between the three groups (novice, experienced and expert). Participants who had a professional qualification or a BABCP accreditation provided case formulations of a better quality than the other participants. So for the time being I keep on believing that the true expertise is found in the systematic and comprehensive information gathering and not in the interpretation of (hypothetical) data. I would like to see an experiment in which novices and experts talk to a (real) client and gather information. The information that is produced by that session could then be presented to other novices and experts. Those would have to make several predictions about the patient that could be verified in a longitudinal study. I hypothesis that variance on the second task will mainly be explained by the expertise level of the first therapist with almost no interaction with the expertise level of the second therapist.

Written by Martin Metzmacher

October 12, 2008 at 11:15 am

Self-Enhancement: A Universal Process with Culture-Specific Content?

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The individual is the smallest entity, that can arise from any group-division. The word individual actually means “that which is un/(in)-dividable”. Thus the meaning of the individual is closely connected to the group, because the individual only gets meaning in the context of the group. In the same way that the individual gains meaning from the group, the self gains meaning from the culture. As the experiences of our daily life shape your thought and realities, it makes sense to assume that the mental representation of our-selves are shaped by those experiences. Because the self is related to the group, the “independent self” is also an expression of a social mode of interaction. Although the content of the term seems non-social, the implicit context of the term is social.

For a long time the constructs of social psychology have been assumed to be universal. Especially the highly appreciated concept of self-esteem was seen as a basic cognitive process that extends to all humanity. However in the recent past this view has changed. In the same way that Newton’s mechanic does not make sense in a quantum universe, some constructs of (European) social psychology make no sense in an intercultural, globalized world. And so we find ourselves in the middle of a fierce empirical battle between two opposing views: Universalism and Panculturalism. The one side, Universalism claims that self-enhancement is a basic cognitive process that is shared by all humans. The Panculturalists claim that self-enhancement is a cultural process that is functional in some contexts (cultures), but not in others. This one example can be seen as a battle within a much greater war, namely: Does the structure of the mind, as we know it today, also apply to different (non-European) cultures or do we need an own way of psychology for every kind of culture there is? Those that still cling to the Cartesian system of science will be afraid psychology will lose it’s status as “real science” when it cannot provide universal laws. How 20th century is that…

The concept of self has gone through a transformation phase in the last years. Whereas before it was defined as an independent entity that stresses the role of the subject, later definitions of the self also allow a definition in more interdependent terms, which better represent the way people in the eastern world experience being an individual. However the role of the self is still not defined conclusively. Recent studies have shown that independent / interdependent are not the two extremes of one dimension, but that individuals incorporate both constructs within themselves. The meaning of the term enhancement is even more unclear: Usually if you want to enhance something you want to make something better. However as the object of the enhancement, “the self”, is not clearly defined, the process also remains somewhat undefined. I believe the main point where the two views differ from each other depends on the definition of the self. Whereas the Universalists resolve the unclearness by moving to a more abstract level, saying that the self defined by the culture can be enhanced in ways specific and natural to that culture, the Panculturalists implicitly still hold on to the independent, western view of the self. For them enhancement = good = more self-esteem.

If you take the meta-perspective on the discussion at hand, one could wonder if there can ever be an answer to the problem at hand, because both groups argue on a different level of abstraction. Whereas Panculturalists seem to discuss the content of self enhancement, the Universalists discuss the more basic aspects of the process itself. I believe that both views are right in some regard. There definitely is a universal human wish to be a good and appropriate person and there are cognitive processes to make sure that we behave accordingly. However what is considered good and appropriate differs between cultures, thus the deducted goals and ultimately the behaviour might be very different. When we look at self-enhancement on an abstract level, we see its the universal components. If we look at the content of the process, we see the cultural boundaries of the process. In order to really see the big picture and the underlying processes we will need multicultural psychologist. They will be able to distinguish between universal process and culture-specific content much better than most researchers today, because they will live in a multicultural environment and their sense of self will be different from that of a person who grew up with one dominant perspective.

Through the evolution of human societies from early hunter groups to cyber-communities there has been one constant: The need for social acceptance and support. Notwithstanding the differences between the two positions, Panculturalists and Universalists have highlighted the diversity in which humans choose to live together and the diversity of self-concepts and related processes that are used to adhere to the standards of the group. Being able to perceive oneself as an object of social interaction and reflect on that interaction is a key prerequisite for the development of elaborated and fine tuned rules that guide our social interactions: culture. It remains to be seen how new cultures and new ways of social interaction brought about by digital communication technology and globalization will influence the self-concept of generations to come. Maybe the discussion about the nature of the self and the related cognitive processes can never end as long as human culture and interaction styles evolve, because our self-concepts will also keep on evolving.

Written by Martin Metzmacher

October 7, 2008 at 4:02 pm