Book review: High-quality psychotherapy research by Areán and Kraemer (2013)

by with Comments Off on Book review: High-quality psychotherapy research by Areán and Kraemer (2013)

Randomised controlled trials (RCTs) are great, the gold standard of empirical research. The only thing better than RCTs are systematic reviews of lots and lots of RCTs. (So the story goes.) The reader may have noticed that RCTs evaluating CBT for psychosis have been vigorously debated for many months after a review was published in the British Journal of Psychiatry (Jauhar et al., 2014). Maybe not everyone agrees that RCTs are great (disclosure: I have analysed a couple), but I think it’s fair to say they are unavoidable whether you are trying to design or demolish them.

High-quality psychotherapy research by Patricia Arean and Helena Chmura Kraemer sets out to be a “practical, step-by-step guide” to designing and running RCTs. So why bother with an RCT? Observational trials, the authors explain, might involve studying participants who choose one of two or more interventions of interest by simply observing how they get on. This is problematic as differences in outcomes might be due to whatever factors led to them ending up receiving an intervention rather than the effect it had. RCTs use randomisation to overcome this problem so that people differ only in terms of the intervention received. That’s about it for the “why”: don’t expect debate on the epistemology.

The book’s strengths emerge as it develops: it catalogues issues that should worry study investigators and the authors draw on their own experience to offer hints. The Delphi consensus-building approach is introduced to solve the problem of developing an intervention manual and examples are given of how to word a letter asking for feedback on the proposed result. Randomisation techniques are introduced including horror stories of how they have gone wrong and invalidated RCTs. Ideas are provided for control groups, e.g., waiting list, usual care, and “gold standard” controls, and their strengths and drawbacks. The importance of not using pilot study results to determine sample size choices is explained. Guidance is provided on the people required; for example you need three or more therapists, at least two research assistants in case one takes ill, and a good statistician amongst other people. The Appendix includes a sample budget justification. All practical advice.

The text runs to under 200 pages so this could never be a comprehensive guide to all aspects of RCTs. What this book does do well is provide a systematic menu of options and ideas for things to consider. It might possibly give some ideas of what to demolish too, should you be so inclined, but this book is really only for those who are already sold on RCTs and want to get on with the seemingly painful task of designing and running one.

References

Areán, P. A., & Kraemer, H. C. (2013). High-quality psychotherapy research: from conception to piloting to national trials. Oxford University Press.

Jauhar, S., McKenna, P. J., Radua, J., Fung, E., Salvador, R., & Laws, K. R. (2014). Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. The British Journal of Psychiatry, 204, 20–29. doi:10.1192/bjp.bp.112.116285

 

Book review: Power, interest and psychology by David Smail (2005)

Power, interest and psychology argues that psychotherapists need to take seriously how the social forces of interest and power affect how we all – therapists and clients alike – think, feel, and behave. The main targets of the book are what Smail believes to be the over-ambition and limited reach of therapists’ actions: warmth and empathy, debating beliefs, the “transference” – exploring and making explicit how the relationship between therapist and client might mirror relationships outside the room. The various therapeutic techniques, he argues, are dwarfed by the harsh social environment outside the therapy room. I read this book with interest as a (non-clinical, academic) lecturer who works with many kinds of psychotherapists and counsellors.

Smail rejects interventions which assume that insight leads to change, that we have individual will power which therapy can encourage, and that conscious thoughts accessible in therapy precede action. But what about clients who show improvement during the first few sessions of therapies which use these forms of intervention? He argues (pp. 24–25) that

“such initial gains tend not to last… Rather like tender plants that thrive only in a greenhouse, it seems that people find that there is still a cold and hostile world waiting for them at the end of their therapy sessions…”

The exceptions cited are clients who are young, attractive, verbal, intelligent, and successful – people who tend to be privileged by society. There is some research support for his clinical experience, for instance showing that cognitive ability positively correlates with outcomes (e.g., Mathiassen et al., 2012). A counterargument is evidence showing that “early responders” tend to sustain  better outcomes at long term follow up (Haas, Hill, Lambert, & Morrell, 2002; Lambert, 2005). However these correlational studies are open to attack: perhaps the “early response” just signals existing social and material resources which were easily activated by therapy (friends, family, money, etc.).

