Theoretical Orientation?

[Sorg1123]

Is anyone else having a hard time defining their theoretical orientation? I get the feeling that my inclination toward CBT may be premature as my experience is mostly in behavior modification and I don't have much experience exploring other models. Also, I expect my perspective to evolve while in graduate school (why else go?) Can anyone else relate to this? Care to share your story?

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[Anon15]

I have worked in two research/clinical setting, both hospitals in major cities, both very different orientations. One was very CBT/DBT and the other was very old school psychoanalytic (couches and all)/psychodynamics. Personally, I lean heavily on the CBT end. I like the work of David Barlow (e.g. exposure therapy). He heads up CARD at Boston University.

I certain think some aspects of pychodynamic orientation are useful (e.g. I am big fan of defense mech) however, I have heard one to many psychodynamically oriented psychiatrists state that his/her patient is not making any progress in therapy because he/she cannot overcome his/her urge to have sex with them. Probably not the norm, I worked in a very "old school" establishment.

I think you will find your way through your coursework and further experience in different settings.

 

[doctorpsych]

Is anyone else having a hard time defining their theoretical orientation? I get the feeling that my inclination toward CBT may be premature as my experience is mostly in behavior modification and I don't have much experience exploring other models. Also, I expect my perspective to evolve while in graduate school (why else go?) Can anyone else relate to this? Care to share your story?

I think most undergrad psych students are more aligned with psychoanalytic/freudian, not surprised given much of the classes in undergrad are breath/intro course... coupled that with hollywood's fascination with ego, DID, defenses, unconcious, hypnosis, 'couch' therapy... psychoanalytic orientation fascinates people and makes good movies... CBT is not as fascinating, rather simple in comparison to analytical theories... but not to discredit anything here...

in my own experience, I started out leaning more toward freud... then in grad school became more beckian-ellis-barlow, then in practice began to incoorporate both... there are some pretty interesting 'combined' theories like schema therapy (Young)...

 

[50960]

There is really no utility in having a theoretical orientation that you identify with until you have been seeing patients for a few years because it will change drastically after that. Also, to be a good psych you really need to be able to use many modalities well, so eclectic is the real endpoint for most.

 

[Therapist4Chnge]

I was going to post something like this up a couple days ago. I wanted to inquire about people's orientations, and the settings they are in, etc.

Anyhow.....

I think people starting out will latch onto one orientation and work with it; CBT seems to be the prevailing one at the moment. I think it is important to become comfortable and effective in one orientation before starting to really dive into others. Of course, there are elements that can be cherry picked here and there, but a strong foundation is needed in each orientation before you really start using it as a primary treatment orientation.

I think the longer someone practices, the more likely they'd be to trend towards 'eclectic' because they'd integrate numerous interventions and frameworks, depending upon what is appropriate for the pt.

I am at the beginning of my career, so i'm actually going through much of this now. I am sure I will shift throughout my career as I acquire more experience and knowledge. I've found a psychodynamic conceptualization to work best for me, though others might prefer another approach.

That being said, I don't limit myself to working only psychodynamically (I lean towards an object relations approach) in treatment. I think there are great pieces in a number of different orientations, but it is important to not utilize conflicting approaches. I take stuff from Carl Rogers, Harry Stack Sullivan, Beck, a bit from Frued, and then stuff I picked up along the way. Some pts would not do well with certain orientations, so flexibility is important.

I like to integrate CBT interventions as needed (it works well with certain types of patients), but I've found it to be a bit to 'surface level'. Dealing with distorted thoughts, thought log/journaling, etc....can be great, but I think some pt's lean on the 'tasks' too much (esp. with perfectionists), and instead need to look deeper, which is why I really like a more psychodynamic approach. No matter what you work with, always be aware fo the therapuetic relationship. Without a healthy TR....you are pretty much dead in the water.

I am still very much developing my own style; and I know it will be more of a fluid process, instead of having a definitive beginning, middle, end. I try to talk to colleagues and mentors to pick up as much as I can when i'm not in a session.

I'd love to hear other people's experiences with how they developed their style.

-t

 

[docjohng]

Except for the extreme dogmatic therapists, the majority of practicing therapists do not "stick" to a specific theoretical orientation with their clients. They may be inclined to CBT or psychodynamic or behavioral or client-centered or goal-oriented or REBT, but at the end of the day, they'll work with their clients on a very personal, individualistic and, dare I say, eclectic basis.

So, by all means, learn all you can about each and every theoretical orientation, but incorporate them into your own understanding of the human psyche.

John

 

[Sorg1123]

Thanks all, that's all very helpful advice👍

 

[dakwegmo]

Sorg1123 are you referring to a question on an application, or for a part of your SoP? I take it this is part of the whole application game.

