Behavioural Science Blog

The Science of Human Behaviour

Posts Tagged ‘therapists

The Downside of the Glorious RCTs

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RCTs are great and every empirical scientist loves them. Everyone? No there is a small village in the south of France…Well to be honest I believe that RCT’s are just a hype. Of course they were great in reducing a lot of statistical problems and have helped psychology to become a “respected science” and earn a place in between mother philosophy and father medicine. In the retrospective the big advances in psychology have all been made by individuals that used single case designs (Freud, Piaget, Skinner…). Why is that the cause?

As much as RCTs can tell us about the statistical differences between groups they are not very good at telling us what the processes at hand are. RCT are also often conducted in special settings and with high treatment fidelity and lots of resources, something the “real world” often does not have to offer. All of this makes it complicated to derive any practical treatment value from them. If there is some practical value to it, one will have to search for it by reading the whole article and giving a few hours of thought to it.

Scientists write for scientists (or rather they write to please their peer-reviewers). This is a mindset quite far from the therapist that lives in a world in which all the factors that are excluded from RCT (for obvious reasons), like: economical and technical problems, comorbidity, lack of resources, converge and interact with each other.

The mindset of the therapist often does not entail thoughts of simple causality of X influencing Y, but of a multidimensional system in which all factors interact with each other. Thus the information value derived from RCTs might seem huge for the scientists, but low for the therapist that needs support in his treatment decisions.

Written by Martin Metzmacher

December 5, 2008 at 2:00 pm

Advantages and Risks of Internet-Based Psychotherapy

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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.

Written by Martin Metzmacher

November 26, 2008 at 3:10 pm

The Motivation for Designing a Computer-assisted Procedure for Training Therapists

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While research has found differences between novice and expert therapists those differences do not seem to be significant for treatment outcome. A crucial factor in this finding is that certain processes keep the psychotherapist from learning effectively. One of those processes is the lack of good feedback (on the macro and the micro level). If there is any feedback, it is probably biased (those who get better do not return for more therapy) and incomplete (patients are not routinely followed over a longer period of time). Due to client privacy it is also not possible for a supervisor to be part of a therapy session and intervene at critical moments. A virtual, interactive environment would not pose such limitations. Psychotherapists could train on quite realistic avatars how to intervene in a critical situation (for example suicide) without putting anyone at real risk. The “role-playing” skills of a digital avatar will be much better than a fellow colleague within a few years and the program can be stopped anytime to discuss the process and repeat parts of the intervention. A virtual training would also make sense economically. After the programming, the costs depend only on the running costs of the hardware and the supervisors. Speaking of which, master psychotherapists that now supervise the trainings would gain a lot of free time to do other important things. If the medium of the digital training is video / text-based (and thus does not require VR equipment) the internet would pose an ideal way to reach thousands of interested graduate students.

Written by Martin Metzmacher

November 10, 2008 at 8:40 pm