Therapy, Smail argues, tries to boost the perception of clients’ power to change, when in reality it is actual power that clients often need: power over material resources, finances; control in the workplace; personal characteristics such as confidence and intellect; a good home and family life; a love life; and an active social life (Hagan & Smail, 1997). These are areas which often cannot be influenced by talk in the clinic.

So why has individual therapy grown so popular? Smail argues – and emphasises that it’s nothing to be ashamed of – that therapists rely on income to put food on the table and pay the rent, just like their clients. He illustrates with the example of Sigmund Freud (p. 3) who wrote that

“My mood also depends very strongly on my earnings… I have come to know the helplessness of poverty and continually fear it.”

Freud, he argues, changed his theories so as not to blame clients’ parents since they paid the bills. Smail also argues that there is a great mysticism around therapy (p. 8): “rituals of therapeutic cure… bear a strong resemblance to the spells and incantations of sorcerers”, with practitioners rarely explaining in plain language to clients how their techniques supposedly work. Together these interests help sustain psychotherapy.

Is it really true that therapists can only intervene in the room with the individual client? Couple therapy takes the first step beyond the individual by bringing a romantic partner into the room, and there is evidence it helps with relationship problems (Snyder, Castellani, & Whisman, 2006). Child and adolescent mental health services frequently intervene in the family (Carr, 2009). Multi-family therapy (Asen & Scholz, 2010) brings communities of people into a room and encourages families to help each other as the therapists gradually “decentralise” themselves. There is an awareness of the importance of the systems around people suffering distress.

Another path outside the clinic is via “homework”, such as practicing social skills, which is (ideally) jointly agreed and set in a range of different types of therapies (Ronan & Kazantzis, 2006). Outcomes are better when therapies include homework than when no homework is included (Kazantzis, Whittington, & Dattilio, 2010). Smail, however, no doubt would argue that each of these interventions is limited when there are more material challenges at work such as poverty. What then would the homework consist of? Get a job? Make more money?

“The world is in a bloody mess,” concludes the book, “and even though I know, as do many others, what it would look like if it weren’t, I have no more viable idea than anyone else how to get there.” But there are constructive ideas in this text. Awareness that the causes of many of our actions is a mystery can be positive, for example in terms of accepting that social power flows through us and we shouldn’t blame ourselves for our situation or how we feel. A rich analysis is provided of the sources of this social power. The positive and convincing argument of the book is that the main hope of exercising power is through cooperation with others on all levels from friendship through to political activism. Indeed there is some evidence that activists who “advocate a social or political cause” tend to experience more positive emotions than non-activists (Klar & Kasser, 2009).

To what extent broader societal processes are within the scope of psychotherapy will no doubt continue to be debated. But whatever the scope, Smail suggests (p. 84) that the “appropriate role for therapeutic psychology is to record, celebrate and wonder at the extraordinary diversity of human character” – which sounds to me like a valuable starting point for therapeutic research and practice.

References

Asen, E., & Scholz, M. (2010). Multi-family therapy: concept and techniques. Hove: Routledge.

Carr, A. (2009). The effectiveness of family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 31, 3–45.

Haas, E., Hill, R. D., Lambert, M. J., & Morrell, B. (2002). Do early responders to psychotherapy maintain treatment gains? Journal of Clinical Psychology, 58, 1157–72. doi:10.1002/jclp.10044

Hagan, T., & Smail, D. (1997). Power-Mapping I . Background and Basic Methodology. Journal of Community & Applied Social Psychology, 7, 257–267.

Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta-Analysis of Homework Effects in Cognitive and Behavioral Therapy: A Replication and Extension. Clinical Psychology: Science and Practice, 17, 144–156. doi:10.1111/j.1468-2850.2010.01204.x

Klar, M., & Kasser, T. (2009). Some Benefits of Being an Activist: Measuring Activism and Its Role in Psychological Well-Being. Political Psychology, 30(5), 755–777. doi:10.1111/j.1467-9221.2009.00724.x

Lambert, M. J. (2005). Early response in psychotherapy: further evidence for the importance of common factors rather than “placebo effects”. Journal of Clinical Psychology, 61(7), 855–69. doi:10.1002/jclp.20130

Mathiassen, B., Brøndbo, P. H., Waterloo, K., Martinussen, M., Eriksen, M., Hanssen-Bauer, K., & Kvernmo, S. (2012). IQ as a moderator of outcome in severity of children’s mental health status after treatment in outpatient clinics. Child and Adolescent Psychiatry and Mental Health, 6(22), 1–7. doi:10.1186/1753-2000-6-22

Ronan, K. R., & Kazantzis, N. (2006). The use of between-session (homework) activities in psychotherapy: Conclusions from the Journal of Psychotherapy. Journal of Psychotherapy Integration, 16, 254–259. doi:10.1037/1053-0479.16.2.254

Smail, D. (2005). Power, interest and psychology: elements of a social materialist understanding of distress. Ross-on-Wye: PCCS Books.

Snyder, D. K., Castellani, A. M., & Whisman, M. a. (2006). Current status and future directions in couple therapy. Annual Review of Psychology, 57, 317–44. doi:10.1146/annurev.psych.56.091103.070154

Lightly edited 3 Feb 2019

Create your own economy (updated some more)

Recently I read Create your own economy by Tyler Cowen (thanks Michelle for the tip-off!). Interesting page-turner discussing autism, autistic(-like) traits in non-autistics, and implications for society.

Cowen points out (what is thankfully becoming more familiar) that although autism is often associated with tragedy, many autistics and not only savants have cognitive strengths, e.g., being infovores for their preferred areas of interest, better perceptual skills than non-autistics, less suspectiblity to false memories.  He argues that technological tools available today such as iTunes and Facebook allow non-autistics to have the same abilities.  Non-autistics are driven to do the same sort of organisation and searching for information as autistics are, and this is being made possible by technology. He argues that education is even designed to teach non-autistics some of the cognitive strengths of autism.

One side of autism mentioned in the book and not frequently discussed is that autistics are more likely to talk about feelings than make small talk (has this been studied? Is it true? I would like to know more). The emotional experience of autistics is rarely acknowledged.  Cowan gives examples of people who despite appearing outwardly aloof are deeply sensitive, caring, and who are shocked when they’re told otherwise.

There are plenty of examples in the book of people, real and fictional, who appear(ed) to have autistic traits. I found this a tad tiresome (there has been a lot of it about elsewhere), especially when suffixed with hedges saying that of course we don’t know whether they were autistic. The key point is that “what-we-call-what-it-is-that-I-am-talking-about” (to quote Cowan) probably ought not be derived from a name for a disorder. So viewed this way, most of the book is not about autism, but about a cognitive and emotional profile which many people in society have. This is not to say that autistics do not have cognitive strengths—and he discusses some examples in the book—but I do not see what is to be gained by conjecturing that people are/were autistic. What does this explain?  The details matter, not a one word label. (However this could be because I am deeply suspicious of labels in general!)

Lots of good stuff in the book. In general I think it does a great job of defending the eccentric, and argues successfully that many of the traits eccentrics possess are desirable. Good news for academics!

There are plenty of important points on respecting the individual. I like this of course, and am a big fan of positive individual differences research, e.g., discovering the strengths of people diagnosed with various developmental and psychiatric conditions. But I think my favourite sentence in the book is this (relatively unimportant) one:

“In June 2009, a group of Norwegian astronomers broadbast a Doritos ad to a distant star, forty-two light years away.”

This is genius, and I think it’s a good author indeed who can spot and report such facts. It’s these kinds of things that make society fun.