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We hope everyone enjoys a happy end of 2009 and a hopeful beginning of 2010. We will return on Monday January 4 with new material, at which point PBB will be back to its regular schedule. As the new year begins, we just want to let you know how thankful we are for your readership, commentary, and ideas and we hope that in this next year we are able to provide you with helpful resources and interesting conversations.
Mike and Joye Anestis
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by Joye C. Anestis
We're always looking for good mental health podcasts...and BehaviorTherapist.com has one of our favorites. I've written before about their podcast on current issues in addiction treatment. Here are three more that you might enjoy:
: http://behaviortherapist.podbean.com/2009/11/16/great-myths-of-psychology/
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by Joye C. Anestis
WebMD can sometimes be a dangerous thing. I have often had to recommend that clients avoid looking at it, as it many times contains information that only makes people more anxious. But Jane Pauley has hosted a serious of interesting videos about bipolar disorder that are worth checking out. Now I will say up front that I have not watched all of these videos (there are quite a few), so I can't vouch for the information found in them...but I have watched the excellent interviews with Dr. Robert Leahy and Dr. Holly Schwartz. These professionals offer succinct descriptions of cognitive therapy and interpersonal social rhythms therapy, respectively, for bipolar disorder.
WebMD won't let me embed these videos directly. To watch, click here, then click "Bipolar in Focus" on the left side of the screen. At the bottom of the screen, you can scroll through the thumbnails of videos to find the ones you want to watch.
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by Joye C. Anestis
I recently received notice that the Beck Institute of Cognitive Therapy has its own YouTube channel. Here you can find videos of Dr. Judith Beck and Dr. Aaron Beck discussing cognitive therapy. They also feature videos explaining the training available at the Beck Institute. At PBB, we're always excited to come across like-minded folks dissemination good information online!
Do you know of other YouTube channels which discuss empirically-supported treatments? Let us know!
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by Michael D. Anestis, M.S.
In the past, we have discussed potential DSM-V changes to the following sets of mental illnesses:
In the next year, we will continue to post new articles discussing potential DSM-V changes as new evidence emerges. In the meantime, we would love to hear your thoughts and questions on the matter.
If you are interested in this or other topics discussed on PBB, we hope you will consult our online store of scientifically-based psychological resources.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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by Michael D. Anestis, M.S.
Without question, we at PBB have opinions on the topics we discuss. We wholeheartedly believe that mental health care should be driven by results accumulated through scientific studies. We believe therapists are not magicians bestowed with the ability to use intuition to accurately assess and treat their clients. We also believe that it is imperative that therapists treat their clients with empirically supported treatments.
As is the case with most things, our position is not held in universally positive regard throughout the field. In fact, there are many people who believe that science has no place in clinical psychology and others who misinterpret the data and conclude that science tells us that all treatments work equally well for all mental illnesses. Today, I would like to address this situation by providing you with links to a number of articles we have written on the topic this year so that you can evaluate the evidence on both sides and develop your own informed opinion. In addition to the articles we have written, I highly recommend consulting the work of Paul Meehl and Karl Popper. Both men wrote incredibly influential and brilliant works on the importance of scientific-mindedness, although admittedly both wrote in a manner that made it difficult to wade through all of their material in one sitting without developing a bit of a headache.
With respect to PBB articles, I would recommend opening with our discussion of how we determine whether or not a particular therapy for a particular condition is empirically supported (click here).
From there, I would recommend reading our discussion on why group data is important even though we are all individuals (click here).
My next recommendation would be an article we wrote on how treatments for anxiety disorders that have been shown to work in controlled trials have also been shown to work in "real world" practice (click here). Along those same lines, I would recommend that you consult our article discussing how, even when therapists are trained in empirically supported treatments for eating disorders, they rarely implement them in their practice (click here).
My next suggestion would be consulting our articles on the "dodo bird hypothesis," which states that all forms of therapy work equally well for all conditions (click here and here). This conclusion is dangerous and inaccurate, but is also espoused by many influential figures and, as such, has maintained a ridiculous amount of traction. Additionally, you may want to read our recent article on the importance of comparative treatment trials that can accurately determine whether one treatment is superior to another for a particular condition or set of conditions (click here).
My next suggestion would be to read our article on whether or not therapeutic alliance accounts for success in therapy (click here), then to consult our recent article on how sudden gains occur in therapy and what they mean in terms of whether or not a client gets better and avoids relapse (click here).