One of my apps asked me to identify my approach to clinical psychology. It said to select all that apply and had options like CBT, Psychodynamic, Eclectic, etc. After talking to a grad student there, she said it would be a mistake to put anything but CBT. When I checked one of the grad school guides, it said 94% of the faculty had a CBT approach.

 

[Sorg1123]

My question came from my interview preparations. I wasn't sure how committed I should be to a particular model at this stage of my career.

 

[ClinicalScience]

A clinician's personal theoretical orientation does not matter at all, whether they conceptualize a case in the CBT framework or the psychodynamic framework. What does matter is that their treatments being used are empirically based, and that they are using the treatment that various studies, especially randomized controlled trials, support the efficacy of. For example, even if you hold a psychodynamic orientation, and individual with OCD should be treated with exposure and response prevention - period. No other therapies have demonstrated stronger and more effective results when treating OCD than EX/RP. Therapists should not use personal preference on theoretical orientation in the treatment of their patients - they should use science as a guide, picking the scientifically appropriate therapy (following the treatment manual as closely as is possible) to match the appropriately assessed diagnosis. And when there is no empirically based treatment for a disorder (such as anorexia), you should do everything you can based off of the existing literature to make your treatment as scientifically based as possible.

For way too long people have battled over which theoretical perspecitve is correct, and the only way to objectively determine which therapy is best is through science. This same battle was fought long ago in feilds like medicine, where 150 years ago you could buy Uncle Harold's Snake Oil to cure what ailed you and there was no quality control. Unless you are doing a scientifically based treatment for a specific disorder (or as close as you can get for some disorders) you are being an unethical therapist - the same way that Uncle Harold would be unethical claiming that his Snake Oil cures diabetes.

If you want to do well as a clinician you should keep what I've said in mind. Put this into your grad school applications as your empirical orientation and faculty will be impressed - especially if you are applying to a decent PhD program (apparently Psy.D. programs have not yet accepted this, and for this reason are less respected by Ph.D. programs). Just remember, psychology is not mystical or magical - it is scientific.

 

[toby jones]

I think there might be a bit of a difference between theory and practice. I've always found eclecticism to be appealling as a practice but I really do struggle with how to make sense of it as a theory. Cognitive behaviour theory and psychodynamic theory posit different entities and mechanisms. Sometimes with respect to the same behavioural symptom. It seems to me that with respect to theory we either have to choose between these two rival / inconsistent theories and develop the theory to incorporate more date, or throw both away and develop new models that are 'theory neutral'.

I think that staying informed about the outcomes of the treatment successes of different varieties of therapy is important. It introduces new techniques that a clinician can have in their tool kit in order to draw on it. I think that people can get a little carried away with their concern for the scientific studies, however. Suppose (made up example) that you take a some people with the same diagnosis and CBT is found to outperform brief psychodynamic in the sense that CBT helped 48% of their group and psychodynamic helped 43% of theirs. One could say 'one must practice according to CBT because CBT has empirically been shown to be the best form of treatment for that disorder'. I don't think that this conclusion is adequately justified, however, as it might be that some patients who didn't respond well to CBT would have been helped by psychodynamic and vice versa. In all honesty if a treatment helps 99% of people with that disorder it makes no difference to the client who is in that 1%. A therapists insistence on working with the most empirically validated form of treatment for the disorder could be worrying about the disorder at the expense of helping that individual.

As such I think that it is important for an individual clinician to assess for themselves whether the particular strategies that they adopt are helping that particular patient or not. In other words the individual therpist should be a scientist with respect to that particular patient rather than assuming that that particular client will respond according to the statistical average across populations of people of same diagnostic category. Of course reading about different varieties of therapy can help one add strategies to ones tool kit. I do think that eclecticism in practice is likely to be the most helpful but I am concerned about eclecticism in theory.

(But maybe you don't really need a consistent theory to practice it is okay to switch lenses. Perhaps the theory is just important if you do want to know the nature of the inner causal mechanisms).

 

[Logic Prevails]

Good post TJ (you gotta work on keeping them shorter though)

My gut feeling is that most paradigms out there are better at providing treatment approaches than full fledged theories for understanding people; all of them miss something in trying to simplify things and none are sufficient on their own.

My own "theory" of psychology is based mostly on attachment, psychodynamic (defenses and whatnot), existential, and cognitive-behavior theory. My yardstick for integration is whether it fits with my knowledge of neuroscience. For example, I don't buy into certain aspects of CBT treatment (i.e. that thought always preceeds emotion) and I am quick to dismiss bandwaggon treatments like EMDR and NLP (they just don't fit the big picture). My theory is broad and constantly evolving. I don't think you could sum it up in a single textbook. I think most good psychologists will go a similar eclectic route, however I've run into others that get brainwashed by a particular school of thought and are afraid to venture out of their comfort zone to learn more.

