Psychotherapy Brown Bag

Psychotherapy Brown Bag YouTube Channel Update

Greeting folks.  I have posted two new videos on the PBB YouTube channel.  On a high note, my film making skills improved to the extent that I now fit in the picture, but on the down side, I overshot the YouTube 10 minute limit by a long shot and had to divide the video up into two parts.  The videos are an overview of my critique of the Shedler article.  As always, the material on YouTube is much less detailed than our writings here.  They simply mark an attempt to reach another group of folks less inclined to read the site but still interested in thinking about this stuff.

As always, we welcome your thoughts but please keep them civil.  Even if you disagree vehemently, we can still discuss this without resorting to accusations, name-calling, and the like.  Enjoy!

Part 1

Part 2

Evidence-based treatments for PTSD: Combating faulty claims that all treatments are the same

by Michael D. Anestis, M.S.

Today I find myself a part of a familiar scene.  I'm sitting at my desk, looking at my computer with half of the screen showing a Firefox browser in which I am typing a PBB post and half of the screen opened to a PDF of a published journal article discussing the dodo bird hypothesis.  For regular readers, this might leave you with flashbacks to the movie "Groundhog Day," minus the comedic genius of Bill Murray (although, admittedly, this is not how I would hope somebody would describe PBB).  Why the recurring theme?  Well, as I have said before, my frequent commentaries on this issue are due to the persistence of those who believe in the faulty conclusion that all psychological treatments are equal for all disorders.  With all of the misinformation out there, I think it is important to call attention to the facts every time distortions receive publicity.  This is, after all, an incredibly important question.  If all treatments work the same for all conditions, this means that a remarkably large number of helpful resources are available in any given community for individuals suffering from mental illnesses and nobody needs to put much effort into determining which is the best available option.  If, on the other hand, particular treatments are more effective than others for particular diagnoses, this means that it is important that we learn to perfect new treatments and that consumers become educated regarding which treatments are most likely to help them so that they can successfully navigate a marketplace flooded with inferior options.  We have covered this a number of times in the past, but as a freakishly quick recap, here's what we know: the dodo bird hypothesis is wrong and all treatments are not the same for all disorders.

If we know this, however, why does the belief persist?  There are a number of answers for this.  For one thing, some highly educated individuals have run a number of remarkably flawed studies on the matter that have resulted in misleading findings.  Because so few of us are trained to look at data and understand what a particular study really tells us, we hear their conclusions and, because we respect the authors' credentials, assume that they are speaking truthfully.  Additionally, most of us who are trained in data analysis and who understand the actual answers to this question do very little to make our voices heard and, as a result, misinformation is able to persist.  This is where we hope PBB comes in, as we aim to provide you with descriptions of what we really know, based upon scientific studies.

Fortunately, my job was made a little bit easier than normal today.  Jed Siev, whose work we have covered on PBB on a number of occasions, emailed me last night and called my attention to an article just published in Clinical Psychology Review by Anke Ehlers and a number of colleagues in the United Kingdom, Australia, and the United States (2010).  In this study, the authors examined a recent meta-analysis by a number of prominent dodo birders (Benish, Imel, & Wampold, 2008) that claimed that all treatments for PTSD work equally well.

Ehlers and colleages (2010) opened their article by pointing out that a number of meta-analyses have demonstrated that trauma-focused psychological treatments - that is, treatments that devote much of their focus to discussing, in detail, the nature of the traumatic event - produce superior results in the treatment of PTSD (e.g., Australian Centre for Posttraumatic Mental Health, 2007; Bisson & Andrew, 2009; Bisson et al., 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005; Cloitre, 2009; Seidler, & Wagner, 2006; van Etten & Taylor, 1998).  Trauma focused psychological treatments can involve various forms of cognitive behavioral therapy (e.g., prolonged exposure) as well as eye movement desensitization and reprocessing (EMDR; click here for access to articles we have written on the degree to which EMDR is actually any different from CBT).  Further meta-analyses have shown that, within this group of treatments - those that focus on the trauma itself - results tend to be equal, meaning that no trauma-focused approach is better than any other (e.g., Bisson & Andrew, 2009).  So, the point Ehlers and colleagues (2010) were making here is that there is a substantial history of research demonstrating that one particular class of treatments is particularly effective in treating PTSD, but that within this class, the treatments are equal to one another.

Despite this large evidence base, Benish and colleagues (2008) concluded on the basis of their own meta-analysis (as they have done in response to all of the meta-analyses they have run over the past couple of decades on various psychological treatments) that all "bona fide" PTSD treatments are equal.  Benish and colleagues defined a particular treatment as "bona fide" is they determined that it was "intended to be therapeutic."  This, of course, is not based upon any empirical standard or treatment technique, but rather on the opinion of the Benish and colleagues.

The goal of Ehlers et al (2010) was to address the contradicting results of the Benish et al (2008) study relative to prior work on PTSD.  In doing this, they made several points, each of which I will explain in detail.  Essentially, they had two main critiques:

• The manner in which Benish and colleagues (2008) selected studies to include in their analysis was remarkably biased and completely skewed the results
• The analyses used by Benish and colleagues (2008) failed to demonstrate that certain "bona fide" treatments were more effective than natural recovery.  In other words, several studies failed to show that the treatments themselves rather than the mere passage of time resulted in symptom remission

Let's take a look at what Ehlers and colleagues (2010) meant when they made each of these critiques:

Bias in selection

In any meta-analysis, the authors have to decide which studies on a topic to include and which to keep out.  There is no clear cut rule on how to do this and, depending on which studies you select, you are likely to get different results.  Now, your instinct might be to say "just select the best ones," and that sounds great, except people interpret the meaning of the word "best" very differently.  This, of course, is a complaint I have made about meta-analyses on PBB many times before, but it bears repeating every time it is relevant.

In a review published by Cloitre in 2009, 44 comparisons of different forms of PTSD treatment from 27 studies were included.  Benish and colleagues (2008), on the other hand, claimed to have only found 26 comparisons in 22 studies and ultimately included only 17 comparisons from 15 studies in their analyses.

You might ask, "how did this happen?"  Ehlers and colleagues (2010) pointed out that Benish and colleagues (2008) did not include most trials involving supportive (e.g, non-directive, Rogerian, person-centered) psychotherapy.  Their rationale for this is that they did not believe supportive psychotherapy was "intended to be therapeutic" and, as such, was not bona fide.  Given than this is the most commonly used form of treatment for PTSD in the British National Health Service (Ehlers, Gene-Cos, & Perrin, 2009) and that it is commonly used in the US as well - Pingitore, Scheffler, Haley, Sentell, & Schwalm (2001) found that 58% of practicing psychologists in California use this approach - it seems a bit strange to assume that individuals utilizing this form of treatment are not intending to perform a therapeutic function.  Additionally, given that social support has been linked to PTSD recovery (Ozer, Best, Lipzey, & Weiss, 2003), it is difficult to argue that clinicians have no reason to believe that supportive psychotherapy has a chance to be helpful.  Perhaps even more importantly, however, given that one of Bruce Wampold's strongest claims is that common factors - and particularly the therapeutic alliance  - are the driving force of success in psychotherapy, it seems counter-intuitive for he and his colleagues to eliminate treatments that base their entire focus on developing a strong alliance between client and therapist. Taking this a step further, Benish and colleagues (2008) chose to eliminate all trials of supportive psychotherapy even if they outperformed a no treatment control condition.  In other words, whether or not it impacts the client does not determine if a treatment is "bona fide."  All that matters is that Benish and colleagues (2008) feel that it is.  In making this decision, they took out a large number of treatments that could be compared to trauma-focused psychological interventions, thereby increasing the chances that they would be able to support their point, that all treatments are equal (this becomes easier to do when you exclude any treatment that is not equal).  Along these lines, Benish and colleagues (2008) included two studies of present centered therapy (PCT) but did not include two supportive psychotherapy trials in which the same techniques were used.  It is not at all clear why they made this decision.

