Posts Tagged ‘therapists’
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.
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.
The study of Hillerbrand and Claiborn is a 2 (level of expertise)x3 (levels of problem structure) design. 17 expert and 15 novice psychologists with good diagnostic abilities read well structured, ill structured or random structured cases. Consistency of the relevance of the information supplied varied between the cases. Relevance was the extend to which information necessary for a particular diagnosis was identified in the case. As dependent measure the accuracy of the diagnose was used, as well as the number of diagnoses, the rationale for the diagnosis and the predictions for future behaviour.
Significant differences between clinicians and novices were on ratings of their knowledge, confidence and perception of the cases’ clarity. The cognitive process however did not seem to differ. Clinical reasoning skills have been found to be present in lay-persons. It might therefore be hard to distinguish an expert from a layperson, as experience is not a sufficient condition for expertise. On the other hand you can wonder is a second or third year student is a lay-person. Certainly the training received so far will have had some impact on the cognitive processes at hand (hopefully).
The task itself is also important to consider: Whereas clinical therapists mostly have a face to face conversation with the client, in experimental studies (such as this one) the interaction is often substituted by a text about a clinical case. This way of data perception might be more appropriate for a undergraduate student, who is used to reading cases, but less used to direct therapeutic contact.
In the study of Brammer participants came from a doctoral program (n=83) or were graduate students of psychology. With the use of a computer program the structure of information exchange between the therapist and the client was simulated. After reading the case the participants could ask questions that were answered by an artificial intelligence that used pregenerated answers. As the participants asked more questions, the answers supplied additional information concerning the case. The diagnosis was sent to a panel of experts who voted the fit a the diagnosis on a 4-pooint Lickert from unlikely to definitive. The possible diagnoses were restricted to major depression, Bipolar II disorder, alcohol abuse, acute stress disorder, borderline personality disorder, nicotine dependence.
The number of diagnostic questions asked were related to correct diagnosis, as well as the level of training and the years of experience. Due to the correlational evidence no causal assumption can be made. For example the number of diagnostic question was also related to the total number of questions. Path analysis revealed there was no direct effect of level training or years of experience, instead the effect was mediated by the numbers of diagnostic questions asked.
Although the task is not a real interaction with full non-verbal communication, the interaction simulated between clinician and client was differed from a pure evaluative task. The clinician was also required to perform a skill.
The third study also compared novice and experts, but introduces intermediate level experienced clinicians as a control group. All 10 cases used as material were prerated by a panel of experts. The DSM diagnosis and the discussion was given for every case. Difficulty was enhanced by cutting back the length of the description by two thirds.
The time it took for the participants to reached a conclusion (indicate the diagnostic classification) was measured. The dependent measurement was the number of correct answers each participant gave.
The pattern that emerged form analysis can best be explained by a third-degree polynomial function. Therapists without any experience start of giving about 40% correct answers. As experience increases a decline in the percentage of correct answers is visible (less then 30% in between the second and third year of inexperience). The curve then mounts again and nears asymptotic level at about 40% correct answers.
Both experts and novice took longer to come to a conclusion than psychologists of intermediate level. This pattern also emerged in the previous study where the number of (diagnostic) questions was related to categorization quality.
Other studies who compared sub experts and experts in their cognitive structure of decision making found that there was only a difference, when time was limited. This might be the case on a face to face interaction, when decisions to pursue a specific topic have to be taken during the interaction. It might well be that the sub experts are equally able to judge the criterions of mental illness in a written form but would fail to achieve this knowledge in a real life interaction, because they do not have the conversational skills necessary.
I believe that the most important factor is to have a clear understanding of the scientific knowledge of a specific illness and be able to get all related information necessary from the client. This might be easier with a well-structured problem than with a difficult case including multiple comorbid illnesses, because the possible causal relations are much not too complex.
This hypothesis is also supported by the findings of the study of Brammer, where the quality of the diagnosis was related to the numbers of diagnostic questions asked. The difference between experts and novices can be found in the process of information gathering, rather than evaluation of the acquired data. Training new therapists might indeed by quite straightforward teaching them to ask more questions and shape the questions in a way so that the answer yields diagnostic value.
I imagine standing in china in front of a coke-vending machine. If I am an expert (and if I know Chinese) I know which button to push to get the coke. The way I see it giving cases to lay-persons is like telling exactly which button to push. Taking out the coke is easy and I do not expect Chinese and Europeans to do that differently. So the most important thing, the general background knowledge, that makes you remember to ask about manic episodes when hearing of depression, is not considered in these studies. The crucial questions to study how clinical psychologists make diagnostic classifications, might not be the ones that are asked, but those that are not asked.
In medicine, diseases are classified according to the physiological problem that is presumed to have caused the disease. Classification is guided by advanced biological and chemical theories that have proven to have explanatory value. For mental illnesses that is a different story, because the working mechanism is mostly unknown and there is no unified scientific framework that can explain the abnormal processes. Mental health professionals for different schools might explain any given symptom according to a different theory. In that light the DSM was created to be purely atheoretical and give a minimal framework on which everyone involved could agree upon. The resulting manual has helped communication about mental illnesses and has fostered comparable research in the field of mental health. However it is questionable if the structure of the DSM is compatible with the reality of humans, who (for the most) are driven by the unstoppable urge to make sense of their environment. Indeed it was found in many studies that therapists often classify without adhering to the specific rules laid out by the DSM. They are guided by internal rules, that work in a different way than the DSM checklist. For example therapists regard some symptoms as more important for a specific diagnose than others (concept of centrality). The DSM on the other hand usually assigns equal weights to all factors. Because the concept of centrality has profound influence on memory and other cognitive processes the therapist’s personal theory plays an important role in the classification. I believe that the DSM should be regarded as a tool supporting communication that allows discussion about the different theories at hand. It can and will not replace the theories people have. If a theory based classification system is available (for a specific disease) it should be used next to or instead of the DSM.