In short, my theory is my own moshpit of accumulated knowledge; in practice, I might look more or less like a CBT, psychodynamic, or other practitioner, depending on how I conceptualized the individual in terms of their presenting concerns.

 

[toby jones]

Thank you. Yes, I do need to work on keeping them shorter. I think I'll set myself a line limit.

🙂

 

[Psyclops]

A clinician's personal theoretical orientation does not matter at all, whether they conceptualize a case in the CBT framework or the psychodynamic framework. What does matter is that their treatments being used are empirically based, and that they are using the treatment that various studies, especially randomized controlled trials, support the efficacy of. For example, even if you hold a psychodynamic orientation, and individual with OCD should be treated with exposure and response prevention - period. No other therapies have demonstrated stronger and more effective results when treating OCD than EX/RP. Therapists should not use personal preference on theoretical orientation in the treatment of their patients - they should use science as a guide, picking the scientifically appropriate therapy (following the treatment manual as closely as is possible) to match the appropriately assessed diagnosis. And when there is no empirically based treatment for a disorder (such as anorexia), you should do everything you can based off of the existing literature to make your treatment as scientifically based as possible.

I disagree. Your view on empirically validated treatment (EVT) is Utopian at this juncture (maybe you spend your days reading Walden II😀 ). The huge, and I mean huge drawback of the EV in EVT is that it is artificial. Those who are clinicians or have had a decent amount of clinical exposure will tell you that OCD, MDD, GAD, you name it rarely presents by itself. Regardless, there is the phenomenological experience of having the disorder as well. Your heart is in the right place, but be patient. Remember, a large par of science is theory, in fact without theory science is nothing. Theory informs empirical work, vice versa, and round and round we go.

For way too long people have battled over which theoretical perspecitve is correct, and the only way to objectively determine which therapy is best is through science. This same battle was fought long ago in feilds like medicine, where 150 years ago you could buy Uncle Harold's Snake Oil to cure what ailed you and there was no quality control. Unless you are doing a scientifically based treatment for a specific disorder (or as close as you can get for some disorders) you are being an unethical therapist - the same way that Uncle Harold would be unethical claiming that his Snake Oil cures diabetes.

I disagree. At this juncture, the science says therapy works. And the specifics are not that impressive.

If you want to do well as a clinician you should keep what I've said in mind. Put this into your grad school applications as your empirical orientation and faculty will be impressed - especially if you are applying to a decent PhD program (apparently Psy.D. programs have not yet accepted this, and for this reason are less respected by Ph.D. programs). Just remember, psychology is not mystical or magical - it is scientific.

Put this in your grad school application and you can gurantee you will not get in many places. Even those from the almighty clinical science academies list. No one likes a know it all grad student.

 

[Psyclops]

Cognitive behaviour theory and psychodynamic theory posit different entities and mechanisms.

I agree it is ok to switch lenses. But i disagree with the quoted statement. I think many times they are talking about the same things, the key is to be able to fluently speak in both CBT and psychodynamics to know when they are and when they are not.

 

[toby jones]

I need to learn more about current psychodynamic theories. I had a bit of a look online for Schore and read a little about his project. I will get hold of his books, but it will take me some time to get through them. In the meantime... My thought was that psychodynamic theories (in their efforts to describe the structure of mind) post entities with certain properties (e.g., the id, ego, super-ego, dynamic unconsicous). The mechanisms (e.g., repression, and so forth) are defined as interactions between these entities. It seems that current psychodynamic theorists aren't literally committed to those entities, however. Rather they are attempting to shift the focus to the mechanisms and also to attachment theory (which seems perfectly consistent with experimental psychology to me). It is hard to know what to make of the processes if one doesn't buy into the entities, however. Seems that if we are interested in having an account of the structure of the mind (and the causal processes between the structures) then psychodynamic theory is inconsistent with cognitive theory, for example. I need to read up.

I do hear what you are saying about getting the general impression that the mechanisms that different theories appeal to seem to be fairly much the same thing and that it is just the terminology that is different. I do think that there is much work to be done with respect to translation between theories in order to get clearer on their ontological committments and points of difference, however. Seems to me that there are important insights from each and integrating them would be the best bet. Why is it that an eclectic approach seems to work best in practice? With respect to an integrated theory, however, there is a long long long long long way to go IMHO.

 

[Logic Prevails]

TJ: If I were you, I would start with Dan Siegel's "The Developing Mind" (1999) - he tries to present a unified theory of how the brain/mind develops, and I think he is quite convincing.