The two studies that Benish and colleagues (2008) included examined the use of PCT and trauma-focused CBT in clients with multiple, prolonged traumas (McDonagh et al., 2005; Schnurr et al., 2003). In one of these studies, CBT was used in group format despite the fact that no empirical evidence exists suggesting that this is a valid way to deliver the treatment.  In each of these studies, Benish and colleagues (2008) concluded that the two treatments were equal despite the fact that, in one trial, CBT outperformed PCT in reducing avoidance, numbing, and possibly overall PTSD symptoms for individuals who received a full dose of treatment and, in the other trial, CBT outperformed PCT in the proportion of clients who, at 3-month follow-up, no longer met criteria for PTSD (82% for CBT vs 42% for PCT).  Regardless, Ehlers and colleagues (2010) pointed out that even if we ignore these differences, we are left with two possibilities: PCT and trauma-focused CBT are equal to one another or the difficult-to-treat client base obscured the results.  Results of two recent trials help to clarify this.  In Schnurr et al (2007), which Benish and colleagues (2008) chose not to include in their analyses, prolonged exposure outperformed PCT in the treatment of female veterans with PTSD.  In Ehlers et al (in preparation), trauma-focused CBT again outperformed PCT.  Given these recent findings, and the lack of findings with results indicating PCT ever outperforms CBT, you really have to start to wonder.

Do treatments benefit patients more than the simple passage of time?

The point made here by Ehlers and colleagues (2010) is that Benish and colleagues (2010) did not take nearly enough care to ensure that what they were measuring was actually doing what they claimed.  Of all the treatment comparisons they looked at, only 6 involved treatments other than trauma-focused CBT and EMDR.  On the basis of a single small study published in 1989, Benish and colleagues (2008) concluded that psychodynamic therapy and hypnotherapy are just as effective as trauma-focused psychological interventions for PTSD.  The thing is, neither hynotherapy nor psychodynamic therapy was consistently more effective than a no treatment waitlist control condition in that study and there were a number of important symptoms that did not improve at all in clients who received these treatments.  In other words, simply waiting around and not getting treatment resulted in greater improvement than did receiving psychodynamic therapy or hypnotherapy.  That's not impressive.  This, of course, did not stop Benish and colleagues from concluding that all treatments for PTSD are equal to one another.

Benish and colleagues (2010) pointed to the fact that an early version of exposure therapy - a form of trauma-focused CBT - was used in that trial as well and did not perform very well (although it outperformed the other approaches).  The problem with their point there is that that particular form of exposure - trauma desensitization - is no longer widely used.  Scientists recognized its deficiencies, adapted, and developed more effective forms of treatment that routinely result in greater treatment effects.  As they tend to do in their analyses, however, these folks overlooked that fact, collapsed treatments together arbitrarily, and found null findings that they mistakenly believed represented equivalence across treatments.  This of course, is akin to comparing your first draft (and ignoring subsequent drafts) of a paper to a classmate's final draft, developed after several rounds of careful revisions, and then drawing conclusions about the degree to which each of you attend to details. I suspect you would be unlikely to do that unless you were intentionally trying to support the notion that you are inferior.

So what should we do?

I love the comments that Ehlers and colleagues (2010) used to open this section of the paper, so I will simply present them here (p.273)

"Meta-analyses oversimplify maters.  They require arbitrary decisions about categories and inclusions and exclusions, and these decisions influence the results."

Ehlers and colleagues (2010) see things in a manner very similar to me on this point.  They believe that dodo birders have made untenable decisions in choosing which studies to include and exclude in their meta-analyses, and as a result, they have painted a picture that has absolutely nothing to do with reality.  Because few people ever actually look at the studies chosen and excluded by the authors of meta-analyses, the conclusions they make are simply taken at face value, regardless of whether or not they have any connection to the truth.  This, of course, is true of meta-analyses that support empirically supported treatments as well, so the answer is not to simply discard the ones we dislike, but rather to focus our attention on the results of direct comparisons of treatments to one another in adequately powered samples so that we can no manipulate the data to simply tell the story we want to hear.

Ehlers and colleagues offered up several ideas for how to improve this situation.  First, authors of meta-analyses need to be more transparent regarding which studies they included and excluded.  By listing all members of each category, they make it easier for readers to see what's going on and to determine which studies simply went undiscovered by the authors.  Second, they suggested that only trials that adequately measure the degree to which treatments are implemented according to their protocol be included.  Rather than excluding studies on the basis of arbitrary decisions regarding whether or not they are "bona fide," a category made-up by Wampold and colleagues, empirical data regarding the degree to which treatments were effectively implemented and outperformed a no-treatment control condition should be a determining factor regarding whether or not they are included in an analysis.

Summary

The basic point of the Ehlers et al (2010) study was to refute the notion that all treatments for PTSD are equal to one another.  They did this by examining a meta-analysis by Benish and colleagues (2008) and demonstrating some important flaws in their approach.  These flaws are very similar to the flaws from earlier Wampold work as well as the recent study by Shedler on psychodynamic therapy.  Because issues like this keep coming up, the value of properly run meta-analyses versus the danger of poorly run meta-analyses is becoming an important issue to consider.  The current practices are leading to the proliferation of flawed conclusions based upon sloppy data.

To wrap this article up, I want to demonstrate the degree to which certain meta-analyses stray from the truth by summarizing a fantastic table included in the Ehlers et al (2010) study.  In this table, the authors demonstrated that Benish and colleagues (2008) have a habit of including small components of quotes from earlier studies that do not reflect the actual statement being made by the original authors. 

Benish and colleagues (2008) quoted McDonagh and colleagues (2005) by saying "treatments did not differ significant at any assessment time point on any measure" and "no significant differences."  Sounds damning, huh?  I mean, no treatments were different from one another at all.  Let's see what the entire quotes said though:

"Our hypothesis that CBT would be superior to PCT in promoting recovery received support from the finding that CBT was superior to PCT in achieving remission from the PTSD diagnosis at follow-up...the two active treatments did not differ significant at any assessment time point on any other measure."

"CBT participants were significantly more likely than PCT participants to no longer meet criteria for a PTSD diagnosis at follow-up assessments."

Those two quotes from the actual study seem to be at odds with the partial quotes that Benish and colleagues (2008) used, huh?  Indeed they are. This technique - quoting a person out of context or only including parts of quotes, is a common method of manipulating a situation to make it seem more supportive of our viewpoint than it actually is. It happens in politics, in middle school cafeterias, and professional wrestling to great effect, but it has no place in science.

Sometimes the results of scientific studies do not turn out as we expected and we are forced to change the way we think about things.   Other times, however, surprising results are due to poorly run studies.  I can't stress this point enough: before you take anyone's word for something, ask how they came to their conclusions and look to see if anyone else has provided a counter-argument exposing their errors.  In the case of the dodo birders, highly accomplished individuals are regularly publishing conclusions that simply are not supported by the facts and, unfortunately, their errors have the potential to keep people from seeking the right form of therapy for their particular condition..

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If you would like to learn more about PTSD and its treatment, we recommend the following items, each of which is available through our online store of scientifically-based psychological resources:

• Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide by Edna Foa, Elizabeth Hembree, and Barbara Rothbaum

• Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook by Barbara Rothbaum, Edna Foa, and Elizabeth Hembree

• Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide by Edna Foa, Kelly Chrestman, and Eva Gilboa-Schechtman

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Clinically significant distress or impairment: essential to a diagnosis or redundant?

by Joye C. Anestis

We've spent a good amount of time covering some potential diagnostic changes in the upcoming DSM-V.  The proposed changes discussed on PBB so far include altering the format of the mood and anxiety disorders, changing the PTSD diagnostic criteria, shifting to a dimensional model of personality disorders, removing some of the autism spectrum disorders, and creating a hierarchical model of eating disorders.  Besides diagnosis-specific changes, rumblings of broader changes are also underfoot. 

In an effort to reduce the false positive rate of diagnoses (i.e., to rule out individuals who met the diagnostic criteria for a disorder but whose symptoms are not harmful enough to be considered disordered), the DSM-IV added a clinical significance criterion to almost all symptom sets, requiring that the symptoms must cause clinically significant distress and impairment to warrant a diagnosis.  For example, criterion C of a major depressive episode states: "The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (APA, 2000, p. 356).  The authors of the DSM-IV were attempting to not over-pathologize milder forms of symptoms that may be present but aren't getting in the way of an individual's ability to function.  Despite the laudability of this intention, no field trials were conducted to test how effective this addition was in actually eliminating false positives.

One proposed change for the DSM-IV is the removal of this clinical significance criterion from the diagnostic criteria and making it a separate dimension.  There are two prominent arguments promoting such consideration.  First, some argue that the clinical significance criterion is redundant.  The wording of the symptoms themselves already ensure impairment and distress.  Second, significant distress or impairment can be part of a "normal" reaction to loss or stress - thus, the goal of eliminating false positives may not be being met.  Another reason the DSM-V Task Force is reportedly considering this change is to make the DSM-V  more compatible to the ICD (the International Statistical Classification of Diseases and Related Health Problems), the classification system used by the rest of the world, which avoids reference to role impairment in its criteria (it is also under revision, and the revision task force is reportedly considering completely eliminating any statements about functioning or disability).