Finally, I would recommend that you read our article on an influential paper published a couple months ago that successfully called a lot of attention to the gap between what scientists have shown to be true and effective and what is actually implemented in clinical practice (click here) as well as our article on a subsequent NPR program that covered the topic (click here). You can listen to the NPR program for free by following the links in the article.
The comment sections in these articles remain open and we would love to hear your thoughts and/or questions. If you would like to learn more about these or other topics discussed on PBB, we hope you will consult our online store for scientifically-based psychological resources.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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by Michael D. Anestis, M.S.
As we approach the end of 2009, I thought it would be worthwhile to post some summary articles that take some of the topics we have discussed over the past year and combine them into a more digestible format. Along those lines, today's article will center on a number of different forms of psychotherapy that are fairly popular and yet have either a complete lack of evidence regarding their effectiveness or - worse yet - evidence that they, in fact, either do not work or actually cause harm.
Remember, our primary goal at PBB is to take scientific research and make it readily available to as wide an audience as possible, including both professionals and folks outside the field either curious about the topic or in need of help. In doing this, our emphasis is on discussing the many forms of psychotherapy (and pharmacotherapy) that have been shown repeatedly through scientific studies to actually be helpful for various mental illnesses. The fact is, over the past several decades, we have developed a large number of therapeutic interventions that, without question, are effective in treating a wide variety of mental illnesses. Despite this development, many therapists persist in using forms of therapy that lack such support - a practice we believe to be completely unethical. In addition, we do such a poor job of marketing our effective therapies that most of the people who are in need know very little about them.
The first article I would recommend consulting on this topic was posted on PBB back in April. This article, which discusses Scott Lilienfeld's (2007) paper on treatments that cause harm (click here), provides a quick discussion about several forms of treatment that not only fail to accomplish their goals, but actually tend to make things worse.
After reading that, I would recommend turning your attention to article we have written on the following types of therapy, none of which have any data backing up their effectiveness and some of which actually have been shown not to work:
Several of these articles prompted extensive conversations in the comment section and they remain open for additional comments should you have thoughts and/or questions you wish to share. Importantly, remember that when a therapy lacks any evidence, that does not mean that it does not work; however, it does mean that there is not evidence supporting its ethical implementation for the treatment of mental illnesses, particularly when empirically supported treatments already exist for the disorder(s) in question.
If you would like to learn more about this or other topics discussed on PBB, we hope you will consult our online store for scientifically-based psychological resources.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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by Joye C. Anestis
***Thanks to a thoughtful thread on the ABCT listserv for inspiring this post and leading me to this article.***
An important and thoughtful question often posed by clients who are experiencing some symptom relief from treatment is "what is the likelihood that my mental illness will recur?" Just as, say, a cancer patient would want to the know the odds of relapse, so do those being treated for mental illness. The answer to this question can be complicated, as it not only depends on which mental illness you're dealing with but also, importantly, what treatment you received. There is ample evidence that relapse rates differ between treatments. The fact of treatment-influenced relapse rates is another important consideration when presenting therapies to clients...seems only logical to consider using the most effective treatment available with the most hopeful relapse data.
For today, I'm only going to focus on major depression. In 2007, Vittengl, Clark, Dunn, & Jarrett conducted a meta-analysis of studies examining the relapse-recurrence rates in cognitive-behavioral therapy (CBT) for major depression (if you are unfamiliar with meta-analysis, click here for a review). These authors were interested in answering 4 questions (the questions are delineated below). 28 total studies met their inclusion criteria (see the article for details on what these were) and were included in the review.
How common is relapse-recurrence in those who respond to acute-phase CBT (CBT applied during a major depressive episode with the goal reducing depressive symptoms and producing remission)?
Does acute-phase CBT reduce relapse-recurrence more than other acute-phase treatments?
Does continuation-phase CBT (CBT applied to prolong remission and reduce the likelihood of relapse-recurrence...essentially booster sessions of CBT) reduce relapse-recurrence more than nonactive control conditions?
Does continuation-phase CBT reduce relapse-recurrence more than other active treatments?
