Posts Tagged ‘Psychotherapy’
The ability to choose an evidence-based psychotherapy on the base of scientific knowledge has been a negligible factor in the evolution of the human brain. One could argue that empirical science itself fosters a style of thinking that is counter-intuitive for many of us. Personally I believe that the human way of trying to identify causal relations in a chaotic universe is the main reason of the evolution our kind has taken in the last few thousand years. But our susceptibility to see causal relations can also be a big problem. Thus I believe the main reason why fad therapies can book so much success is that the human mind is not made to think empirically. And if people do think the scientific way there are lots of downfalls, because the empirical science we have today is far from perfect and methodological problems lurk around many corners. It is easy to express (warrant) criticism of the scientific method (which currently is strongly connected to positivism) and shake up people’s reality. This can be a good thing, if you want to get people start thinking themselves, but far more often those who condemn the scientific system propose to let go of all empirical science altogether and adopt a system of their own choice. Funny enough these systems often try to build on the credibility of science, but in the end are not provable.
Whereas in the field of medical health, imbalanced can often be cured by the ingestions of medication, the parallel in the mental health would be ingestion of new thoughts in order to resolve psychic imbalance. While the body can react quickly to changes in the system, the plasticity of the neuronal structure is less flexible. Ingestions of new mental processes need to be repeated many times in order to change the underlying biological substrate. While most people understand that the process of loosing weight requires constant attention to food intake and regular exercise, most people do not understand that mental change is comparably slow. When a “quick and easy” fix is offered, people hope to circumvent the long trajectory of psychotherapy.
To sum it up (and two minor new points):
- The human mind is not made to think in a scientific way.
- Problems with the scientific method often lead people to turn to religion/quick’n’easy solutions/fad therapies.
- Normal therapy usually takes time, money and is painful.
People love to fall for the “it’s easy and painless” trick
- Many conditions do not have a real “cure”. Some can not accept that.
- Authority figures support fads and get rich doing so.
Elements of scientific approach violated in fad therapies
If any given theory is considered scientific (within the current paradigm), this usually means that it is objective, testable and replicable. There are different ways in which fads can be non-scientific. Mostly they are scientific in some ways, but not in all. Here are some of the preferred ways of fads for being non-scientific:
- There is no operational definition, no specifications of the processes and how they are related to important constructs and variables.
- There is no theory at all.
- The cause and effect relationship between the characteristics and consequences of environmental events and experiences has not been researched using sound methodology.
- Causal relationships are presumed without any reason or people are made to believe that there is a causal relationship by presenting correlational evidence.
- Alternative explanations are not pursued.
- Effects are generalized without reason to do so.
- Evidence is subject to biases.
- Unwarranted predictions are made.
Internet-based psychotherapy is a hot topic since a few years. The main advantage is money: Computers are much cheaper to run than licensed psychotherapist. So if a computer could achieve the same or nearly the same treatment outcome as a human expert this would be a huge advantage, as computer systems can be replicated almost infinitely (and once the program is written at almost no costs). We have to keep in mind that for political and economical decision making the effect size is not the only important factor. When considering which project to found something like “effect size“ / costs is more appropriate. In times of long waiting lists and many people without health insurance, cheap treatment means reaching more people. Another advantage is that physical boundaries are not important anymore. If a specialist for a specific therapy is 1000km away it just does not matter anymore. Furthermore the possibilities for comprehensive care, by involving personal with different expertise (social workers, psychologists, physicians) can be achieved by using the internet as a medium.
On the other hand there are some drawbacks. Privacy is a difficult factor as digital information is much more vulnerable than a handwritten dossier. Traffic which uses the internet (and not some special intranet) is always at risk, not to mention the risks on the computer of the client and therapist itself (viruses, Trojan horses, etc…). Face to face contact also offers additional information about the client (non-verbal communication, punctuality, interaction with other patients/staff members) that are lost in a digital environment. Therapeutic alliance is also more difficult to achieve in purely internet-based psychotherapies. I believe that ultimately internet-based therapy will play huge role in mental health care, especially in the concept of stepped-care. There are many ways to use computers and the internet to improve on the (very expensive) system we have today, but face to face therapy will always be an important part of every sever disorder, as (disturbed) human interaction often lays at the core of the problems. That said, we should try to develop digital forms of psychotherapy because not only will that give access to important help to much more people, but we will also be able to learn about the therapeutic process from that experience. In turn that will also increase efficiency of traditional psychotherapy and supply us with new hypothesis and theories.
http://www.vrphobia.com (which turned up as #1 in Google) is an organization that is called Virtual Reality Medical Center. They treat all kinds of anxiety related disorders, but seem to focus mainly on specific phobias. After the intake session the client is taught skills to suppress automatic fear reactions. In the following sessions the client is gradually exposed to the feared stimulus. In other words: VR desensitisation.
Obesity and addiction have some common properties. This research seeks to integrate some findings of addiction research into eating disorder therapy. In that light they make use of VR for distinct goals: Help the client to experience the own body in situations that are normally avoided. This experience is supposed to have influence on body perception and also empower the client. In the VR patients came “face to screen” with their personal risk situations (supermarket, gym, etc…) and could train emotion regulation and problem-solving skills in a save environment. The randomized clinical trial seems to indicate that the ECT group did indeed better than standard CBT.
As http://www.cybertherapy.info/cybertherapy/8_Optale.pdf shows also psycho-dynamic therapists start to see the merits in using new technology. Erection dysfunction and premature ejaculation are treated in a virtual environment (the porn industry will love that application) together with standard psychotherapy. The possibility to enact the new strategies in a save and private environment is supposed to speed up the therapeutic process. First clinical trials seem to indicate that this might indeed work for some clients, also it is not clear for whom exactly. Sample size is not adequate in study 1, power is much stronger in study 2. Results are not telling a clear story (yet?).
By the way:
http://www.cybertherapy.info/ is the most comprehensive and excellent source for material about VR in psychotherapy that I could find on the net. Especially have a look at the free books, like http://www.cybertherapy.info/pages/book2.htm or http://www.cybertherapy.info/pages/book3.htm. The articles are downloadable as PDF (just scroll down). Especially look at book 3 session 2 that comprises some clinical controlled trials with cybertherapy (which seems to be the keyword I was desperately looking for).
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.
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.
The probabilistic nature of behavioural phenotypes proclaims that people with a specific syndrome will have a heightened probability to exhibit specific behavior or developmental pathways that are different to others, who do not have the specific syndrome. The advantage of probabilistic nature of the construct is that it can account for exceptions and it is probably more ecological valid that a simple causal explanation. (Short excursion: I believe that statistical models that only test direct effects will be outdated in a few years, as we come to appreciate the complexity of behavioral science. Developmental psychopathology is leading the way with extensive use of structural equation modelling and a flexible theoretical framework that works with risk and protective factors. Such models have to potential to raise explanatory value beyond the simple causal models that are employed in most research today.) The behavioural phenotypes are less important for individual therapy where extensive diagnose should be performed, but they have stronger implications for intervention. If risk factors can be identified that apply for a certain population, specifically tailored interventions might be given to the whole group instead of individual therapy later on. That way specific skills and behaviors might help mentally retarded children to cross into a developmental stage, that could not have been reached without the intervention. The crucial thing is that intervention might be necessary at an early age, when children are most sensitive to the intervention, even thou the problematic behaviour might arise only in a later developmental stage.