A recent study in the American Journal of Psychiatry aimed to empirically assess the effectiveness of the clinical significance criterion to reduce community prevalence rates of major depression.  Specifically, authors Wakefield, Schmitz, and Baer wanted to test the redundancy hypothesis, proposing that neither distress or impariment would have a significant effect on the prevalence rate of major depression in the community.  A community sample was chosen for this study because they are the most likely to suffer from false positive rates.  It is less likely that a person presenting at a clinic would receive a false positive diagnosis of depression.

• Method: The authors obtained data from the National Comorbidity Survey Replication (NCS-R), a community-based epidemiological survey of the U.S.  For unexplained reasons, analyses were restricted to respondents aged 18-54 (n = 6,707).  The administration of the interviews, and subsequently the analyses, got a little complicated.  First, participants were given a screening questionnaire which asked questions about persistent sadness.  If a participant answered yes to any of the persistent sadness questions, then they were asked questions about clinical distress (e.g., How severe was your emotional distress?).  Those who reported distress were then evaluated for major depression.  A depression diagnosis required 2 weeks of 5 or more of the DSM-IV symptoms (DSM-IV criterion A).  The NCS-R did not utilize the DSM-IV's bereavement exclusion (an individuals cannot be diagnoses with a major depressive episode if they have lost a loved one within the previous 2 months), allowing for the possibility of more false positives than usual.  Questions regarding impairment were asked after the symptom interview.  A positive response to any of 10 distress and impairment questions satisfied the clinical significance criterion. 

• Results: Interestingly, even though an earlier DSM-III-R-based National Comorbidity Survey did not include a clinical significance criterion, the prevalence rate in the current sample (18.3%) was higher than that in the previous sample (15.2%).  The redundancy hypothesis for distress was strongly supported in this sample.  Of the respondents who reported at least 1 mood symptom for 2 weeks (n = 2,071), 97.2% (n = 2,016) satisfied the distress clinical significance criterion.  Of these 2,071 folks who were evaluated for distress, 60.5% (n = 1,254) met criteria for a diagnosis of major depression.  Of the 817 folks who did not meet diagnostic criteria for major depression, 93.5% satisfied the distress criterion.  The redundancy hypothesis was also strongly supported for the impairment clinical significance criterion.  Of the 1,542 participants who satisfied the Criterion A requirement, 96.2% (n = 1,487) satisfied the impairment criterion.

The findings reported by Wakefield and colleagues indicate that the clinical significance criterion does virtually nothing to distinguish normal sadness from major depression.  I am intrigued by this finding, as the requirement of clinically significant distress and impairment is often emphasized when clinicians are being trained to make diagnoses.  It's very rare to apply a diagnosis to an individual who is not distressed and/or imparied by the symptoms (for example, while a clinical significance criterion is included in the general diagnostic criteria for a personality disorder, some are not bothered by their symptoms - although others might be).  The authors are careful to point out that they do not support the idea that the distress/impairment criterion should be uniformly removed from all symptom sets in the DSM-V.  Instead they propose a disorder-by-disorder analysis of this issue (I find it hard to believe that this will actually happen...that's a lot of work!).  Based on this data (although replication is definitely needed), it does appear that the major depressive episode symptoms cover distress and impairment to the extent that a separate criterion isn't necessary (although I don't see how it would hurt anything to leave it in).  But I can definitely see the necessity of it for other diagnoses...some folks have specific phobias that don't interfere with their lives and some personality disorders could cause us to over-pathologize "different" behavior without such a criterion.  What do you think?  Are you aware of other data on this issue?  Can you think of other disorders that may really need a specific clinical significance criterion?

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If you would like to learn more about this and other topics discussed on PBB, Psychotherapy Brown Bag recommends that you consult their online store of scientifically-based psychological resources.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Guest Article - Impediments to progress in psychotherapy and new ways to address them

by William Campbell, B.A. and Reid Hester, Ph.D.

Clinicians who don’t regularly treat patients with alcohol use disorders might be surprised to discover that one quarter of all clinical patients engage in heavy, problematic drinking. Even clinicians who are well aware of their patient’s misuse of alcohol often struggle with how to incorporate a treatment of the drinking behavior into their overall therapeutic plan. This is important, because unless clinicians have assessed and accounted for their client’s drinking habits, they may not suspect that a “hidden” behavior is inhibiting the course of treatment.

When most of us think of evidence supported treatments for substance abusing clients, we probably think of intensive motivational and behavioral regimens like the Community Reinforcement Approach and Motivational Interviewing, usually for severely dependent clients. But what about less dependent or abusive drinkers, who for one reason or another are struggling to control their drinking, but otherwise have no desire to quit? What treatments exist for them? This question is especially pressing in light of the fact that the vast majority of people struggling with their drinking belong to this latter group; they account for the larger proportion of the costs to society associated with alcohol abuse and, as a group, they tend to have much better treatment outcomes than more dependant drinkers. Epidemiological research suggests that there are four times as many individuals with alcohol problems with no evidence of dependence relative to those who meet the criteria for dependence (NIAAA, 2000). Furthermore, a recent report indicates that this group is increasing in size while the prevalence of alcohol dependence is declining (NIAAA, 2004).

With just such a treatment population in mind, Dr. Reid Hester has been working since the early 1990’s on interventions to help struggling drinkers moderate their consumption, specifically through the use of computer and internet-based interventions. Dr. Hester has developed programs like Drinker’s Check-up that combine assessment and feedback to help people curious about the severity of their drinking get an accurate idea of how they relate to other people with similar problems. More recently Dr. Hester developed the intervention Moderate Drinking (MD), that combines a similar assessment process with a self-directed intervention based on the methods of Behavioral Self-Control Training (BSCT). BSCT is a behaviorally focused protocol that utilizes elements of self-assessment, monitoring, goal setting, and the exploration of drinking “triggers” to help self-motivated drinkers either regain control of their habit, or find their way to abstinence. BSCT, delivered in various formats, has been tested in more clinical trials than any other intervention devoted to alcohol problems, and its efficacy has been consistently supported by this research. As one prominent researcher noted, "BSCT has become the standard moderation-oriented treatment” (Heather et al., 2000).

Funded by NIH, we recently conducted a randomized clinical trial with 80 heavy drinkers to test MD’s effectiveness. Participants randomly assigned to the experimental group had access to both the MD program and use of the resources of Moderation Management (MM), an on-line support-group for people wishing to change their drinking. Those in the control group were enrolled in MM but did not have access to the MD program. We hypothesized that both groups would reduce their drinking and alcohol-related problems and those who had access to the MD program would have better outcomes than the control group.  And they did (Hester, Delaney, Campbell, & Handmaker, 2009).

At 3-month follow-up, individuals in both groups reduced how much they drank per drinking occasion, as well as reducing how intoxicated they got on those occasions by drinking more slowly.  What’s more, the participants with access to the MD program actually drank on fewer days. They also reported a greater reduction in the following alcohol related problems compared to the control group: physical and psychological health; interpersonal issues; and taking care of one’s responsibilities.

There was a notable exception: binge drinkers, who are defined by the NIAAA as having 4-5 drinks on average per occasion, did not do as well in either group—an indication that the degree of severity of abuse may moderate success in a self-directed protocol like BSCT. However, the corollary is not true, in that severity of clinical distress, as measured by the Brief Symptom Inventory, was not a mediator of drinking outcome.  In other words, the level of psychological distress in our study participants did not have a negative impact on their success with changing their drinking.

This latter finding has a direct implication for clinical practice. Clinicians with depressed or anxious clients, who happen also to be struggling with their drinking, ought to explore the possible benefits of referring their clients to Moderate Drinking or other available BSCT protocols. Behavioral programs like the one employed by MD can be helpful to therapists because of the clarity of their therapeutic targets, and the client will have direct tie-ins between the companion motivational and affective exercises and the work done in session. Assigning such “homework” might help clients get a handle on their drinking, increase their sense of self-efficacy, and enhance the overall course of therapy.

We have completed our 12 month follow-ups and are currently preparing a manuscript that reports those outcomes. Twelve months is the minimum time period to examine long-term outcomes because relapse rates flatten out by that time. Stay tuned.