So, relapse is common in any treatment for depression, but the rates are significantly lower for CBT than for medication...and providing booster sessions of CBT after acute treatment serves to further decrease the relapse rates. The authors interestingly place these findings in a public health perspective (I personally love it when researchers do this, because I find it really drives the point home)...so here's what these findings really mean:
Considering the cost (both time and money) of long-term pharmacotherapy and the lack of desire in patients to take medication in the long-term, acute CBT with booster sessions seems the best way to combat relapse.
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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by Michael D. Anestis, M.S.
Over the past few weeks, many of you have likely heard that President Obama is reviewing a fairly controversial policy involving the military. The policy dictates that the president will not send letters of condolences to the families of soldiers who die by suicide. I have a fairly strong opinion about this policy, but I have no interest in making PBB a political forum and, besides which, my views on this policy have no bearing on my views of this or any other administration. Instead, I would like to focus on the conversation that has emerged in response to the policy review.
On Friday December 11, an Op-Ed piece on this issue written by a psychiatrist named Paul Steinberg appeared in the New York Times (read the article here). Quite frankly, this article managed to be both remarkably offensive and shockingly inaccurate in a fairly small amount of space. I immediately circulated the article to colleagues, many of whom also devote much or all of their professional pursuits to the systematic investigation and treatment of suicidal behavior and their responses were equally strong. The next day, Joye and I drafted our own Op-Ed piece in response and submitted it to the New York Times. The three business day review window has passed, meaning that the piece will not appear in the paper, so I would like to post it here instead. What follows is the text of the article we submitted, followed by a quick discussion of the research that was alluded to in the letter itself (NY Times space limitations required that we not delve further into that information):
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by Michael D. Anestis & Joye C. Anestis
In Paul Steinberg’s discussion of presidential condolence
letters for the families of soldiers who die by suicide, he discussed a number
of pivotal issues. We believe he is correct
in his assertions that de-stigmatizing help-seeking behavior is vital, that
action must be taken in order to curb military suicide rates, and that
glorifying suicide is ill-advised. That
being said, we also believe that his discussion included a significant number
of factual errors and logical holes that detract from the issue and could serve
to perpetuate myths regarding the nature, assessment, and treatment of suicidal
behavior.
In justifying the lack of presidential condolence letters sent
to the families of service members who die by suicide, Dr.Steinberg expressed
concern that such letters would glorify the behavior. He mentioned that impulsivity is associated
with suicide and worried that, by simply reporting about such deaths, we might
induce suicidal behaviors.
On an intuitive level, this argument makes a lot of sense
and we can completely understand why people might have a strong emotional
response in either direction. Our
position, however, is that although suicide is an emotional issue, we should
not let emotions and intuition guide our understanding when empirical data
exist to help us make more objective and accurate decisions.
As it turns out, although impulsivity is associated with
suicide, suicide attempts are not an impulsive behavior. Our research and that of many others has
demonstrated that impulsive individuals both in the military and in the general
population tend to encounter more painful and frightening experiences during
the course of their lives and, through repeated exposure to such events, they
develop a greater ability to tolerate physiological pain and a reduced fear of
death. As a result, they acquire the
capability to make lethal attempts at their own lives. Taking such action, however, is a process
built up to over time and accompanied by significant planning and
preparation. In other words, although
exceptions exist in any situation, suicidal behavior is rarely if ever a sudden
response to a single event. As such,
Dr.Steinberg’s assertion that impulsive suicidal behavior might be a response
to condolence letters and the reporting of suicidal behavior does not hold up
when tested scientifically.
A second factual error in Dr. Steinberg’s discussion was the
idea that reporting on suicidal behavior could prompt suicides that might not
otherwise occur. In fact, research has
shown that assessing for suicide risk directly and discussing suicidal thoughts
has no such impact, regardless of an individual's current risk level. Instead, openly discussing these issues and
assessing for risk in a systematic manner appears to drastically reduce deaths
by suicide. Furthermore, while research
has demonstrated that suicides can cluster together, the evidence does not
support the notion that suicidal behavior is contagious. In this sense, it does not seem reasonable to
assume that consoling the families of soldiers who die by suicide will prompt thoughts and behaviors unlikely in the absence of such compassion.
In addition to these factual mistakes, Dr.Steinberg’s
discussion featured a number of logical errors.
He mentioned fears that overt displays of compassion for individuals who
die by any means might venerate death and cause vulnerable individuals to
consider death a better option than life.