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If you would like to learn more about this and other topics discussed on PBB, Psychotherapy Brown Bag recommends that you consult their online store of scientifically-based psychological resources.

William Campbell is enrolled in the clinical psychology doctoral program at the University of New Mexico and works as a research assistant at Behavior Therapy Associates

Dr.Reid Hester, a long time investigator of substance use disorders, is Director of the Research Division at Behavior Therapy Associates in Albuquerque, New Mexico.

Abandoning science and logic in the pursuit of an agenda

by Michael D. Anestis, M.S.

I try to keep a calm stance towards the topics we cover on PBB.  Obviously, Joye and I have our own beliefs about things, but we try to keep our opinions out of our writing to the degree that such a move is possible and to base all of our comments on empirical evidence.  In doing this, we try to keep emotion out of the picture and to therefore make it easier to facilitate civil conversations amongst readers.  That being said, occasionally a story takes hold in the media that simply makes me incredibly angry.  When the story is prompted by ignorance (e.g., a journalist with no training in data analysis writing on a topic with which he or she is unfamiliar), I find it relatively easy to turn that anger into frustration and understanding and to channel that into a calm discussion of the facts, thereby debunking myths and errors.  When the story is prompted by a willful misrepresentation of the evidence and an open effort to distort reality through a highly restricted discussion of data based purely upon highly flawed studies, on the other hand, my response is a bit more harsh.  All of this being said, today I would like to reflect on an article posted on a number of websites, including that of the American Psychological Association, an organization more than capable of looking at all of the data and accurately describing the facts (thanks to PBB guest author Dr. James Coyne for alerting me to this and making my topic choice for the day that much easier!).

This article is essentially an advertisement for the meta-analysis on psychodynamic therapy written by Jonathan Shedler and published in the American Psychologist that we discussed recently on PBB (click here for our coverage of the piece as well as free access to the journal article itself).  Now, keep in mind as you read my article today that I have nothing against Dr.Shedler as a person or psychodynamic therapy as a general concept; however, I do have strong negative opinions about sloppy interpretations of data and misrepresentations of facts and the article covered today is weighed down heavily by both of those things.

Before reading my discussion of the article, you might find it useful to read it for yourself so that you can form your own impressions first.  Click here to read it on the APA website and here to read the same text on Health Canal (you can leave comments on the article at Health Canal).

My approach today will be to quote the text of the article (in bold and italics) and then to reply below the quote.

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"Psychodynamic psychotherapy is effective for a wide range of mental health symptoms, including depression, anxiety, panic and stress-related physical ailments, and the benefits of the therapy grow after treatment has ended, according to new research published by the American Psychological Association"

In just about any news article, the first sentence (and the headline) will be an attention grabber and that's fine.  The thing is, the claims put forth in this sentence are, in large part, based upon horrifically flawed data.  Unfortunately, the vast majority of readers of that article are unaware of this fact and will never encounter those data.  As such, their lasting impression of this issue is an unfounded claim.  When discussing science, this is a dangerous approach.  When the APA is publishing material on its site, such a non-scientific approach is highly unimpressive.

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“The American public has been told that only newer, symptom-focused treatments like cognitive behavior therapy or medication have scientific support,” said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. “The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last.”

As with the sentence discussed above, I understand that including quotes by the authors of the article is a useful tool, but here again, a conclusion is stated and a passing reference is made to data...but the reader is left to believe that they are high quality data that produce irrefutable results.  As we discussed in detail in our original coverage of the Shedler piece, this is so far from the truth that it would be difficult to overstate.

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To reach these conclusions, Shedler reviewed eight meta-analyses comprising 160 studies of psychodynamic therapy, plus nine meta-analyses of other psychological treatments and antidepressant medications. Shedler focused on effect size, which measures the amount of change produced by each treatment. An effect size of 0.80 is considered a large effect in psychological and medical research. One major meta-analysis of psychodynamic therapy included 1,431 patients with a range of mental health problems and found an effect size of 0.97 for overall symptom improvement (the therapy was typically once per week and lasted less than a year). The effect size increased by 50 percent, to 1.51, when patients were re-evaluated nine or more months after therapy ended. The effect size for the most widely used antidepressant medications is a more modest 0.31. The findings are published in the February issue of American Psychologist, the flagship journal of the American Psychological Association.

The eight meta-analyses, representing the best available scientific evidence on psychodynamic therapy, all showed substantial treatment benefits, according to Shedler. Effect sizes were impressive even for personality disorders—deeply ingrained maladaptive traits that are notoriously difficult to treat, he said. “The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended,” Shedler said. “In contrast, the benefits of other ‘empirically supported’ therapies tend to diminish over time for the most common conditions, like depression and generalized anxiety.”

First off, the writer of this article should be applauded for including actual data here and attempting to explain the meaning of effect size.  Most mental health articles choose to skip such information, which is a disservice to the reader.  That being said, here is where the use of meta-analysis caused some real problems.  The numbers cited by the author sound highly compelling, but the results reflect poor data and low quality studies included in Shedler's meta-analysis.  If anyone takes the time to look at the actual results of the studies included in Shedler's work, they'll see a completely different picture and, again, I encourage you to read our earlier article on this topic to see precisely what I mean here (I describe the actual studies themselves in detail).  I realize that my opinion on meta-analysis is not universally accepted, but it would be difficult to argue against the point that many of the studies included in Shedler's study were of low quality and that the results directly comparing empirically supported treatments to psychodynamic therapy actually directly contradicted his conclusions.

Moving beyond this point, Shedler referred to these studies as the "best available scientific evidence on psychodynamic therapy."  That's fine...except that this evidence is of poor quality.  If this is the best that is available (an arguable assertion), than what is available is not good enough.

The claims of follow-up results are also not supported by the evidence.  That being said, click here to read a guest article written by John Ludgate, Ph.D on relapse in cognitive behavioral therapy (CBT).  That text will provide you with a more thorough understanding of what we know about this topic.

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“Pharmaceutical companies and health insurance companies have a financial incentive to promote the view that mental suffering can be reduced to lists of symptoms, and that treatment means managing those symptoms and little else. For some specific psychiatric conditions, this makes sense,” he added. “But more often, emotional suffering is woven into the fabric of the person’s life and rooted in relationship patterns, inner contradictions and emotional blind spots. This is what psychodynamic therapy is designed to address.”

This argument is one that consistently makes me irate.  It does so for a number of reasons.  First, it belittles the importance of symptoms.  Here's the thing, symptoms like panic attacks, suicidal ideation, the inability to experience pleasure (anhedonia), hopelessness, non-suicidal self-injury, binge eating, substance withdrawal, and antisocial behavior are actually quite important.  Helping a client to no longer experience those things is no small feat and nobody benefits when we act as though this is not the case.  Second, he implies that empirically supported treatments such as cognitive behavioral therapy ignore everything except the symptoms listed in the DSM.  There is no evidence that CBT does this or that psychodynamic therapy does it any less.  It is simply a talking point, repeated by those who oppose the EST movement often enough that people have come to believe that it is true.  Psychology is a science and, as such, our conclusions need to be founded upon evidence.  When people simply make claims like this without any sort of support and we take them at their word for it, the entire foundation of the field collapses inward and those most in need of help - the millions of people suffering from mental illnesses - are harmed.  As it turns out, EST researchers examine the impact of treatment on a vast array of outcomes unrelated to DSM symptoms, by the way, and a quick search through our articles on these treatments will provide you with numerous examples of this.

Additionally, the phrasing used by Shedler lumps proponents of ESTs in with the pharmaceutical and insurance industries, which are highly unpopular with most people.  As such, scientists are suddenly the "bad guys," pushing an agenda upon the people whereas psychodynamic therapists are the anti-establishment offering freedom from oppressive interventions.  The thing is, it's hard to be more closely associated with the establishment than psychodynamic therapy, which is such a popular conceptualization of mental illness and psychotherapy that it hard to find any media representation that takes any other approach.  This group had so much control over this field for so long that the initial two versions of the DSM used their jargon and directly asserted that mental illnesses were best thought of in those terms.  Empirically supported treatments are not motivated by profits (by the way, they take less time and cost less money than most psychodynamic approaches), nor are they associated with unpopular industries.  They represent the belief system of scientists, who rigorously test their theories through systematic investigations.

The bottom line is, whether or not "more often, emotional suffering is woven into the fabric of the person's life and rooted in relationship patterns, inner contradictions, and emotional blind spots," the treatment that makes those symptoms disappear and thereby improves the individual's quality of life is the better choice.  If a particular set of symptoms is treated and the client still has unresolved problems that he or she wants to address, practitioners who utilize ESTs are more than happy to address them.  Nobody is kicked out of therapy or forced to ignore their own problems - instead, rather than the old school psychoanalytic preference of charging hundreds of dollars per session for multiple sessions per week over a period of several years, the newer, evidence-based approaches specifically target the issues that prompted the individual to come in for treatment and address them in an effective, time-limited manner.  EST's simply prioritize things like reducing suicide risk as quickly as possible and I'm not certain I understand the counter argument to that priority.

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Shedler also noted that existing research does not adequately capture the benefits that psychodynamic therapy aims to achieve. “It is easy to measure change in acute symptoms, harder to measure deeper personality changes. But it can be done.”

This comment mystifies me and it's a great example of how our own biases can cause us to put forth arguments based upon contradicting points.  Up until this point of the article, we have been led to believe that the evidence supports psychodynamic therapy.  Still, there is a substantial research base left untouched (or misrepresented) in the Shedler analysis, so an answer is needed.  What answer is offered?  Evidence does not capture psychodynamic therapy.  So....first they say look at all of this incredible supporting evidence and then they attempt to disarm their opponents by pointing out that evidence in general is not useful.  In other words, let me shine a light on bad data that appears to support my case but simultaneously disavow data so that when people point out all of the evidence against my conclusions, I can say that it only contradicts me because it is not capable of seeing the truth.

This is the antithesis of science.  You can not simply shine a light on the results that (appear to) support you and disregard the results that contradict your conclusions.  Either science is good or it isn't (it is, by the way)...pick one.

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The research also suggests that when other psychotherapies are effective, it may be because they include unacknowledged psychodynamic elements. “When you look past therapy ‘brand names’ and look at what the effective therapists are actually doing, it turns out they are doing what psychodynamic therapists have always done—facilitating self-exploration, examining emotional blind spots, understanding relationship patterns.” Four studies of therapy for depression used actual recordings of therapy sessions to study what therapists said and did that was effective or ineffective. The more the therapists acted like psychodynamic therapists, the better the outcome, Shedler said. “This was true regardless of the kind of therapy the therapists believed they were providing.”

I discussed the flaws of this analysis in great depth in our original piece on this topic, so rather than rehash them here, I'll again encourage you to read the original article.  The studies upon which Shedler's conclusion here is based are so flawed it is actually mind-boggling.  He himself said in the original paper that "qualitative analyses of the verbatim sessions transcripts suggest that the poorer outcomes associated with cognitive interventions were due to implementation of the cognitive treatment model in dogmatic, rigidly insensitive ways by certain of the therapists."

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Before concluding today, I want to provide you with another link, brought to my attention through an email sent though the listserv of the Society for a Science of Clinical Psychology.  In this article, published in the LA Times (click here to read it), the results of the Baker et al (2009) report on the use of science in clinical psychology, are debated (click here for our coverage of the Baker et al report).  This is a distinct but related issue and I wanted to call attention to three quotes from the LA Times article to drive home my point for today. 

Quotes number 1 and 2 are from Drew Westen, a vocal critic of the EST movement.  He referred to those who favor the use of ESTs as "largely people who not only don't practice themselves -- and therefore have no idea what would be relevant to practice -- but have a tremendous disdain for people who do practice."  He also said that "[Cognitive-behavior therapy] is deliberately designed to ignore any relevant features of the personality of the individual."

Westen's first points, that EST supporters do not practice, that practicing is required in order to understand therapy, and that EST researchers have disdain for practitioners are, quite frankly, falsehoods.  Many researchers are active clinicians.  In fact, I would bet heavily that the proportion of researchers who practice is substantially higher than the proportion of clinicians who conduct and read research.  Additionally, whereas all researchers are trained in therapy as part of graduate school and internship, not all clinicians are trained in research.  If experience is required to understand one, than aren't non-scientific clinicians the only ones incapable of understanding the entire picture?  Finally, upon what evidence does he base the claim that researchers have disdain for clinicians and, along those lines, what evidence does he have that clinicians have less disdain for researchers?

Westen's second point, that CBT was designed to ignore personality, is absurd.  CBT is designed to address aspects of mental illnesses that have been shown to be common across individuals in order to maximize symptom relief; however, there is plenty of flexibility to work with the client as an individual.  Regardless, given than CBT and variants of CBT (e.g., dialectical behavior therapy) have been shown to be effective in the treatment of personality disorders, it seems a bit off base to say that personality is not addressed in CBT.

Quote number 3 is from Michael Lambert, who said "I don't care what psychotherapy the person is getting.  I care whether they're responding."  He said this in an effort to point out that proponents of ESTs care more about providing a particular treatment than they do about clients responding to treatment.  This, again, is absurd.  The entire premise of the EST movement is that certain treatments have been shown, on average, to produce better results for particular diagnoses.  These treatments are thus considered the best choice; however, nobody believes everyone will respond in the same manner to the same treatment and, as such, assessment is required in order to ensure that improvement is happening.  Because EST proponents believe in this so wholeheartedly, an enormous research base has developed enabling us to better understand the impact of treatment.  Opponents of EST's on the other hand, eschew assessments and, as such, have no idea the degree to which their treatment choice is effective.  So, ironically, in his attempt to criticize the EST movement, Lambert actually explained one of the primary reasons why ESTs are so important.  He also sheds a light on why the research base upon which Shedler built his case is so flawed.

***

So...what's my overall point today?  Quite simply, the point is that when we hear somebody say something is a certain way, we need to always ask how they arrived at that conclusion and, when possible, we need to examine the evidence ourselves.  In a meta-analysis like the one conducted by Shedler, it is easy for the authors to paint a picture that supports their point and to make very compelling statements that sound intuitively profound.  If we do not look at the evidence underlying their conclusions, we are vulnerable to falling into traps.  The claims made by people like Shedler, Westen, and Lambert are not a malicious attempt to mislead the populace, but they represent a sloppy, non-scientific approach to understanding mental health and psychotherapy.  The media stories covering such claims result in a form of deception that makes me remarkably upset.  If we simply listen to their words or the descriptions of journalists who write about them, we will not see things accurately.  When organizations like APA post this type of thing on their website, they make the problem even worse.

Here on PBB, I likely say things readers disagree with on a daily basis.  The thing is, I will always provide you with the citations upon which my points are based and will openly discuss the data with you.  If you know of data I overlooked that calls my point into question, I encourage you to mention it in the comment section so that we can all have a civil discussion about these things.  The next time I change my mind on an issue won't be the first, but this only happens when I am made aware of evidence that makes my previous position a worse reflection of reality than an alternative position.  In the meantime, please, when you read about topics like this, make sure that what the article says is actually supported by valid evidence.

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If you would like to learn more about the 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

Suicidal behavior is not a "spur of the moment" action

by Michael D. Anestis, M.S.

In the research world, the more times we see a result happen, the more confident we become that it represents a real phenomenon rather than pure chance.  This approach keeps us from getting overly excited about one significant result or overly confused by one non-significant result.  Over time, one finding that has been repeatedly supported and, as such, appears to represent a true phenomenon, is a significant relationship between impulsivity and suicidal behavior.  This finding has, by no means been supported without fail, but it has been supported enough times using enough different measures of both impulsivity and suicidal behavior that little debate remains regarding whether the relationship is real.

For those of you who are unfamiliar with the concept of impulsivity, it is loosely defined as the tendency to act without consideration of the implications and consequences of that action.  That being said, a number of competing definitions of the term exist and we have covered those in previous posts (click here for an example).  The general point though, regardless of the sloppiness of a term like "impulsivity," is that data linking the idea to suicidal behavior has prompted a widely held belief that suicidal behavior is often a "spur of the moment" decision rather than a highly planned action built up to over time.

This idea has intuitive appeal.  We've seen it in television and the movies - an individual was going along fine until something awful happened and, because in that moment they saw no other escape, they took their own life.  This decision is portrayed as something that had not occurred to the individual until that moment, as though it suddenly dawned on them that this opportunity existed, that an answer had been revealed. For generations, this has been a popular viewpoint held by many remarkably prolific psychologists, including many whose careers focus almost entirely on the concept of suicide.