If compassion breeds suicidal behavior, however, shouldn’t
Dr.Steinberg’s argument have centered on ceasing presidential letters of
condolences to the families of soldiers who die in battle rather than simply fighting
the shift towards sending letters to those whose family members died by
suicide? After all, wouldn’t this logic
apply to deaths in battle as well? We
contend that compassion has no such impact and that both types of letter are a
valuable and reasonable gesture to the families shaped by military deaths.
In another logical misstep, Dr.Steinberg mentioned that we need to strike a balance between concerns for the families and efforts to avoid incentivizing suicidal behavior. The insinuation here is that condolence letters will prompt a spike in suicidal behavior, as soldiers might come to believe that they will be honored if they die by suicide and this would cause the behavior to seem desirable. The problem with this is that, despite the lack of such letters, January 2009 marked the first time in history that suicide rates in the military exceeded those of the general population. In other words, the lack of condolences is a failed policy if its goal is to prevent suicide. Letters not sent cannot be blamed for events that have already taken place. Additionally, letters sent to families are a private event. It is unclear how such letters would serve to increase suicidal thoughts and behaviors in individuals who have no access to them.
We believe that Dr.Steinberg’s argument is driven by a heartfelt
concern for those who are vulnerable to suicidal behavior. We also believe, however, that his arguments
are based on a misunderstanding of the phenomenon and that his conclusions are
a disservice to everyone involved in these situations. Military suicides are a distressing
phenomenon and Dr.Steinberg is correct in asserting that we should not glorify
suicide as a viable coping option; however, we believe that he is mistaken in
his assumption that letters of condolence would provide such glorification and
that attaching shame to the names of those who die by suicide will somehow
serve as a deterrent.
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Before signing off for the day and opening this up to questions and comments, I would like to clarify a few points from the letter. As I mentioned above, space requirements for submissions to the New York Times rendered it impossible to directly cite the research we alluded to in the text, so I would like to make those citations available here.
In reference to the idea of suicidal behavior being related to impulsivity but not generally being an impulsive event, I would like to direct you to a number of sources. First, click here to read our discussion of Joiner's (2005) interpersonal-psychological theory of suicidal behavior, which provides a clear definition of the acquired capability for suicide. Next, click here to read US Air Force Captain Chad Morrow's PBB piece on suicide in the military. Although we have not yet discussed this paper on PBB, I would also recommend that readers consult Witte et al (2008), in which the authors found that impulsive adolescents engage in more planning for suicide attempts than do non-impulsive adolescents. In other words, individuals at greater risk for suicidal behavior are more likely to engage in extensive planning for suicide attempts, a direct contradiction to a major point of the Steinberg Op-Ed. We also recommend consulting Baca-Garcia et al (2005), who found that the degree to a suicide attempt is impulsive is inversely related to the lethality of the attempt. In other words, when people attempt suicide with little or no planning (e.g., they were prompted by a particularly stressful event), they are less likely to choose a lethal means and therefore less likely to die by suicide. Go to our references page to see the full citation for these and all other papers referenced in PBB articles.
In reference to the idea that suicidal behavior clusters together but is not contagious, we first recommend that you click here to read our discussion of this phenomenon from an earlier PBB article. From there, you will find several citations upon which our claims are based. Additionally, you can click here and here to read our article detailing evidence that openly discussing suicide and assessing for suicide risk does not put the idea of suicide in somebody's head or increase the incidence of the behavior (in fact, it has the opposite effect, particularly for individuals with a history of suicidal behavior and/or current suicidal ideation or depression). Note that the second article linked to was written by a member of the US Air Force (Craig Bryan) and that the data was accumulated in a military sample.
Suicide is a troubling phenomenon and the current numbers in the military are particularly disheartening. That being said, as difficult as it is for most of us to relate to the concept of suicide, it is not as mysterious as it seems. There are many researchers and clinicians who have come to develop a very clear understanding of what contributes to suicide risk and what should be done to prevent suicidal behavior. The points raised in Steinberg's Op-Ed piece reflect substantial ignorance on these points and it is unfortunate that his words were given such a prominent platform.
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If you would like to learn more about the nature, assessment, and treatment of suicide, we recommend the following items, all of which are available through our online store for scientifically-based psychological resources:
by Thomas Joiner
by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
by David Rudd, Thomas Joiner, and Hasan RajabMike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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