At first glance, you might be wondering how, given the above information, I arrived at the title of this article: suicidal behavior is not a "spur of the moment" decision.  After all, there is an undeniable statistical link between impulsivity and suicidal behavior and a number of prominent researchers support the notion of impulsive suicide.  My first response is a quick reminder that a correlation between two variables does not tell us a whole lot about the relationship.  What it says in this case is that, as an individual demonstrates higher levels of trait impulsivity (a tendency, across their life, to engage in impulsive behaviors), the likelihood of their death by suicide increases.  What it does not say is that their death by suicide occurs in an impulsive fashion. In other words, there is every reason to believe that another variable related to both impulsivity and suicidal behavior explains the relationship.  We'll return to that point in a bit.

So...is there any evidence to support the notion that, despite a relationship between impulsivity and suicidal behavior, the action itself is not a "spur of the moment" action?  Absolutely.  In a wonderful study published in the Journal of Affective Disorders and conducted by a number of my colleagues at Florida State University (Witte, Merrill, Stellrecht, Bernert, Hollar, Schatschneider, & Joiner, 2008), the authors looked directly at this phenomenon.  I alluded to this study briefly at the end of 2009 when I published my commentary on the importance of providing condolence letters to the families of soldiers who die by suicide (click here for that article).  Using a sample from the Youth Risk Behavior Survey collected between 1993 and 2003, PBB guest author Tracy Witte and her colleagues (2008) looked at adolescents who had planned for a suicide attempt but did not actually attempt (n = 5,685), adolescents who did not plan but did attempt (n = 1,172), and individuals who both planned and attempted (n = 4,807).

What did they find?  Individuals who had planned without attempting were less impulsive than were individuals who attempted without planning and individuals who had both planned and attempted (this makes sense, given that attempt status is typically associated with impulsivity).  Importantly however, individuals who attempted without planning had lower impulsivity scores than those who had both planned and attempted.  In other words, the more impulsive you are, the more likely you are to plan before attempting.  Additionally, less than 25% of the suicide attempts in this sample were "impulsive," indicating that such a style is far from the norm.

Looking at those results, you might still think 25% is a fairly large number given the title of this article.  Fair enough.  To address that further, it helps to consider another important set of findings, which Witte and colleagues (2008) mentioned in the introduction of their study.  In 2001 and 2005, Baca-Garcia and colleagues found that the more impulsive a suicide attempt is, the less medically serious it tends to be.  In other words, the vast majority of suicide attempts involve significant planning and those that do not tend to be of lower severity.  Now, keep in mind that this does not mean that a lethal impulsive attempt never happens but rather that such an occurrence is extremely rare even relative to other styles of attempt, which statistically speaking are also fairly rare (even with an average of 32,000 deaths by suicide annually in the United States, which is a large raw number that requires significant attention but which represents a small fraction of the population).

So how can we explain all of this?  The most theoretically sound framework appears to be Joiner's (2005) interpersonal-psychological theory of suicidal behavior, which we have covered frequently on PBB.  The theory states that, in order to enact lethal self-harm, an individual must not only desire death by suicide but must also acquired the capability to do so.  The acquired capability is accrued through repeated exposure to painful and provocative events, which over time increase an individual's ability to tolerate physical pain and decreases an individual's fear of death.  Impulsive individuals, over the course of their lifetime, encounter a greater number of painful and provocative events and, in doing so, they develop the capability to engage in lethal suicide attempts.  Developing this ability, however, does not mean that they will engage in the behavior impulsively.  Rather, it simply means that, through their impulsive lifestyle, they have become less fearful of death and pain and that when they consider death by suicide, they are more likely to choose and utilize a lethal means.  They might think about suicide impulsively, with the thought entering their head suddenly in response to a negative event, but they are unlikely to actually make an attempt as quickly.  Instead, frequent bouts of ideation are likely to make them frequently contemplate specific ways in which they would consider attempting and how they might go about acquiring those means and enacting an attempt.  Their thoughts might not be recognized by anyone else around them and, as such, the attempt itself might seem to come from "out of the blue," but the fact that they did not talk about it (or that their words seemed to simply reflect a great amount of discomfort rather than a true desire for death) does not mean that they were not present for a long time, increasing in severity and becoming more specific over time.

Summary:

Without question, impulsivity is related to suicidal behavior.  That being said, the data do not support the notion that suicide attempts tend to occur on the "spur of the moment" without substantial planning.  In fact, a study by Witte and colleagues (2008) indicated that impulsive individuals tend to plan their attempts more than non-impulsive individuals and studies by Baca-Garcia and colleagues (2001, 2005) demonstrated that the more impulsive an attempt is, the less medically serious it tends to be.  Given that only 25% of the attempts in the Witte et al (2008) sample were considered impulsive and that such attempts have been shown in other studies to typically be less severe, this paints a very different picture than what many people have considered.  Rather than being the result of a sudden surge of discomfort and a desire to escape, suicidal behavior appears to be a process built up to over time, the result of substantial planning.  Seen through the lens of Joiner's (2005) interpersonal-psychological theory, this pattern reflects the importance of considering the acquired capability for suicide, which people build up to independent of whether they have any desire for death through the repeated experience of pain and provocation.

Importantly, these findings are not evidence that suicide never occurs impulsively, but rather that this is far from the norm.  Just because two variables are related to one another - in this case, impulsivity and suicidal behavior - does not mean that their relationship is as straight forward as we might intuitively believe.  In this case, the evidence supports a more indirect relationship: impulsivity causes individuals to engage in the types of behaviors and experiences likely to increase their acquired capability for suicide.  When and if such individuals ever experience the desire for suicide, they are thus more likely to actually enact lethal self-harm than are individuals without such a history of impulsive behaviors.  That being said, their attempts are likely to be highly thought out, with substantial planning and preparation, even if those activities are unknown to everyone around them.

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If you or anyone you know is experiencing thoughts of suicide, please dial 1-800-273-TALK, which is an anonymous and free service available 24 hours per day specifically to help with this type of situation.  If you are uncomfortable calling that number, please consider dialing 911 or going to a local emergency room.

If you would like to learn more about suicidal behavior and its treatment, we recommend the following items, all of which are available through our online store for scientifically-based psychological resources:

• Why People Die by Suicide by Thomas Joiner
  

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

New podcasts from BehaviorTherapist.com

by Joye C. Anestis

Our friends at the Cognitive-Behavioral Therapy Center of Western North Carolina (BehaviorTherapist.com) have released two new excellent podcasts, geared toward both consumers and professionals.  We at PBB are continually impressed the the caliber of individuals that are interviewed as part of this series. 

The most recent one is an interview with Dr. Judith Beck, cognitive therapist, director of the Beck Institute for Cognitive Therapy, and daughter of Dr. Aaron Beck, the creator of cognitive therapy.  In the interview, Dr. Beck discusses the basics of the cognitive model, her recent work with cognitive therapy and weight loss (you can also check out her book on this topic, The Beck Diet Solution), the Academy of Cognitive Therapy, how to find a competent cognitive therapist, and current directions in cognitive therapy.  I've attended workshops given by Dr. Beck at ABCT in the past, and she is an excellent teacher and speaker.  Listen to the podcast here.

Earlier in the month, an interview with Dr. Marc Branch of the University of Florida on behavioral pharmacology was released.  Behavioral pharmacology is the study of the effect of drugs on behaviors.  Topics covered in this interview include the behavioral pharmacology perspective on addiction, a discussion of Peter Dews' research, behavioral factors related to tolerance, and exposure and anti-anxiety agents.  I am not as familiar with the field of behavioral pharmacology, so this podcast is an excellent learning tool for me...hopefully, for some of you as well!  You can listen to it here.

We are always looking for podcasts to listen to and advertise...let us know if you know of any other good ones out there that promote the science of clinical psychology (and even those that promote science in general!).

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

How experienced is your therapist and does that even matter?

by Michael D. Anestis, M.S.

In most of our articles, we look at the different characteristics of clients that predict therapy outcomes.  Today, however, I would like to turn that question around and instead look at a characteristic of therapists that many believe is critical to therapeutic outcomes: experience.  I suspect that most everyone, given the option, would prefer to work with a therapist who has decades of experience rather than one who is a novice, perhaps still in the midst of his or her graduate training.  After all, it seems reasonable to assume that, as a therapist spends more time working in the profession, he or she will develop more skill and become better equipped to help their clients battle mental illness.  As it turns out, this is an empirical question, one that we can answer by comparing the outcomes of therapists with varying levels of experience, so we do not need to rely upon our intuition on this matter.

Over the past several decades, a number of researchers have attempted to address the question of how important a therapist's experience is with respect to producing good outcomes.  What may come as a surprise to many of you is that, more often than not, studies indicate that a greater level of experience is not related to better outcomes (e.g., Beutler, Machado, & Neufeldt, 1994; Christensen & Jacobson, 1994).  This finding is not universal or without controversy and some researchers have pointed out that most studies examining experience only consider number of years practicing therapy (or years since graduate school) rather than specific components of experience (e.g., number of clients treated, level of training in that particular treatment) that might be more telling (e.g., Beutler, 1997).  Today, I would like to provide you with a quick summary of some of the research on this topic and then open up a discussion about what we can take away from these findings.

In one widely cited study conducted by Paul Crits-Christoph and a number of his colleagues (1991), the authors found that, while therapists with a greater amount of experience did produce better results overall, this was only true when they failed to use treatment manuals.  In other words, if therapists follow protocols based upon scientific studies that have shown that specific procedural plan to produce quality results, level of experience does not matter; however, when therapists simply improvise and use their intuition to guide treatment, experience matters quite a bit.  Given that empirically supported treatments - those that have been repeatedly shown to produce the best results - utilize manuals, this finding highlights the possibility that experience becomes less important when the type of treatment being used is of a higher quality.   

In a study conducted by John Dunkle and Myrna Friedlander (1996), the authors were surprised to find that therapist experience was unrelated to therapeutic alliance as rated by the client.  The authors had anticipated that therapists with more experience would have an easier time connecting with their clients and making them feel as though the working relationship was strong and conducive to treatment, but as it turns out, newer therapists were just as capable in this regard. 

In a naturalistic study conducted in an outpatient clinic by Franklin, Abramowitz, Furr, Kalsy, and Riggs (2003), the authors found that therapists with little experience in conducting exposure and ritual prevention (EX/RP) for obsessive-compulsive disorder (OCD) produced results just as strong as those produced by therapists with substantial experience in that treatment approach.  Importantly, because it was a naturalistic study, clients were not randomly assigned to therapists and, in fact, the more experienced therapists treated the most severe clients.  To address this, the authors examined whether the two groups differed in their outcomes when statistically controlling for initial OCD severity and found that they did not.  In other words, while the study had some important limitations, the results were consistent with the idea that experience does not impact outcome in a "real world" setting in EX/RP for OCD.

In one final study I want to note (although there are certainly others and I welcome your thoughts on other studies not included in this article), Jonathan Huppert and colleagues (2001) examined the impact of therapist experience in cognitive behavioral therapy (CBT) for panic disorder (PD).  They found that experience had no impact on the number of panic attacks clients were having following treatment (the primary outcome measure); however, therapists with greater experience were more successful in helping their clients reduce several secondary symptoms, including anxiety sensitivity and overall panic severity.

What does it all mean?

Given that the vast majority of the evidence indicates that having a lot of experience does not make a therapist more likely to help their clients get better, what should people consider when making a decision on which therapist to see?  There is no single right answer to that question, but our thoughts are that people seeking help for mental illness should most heavily consider the following variables rather than therapist experience:

1. Does the therapist utilize empirically supported treatments?  Ask your therapist how he or she arrives at diagnoses and makes treatment decisions and ask your therapist what evidence he or she has to support the idea that the treatment being recommended, on average, produces better results than would another form of therapy (pharmacological or psychosocial) for your particular set of symptoms.  This type of information should not be withheld from you and personal experience does not overrule scientific studies, even when it sounds remarkably compelling.
2. Does the office feel like a place that you will be comfortable going for help?  Ultimately, therapy only works if you stick with it, go through the protocol, and work on your assignments between sessions.  If you are not comfortable, you are less likely to do this.  That being said, while we consider this variable important, we think it is significantly less pivotal than the degree to which the therapist provides therapy based upon empirical evidence.

The studies cited in this study do not conclusively rule out the possibility that, at least in some circumstances, therapist experience is important.  That being said, they do make it difficult to justify considering experience to be one of if not the most important consideration in determining whether a therapist is likely to produce optimal results.  Just because somebody has been doing something for a long time does not mean that they are doing it well and, even if they are, it does not mean that they are outperforming their less experienced peers.

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If you would like to learn more about this or other topics covered on PBB, we recommend consulting our online store of scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Thinking it through: How cognitive responses to emotions impact our vulnerability to stress, anxiety, and worry

by Michael D. Anestis, M.S.

Everybody has their own way of responding to negative emotions.  Some of us work to change such feelings while others of us accept negative emotions non-judgmentally as a natural occurrence.  Some of us brood over the meaning of what we are feeling and others of us shift our attention to other, more positive thoughts.  Some of us turn to binge eating whereas others of us inflict bodily harm upon ourselves.  A number of these responses are rather healthy and, in fact, are predictive of positive mental health outcomes, whereas others have been shown to make problems worse and to increase the likelihood of harmful outcomes.

On PBB, we have spent a fairly substantial amount of time talking about emotion regulation - the manner in which an individual attempts to alter or sustain an emotion.  A large portion of that discussion has centered on behavioral methods for changing how we feel, such as binge eating, non-suicidal self-injury, and substance use.  Additional articles, however, have touched on what is referred to as cognitive emotion regulation: attempts to change how we feel by thinking in particular ways (whether or not we are aware that our thoughts are serving that function at the time).  For example, several earlier PBB articles discussed rumination, a thought style involving the tendency to brood over negative feelings.

In an article just published in Personality and Individual Differences, Kimberly Zlomke of the Baylor College of Medicine and Kathryn Hahn of Millsaps College (go Majors!) (2010) took a closer look at the different cognitive emotion regulation strategies used by men and women and how those strategies relate to a number of problematic outcomes, including stress, anxiety, and worry.  To do this, the authors administered a number of questionnaires online to a sample of 1,080 undergraduates.

Results:

In total, the cognitive emotion regulation strategies most frequently used were positive reappraisal (reframing a negative event/emotion in a positive light), refocus on planning (shifting one's thoughts towards ways in which the situation can be resolved effectively), and putting into perspective (considering the negative event/emotion in the context and thereby not overstating its importance).

For men, the use of rumination (brooding over negative emotions) or catastrophizing (thinking about all of the bad things that could happen as a result of the event/emotion) predicted increased levels of worry and stress.  On the other hand, the use of "refocus on planning" predicted lower levels of anxiety, stress, and worry.  

For women, the use of self-blame (assigning fault to oneself), rumination, and catastrophizing was associated with higher levels of anxiety, stress, and worry.  On the other hand, higher levels of acceptance and positive reappraisal predicted lower levels of worry.

What do the findings mean?

Based on this study, it appears that some cognitive emotion regulation strategies are harmful in both men and women.  Specifically, rumination and catastrophizing were both associated with increased levels of worry in men and women.  This is not surprising, as prior research has demonstrated that, while rumination is far more common in women than in men, it is just as harmful for men when they think in that manner (click here for our discussion of such research). 

Perhaps more interestingly, the authors found that other strategies work differently in men versus women.  For men, focusing attention on how to handle a negative event ("refocus on planning") was predictive of lower levels of worry, anxiety, and stress whereas for women, accepting a negative event/emotion and reframing it in a positive light were associated with decreased levels of worry.  In other words, some of the cognitive emotion regulation strategies that work for men do not necessarily work for women and vice versa.

Concerns:

No doubt, findings like these are interesting, but they need to be considered with care and subject to a reasonable amount of skepticism.  Almost any time you compare two large groups of people on a large number of variables, the groups will differ from one another statistically on some of those variables.  Some of those differences are due purely to chance whereas some of them are true differences.  Even some of the true differences are questionable, however, because statistical significance in a large sample does not necessarily reflect a large difference.  All statistical significance means is that the results are not likely due to chance (more specifically, that there is a less than 5% chance of finding the results purely by chance), not that the differences are big. 

All of that being said, if you are going to make comparisons like this, which is a worthy venture, it is important to have guesses made ahead of time as to how the results will end up and evidence from prior studies that support your rationale for making those guesses.  In other words, we need to have a sense of why something happened and be able to use that justification to predict future results rather than simply looking at something that happened and attempting to rationalize it.  Given the lack of research in this area, Zlomke and Hahn should not be faulted for taking a more exploratory approach, but we would need to see these results replicated before we could be fully confident that they reflect a robust series of relationships that generalize across samples.

As it turns out, I have collected multiple data sets on undergraduate samples using the same primary measure - the Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski et al., 2001).  In an effort to see whether or not the findings from Zlomke and Hahn (2010) were due purely to chance, I took a quick look at one of those data sets a moment ago and found the following results (the numbers represent the average score for each group on each CERQ subscale):

	Self-Blame	Acceptance	Rumination
Men	12.03	13.51	12.02
Women	11.10	13.80	12.97
	Refocus on Planning	Positive Refocus	Positive Reappraisal
Men	14.22	10.66	14.79
Women	14.27	10.93	14.54
	Put into Perspective	Catastrophize	Blame Others
Men	14.34	9.48	9.68
Women	14.21	10.31	9.29

Taking it a step further, I looked to see whether any of the differences between men and women on these scores were statistically significant.  None were, although two approached significance: self-blame (p < .078) and rumination (p < .06).

My next step was to see which of these subscales were significantly related to depression and anxiety for men and women.  For men, higher levels of refocusing on planning and positive reappraisal were associated with lower levels of depression.  Also for men, higher levels of rumination predicted higher levels of anxiety.  No other subscales were related to depression or anxiety.

For women, higher levels of self-blame, rumination, catastrophizing, and blaming others were associated with higher levels of depression and anxiety.  Surprisingly, higher levels of acceptance were associated with higher levels of depression.  Also for women, higher levels of positive refocus, positive reappraisal, and putting into perspective were associated with lower levels of depression and anxiety and higher levels of refocusing on planning were associated with lower levels of anxiety.

Now, to be fair, my sample size was only 200 people and approximately two-thirds of my sample was female, so finding significant differences between the groups is a bit difficult.  At the same time 200 people is not tiny, so these results should not be dismissed out of hand.  As you can see from my results, there is reason to be somewhat skeptical of the findings of Zlomke and Hahn (2010). 

In my sample, there were no significant differences between sexes on the use of particular cognitive emotion regulation strategies, although the small sample size may have obscured some differences and, indeed, self-blame and rumination were close to the threshold for significance (p < .05).  Additionally, the manner in which different subscales are associated with problematic outcomes was very different than what was reported in the Zlomke and Hahn (2010) paper.  Now, to be fair here too, I used related but different outcome measures (the Beck Depression Inventory - II and the Beck Anxiety Inventory) than Zlomke and Hahn (2010) did, but the differences are still hard to overlook.  Not only were the results not identical, some completely contradicted one another (e.g., in my sample, acceptance was associated with more depression whereas in their sample it was associated with lower levels of worry).

Take-home message:

So what should you take away from all of this?  First of all, it is interesting to consider the ways in which we manage our emotions through styles of thinking and it is more than reasonable to see if men and women differ in their strategies and if the results of those strategies differ for men and women.  At the same time, if we simply run a large number of exploratory analyses in a large sample, the degree to which we can be confident that our results mean anything is very limited.  When I ran a series of similar analyses with my own data, based upon a smaller but demographically similar sample, my results were very different.  How do we know who is right?  The answer is replication, replication, replication.  There is interesting information to learn here, but to learn it we need to see how these things shake out over time when the same tests are run several times by different people independent of one another.  What we think we learn from one data set needs to be tested in a new one in order to see if our new theories can predict results we have not yet seen or if those theories simply reflect an interesting but misguided attempt to explain something that already happened.

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If you would like to learn more about rumination and worry, we recommend the following items, which are available through our online store of scientifically-based psychological resources:

• Women Who Think Too Much: How to Break Free of Overthinking and Reclaim Your Life by Susan Nolen-Hoeksema
  

• The Worry Cure: Seven Steps to Stop Worry from Stopping You by Robert Leahy

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Mortality rates in eating disorders: adding EDNOS to the equation

by Joye C. Anestis

By now it's pretty much common knowledge that eating disorders are devastating.  For instance, we know that anorexia nervosa (AN) has the highest mortality of any psychiatric disorder (10%; APA, 2004).  Surprisingly, most of these deaths are by suicide, not medical complications associated with starvation (e.g.,Crisp, Callendar, Halek, & Hsu, 1992; Fedorowicz et al., 2007).  The mortality rate for bulimia nervosa (BN) is lower (approxiamtely 0.3%; Keel & Mitchell, 1997), although suicide attempts are highly elevated with this diagnosis (1/3 of women with BN will attempt suicide at least once; e.g., Corcos et al., 2002; Franko et al., 2004).  Less is known about the mortality rate for eating disorder not otherwise specified (EDNOS), the most common eating disorder diagnosis.  This catch-all category consists of almost any pathological eating behaviors that do not fit the criteria of AN or BN (e.g., binge eating disorder, purging disorder, night eating syndrome).  Scott Crow and colleagues recently examined the mortality rate in all eating disorders, and specifically in EDNOS, to cover this gap in our knowledge (the article, from the December 2009 issue of American Journal of Psychiatry can be accessed here).  

Subjects in this study were individuals who presented to the University of Minnesota Outpatient Eating Disorders Clinic between 1979 and 1997 (n = 1,885).  Each client at this clinic completed the Eating Disorder Questionnaire and reported their Body Mass Index (BMI).  These 2 pieces of information were used to generate diagnoses of a current ED (and this reliance on self-report to make diagnoses is a significant limitation to the study that should be considered).  To obtain mortality information, the researchers examined the National Death Index, a computerized database of state vital statistics data compiled by the National Center for Health Statistics.  Updated yearly, it provides vital status information for the entire United States.  Crow and colleagues were able to search this database and classify causes of death into 4 groups: suicide, substance-use related, traumatic, and medical.

The entire sample was overwhelmingly female (95.1%) and white (94.9%).  BN was the most common diagnosis (48.1%), followed by EDNOS (42.5%) and then AN (9.4%).  The mortality rate for BN was 3.9%, which is higher than is generally found, while the mortality rate in AN was lower than expected at 4.0%.  But the main focus of the study was on EDNOS - where they found a mortality rate higher than most would have expected at 5.2%.  Along with reported percentages of death, the authors also calculated  standardized mortality ratios, which they describe as "the ratio of the observed rate of deaths in a population divided by the expected rate, based on the sample's demographic characteristics" (pp. 1343-44).  The standardized mortality ratios for all deaths were 1.70 for AN, 1.57 for BN, and 1.81 for EDNOS.  They also reported separate standardized mortality ratios for deaths by suicide.  They were 4.86 for AN, 6.51 for BN, and 3.91 for EDNOS.  They noted that the elevated suicide risk for AN was not statistically significant, but the elevated risks for BN and EDNOS were significant.

The most interesting and novel finding reported here is the significant number of deaths by suicide in the EDNOS sample - a rate similar to that found in individuals with AN.  It is (I hope) common knowledge within the mental health community that AN is an incredibly lethal illness (see this previous post for a brief discussion about why AN is so lethal, above and beyond the effects of starvation).  The authors note that many perceive an EDNOS diagnosis to be less severe than other eating pathology, and these findings emphasize the fallacy in this perception.  Suicide risk should always be assessed and monitored in EDNOS patients, just as in all patients with mental health problems.  One downfall of this study is that they did not report subgroups of individuals within the EDNOS category.  EDNOS is an incredibly heterogeneous group of behaviors, including individuals who meet criteria for AN except that they have regular menstrual cycles or their weight is in the "normal" range, individuals who meet criteria for BN except that they binge and purge less frequently than the DSM requires, folks with purging disorder, folks who chew and spit out their food without swallowing, and individuals with binge eating disorder.  I think it would have been very interesting to see if certain types of behaviors (e.g., purging disorder) were carrying much of the suicide risk.  Another notable limitation, and one which could have influenced the elevated mortality risk, is that obese individuals with binge eating disorder were referred to a different clinic.  This could have led to a skewed EDNOS sample.

This study also found a lower mortality rate for AN than previous studies.  The authors note that this could be the result of methodological differences between their study and others.  The current study used a current diagnosis of AN, whereas previous studies have used lifetime diagnoses.  In fact, when the authors reexamined their data using lifetime diagnoses, the standardized mortality ratios for all death and death by suicide both increased and became significant.  Furthermore, these were outpatient clients, and perhaps more serious cases of AN would be more likely to seek treatment at an inpatient facility.  

In sum, Crow et al.(2009) present evidence that suicide risk and overall mortality in EDNOS should be examined more closely.  I bet, with the upcoming release of DSM-V and the revamping of the eating disorder section, more research into this heterogeneous category will be conducted.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.