In terms of the psychodynamic stuff, I think people disregard it because they don't understand how it is different from psychoanalysis/Freud and how the approach has changed in the past decade or two. I don't think current psychodynamic therapists rely much on concepts of id, ego, superego, etc. The are just outdated.

Cognitive theory has its limitations. We can't deny that our development is impacted by people/events and that this impact can manifest itself in ways that we are totally unaware. CBT is poorly equipped to deal with certian types of patients (e.g. adequate functioning, highly intelligent individuals who for reasons unknown to them are not able to experience emotion).

In terms of its relevence to underlying neurobiology, I think I could argue that current psychodynamic theory is more consistent than cognitive. There are some interesting research/ideas about how unconscious "defenses" may involve a lack of neural integration (I'm simplifying it here, but you could read more through Siegel/Schore).

A final comment, is that in the world of academia, it seems that CBT is the political correct theoretical orientation; one that raises the fewest eyebrows. In my experience Psychodynamic approaches are more likely to be frowned upon - Maybe because people haven't kept up to date with new advances or because psychodynamic approaches are more difficult to manualize and do efficacy research on (EBT/EVT's are the new buzzwords - especially in academia, though few realize the limitations of these terms).

 

[zenman]

Just remember, psychology is not mystical or magical - it is scientific.

Bull; it should be magical and mystical. In all respect, might you be too hung up on "science?"

I respect the shaman when all else fails.

 

[ClinicalScience]

Although I agree that science is not perfect, it is still the best objective way to approach therapy. Just because there are flaws in some studies, if there are enough studies demonstrating the effectiveness of a therapy, there is probably a reason that those studies are coming out in favor of this therapy. This is why PhD programs emphasize science so much. Just because science is not perfect does not mean that you have the ability to pick and choose whatever you feel like, even if the science speaks against your choice of therapy. For example, psychodynamic therapy should never be used to treat OCD or MDD. There are very effective therapies for both of these disorders that are backup by science, and there is no proof that psychodynamic therapy is better at treating these disorders than just talking to a nice person. Now on the other hand, if psychodynamic therapy is very effective for treating a disorder than by all means use it. In the case that there are 2 approximately equal treatments for a disorder, then you provide the two options for the patient (after informing the patient of their disorder) and let them choose which therapy they would prefer to try. It is not up to the therapist to pick and choose as they please, you should not treat a patient with dialectical behavior therapy or psychodynamic therapy when CBT and IPT are both scientifically supported, and neither of the other two are.

Read the articles published by Chambless et al. on empirically validated treatments if you dissagree, and while you're at it read McFall's manifesto. Without science to test us, its your opinion on therapy vs mine, and there is no room for opinion in therapy - science MUST guide us.

I disagree. Your view on empirically validated treatment (EVT) is Utopian at this juncture (maybe you spend your days reading Walden II😀 ). The huge, and I mean huge drawback of the EV in EVT is that it is artificial. Those who are clinicians or have had a decent amount of clinical exposure will tell you that OCD, MDD, GAD, you name it rarely presents by itself. Regardless, there is the phenomenological experience of having the disorder as well. Your heart is in the right place, but be patient. Remember, a large par of science is theory, in fact without theory science is nothing. Theory informs empirical work, vice versa, and round and round we go.

Put this in your grad school application and you can gurantee you will not get in many places. Even those from the almighty clinical science academies list. No one likes a know it all grad student.

I disagree. At this juncture, the science says therapy works. And the specifics are not that impressive.

According to what evidence are the specifics not that impressive? I've treated OCD, MDD, and GAD with great success using empirically validated treatments. Although disorders often present together and with various difficulties, that is no reason for me to just "pick and chose" what I want to do even though science says otherwise. I'm not that special, and neither is any other therapist out there, to say I know more than the collective understanding of a community of scientific psychologists.

You won't get into psyd programs, where therapists are still being taught to use object relations therapy or "self" therapy to treat BPD, when there is no scientific background for the use of either of these therapies, while dialectical behavior therapy does has scientific backing for its effectivness of treating borderline personality disorder. I attend a very well regarded PhD program, and we implement this very scientifically backed theory into direct treatment of patients in our clinic - very effectively I might add.

You may disagree with the use of empirically validated treatments in therapy, but the truth is that this approach is the only one that goes beyond the embracement of an single theoretical orientation, and allows for the most objective treatment of an individual.

 

[ClinicalScience]

double post

 

[ClinicalScience]

Anyone who publishes in a decent academic journal with a impact factor over 1.0 would disagree - and that includes people who study cognitive, social and developmental psychology.

Bull; it should be magical and mystical. In all respect, might you be too hung up on "science?"

I respect the shaman when all else fails.

 

[Logic Prevails]

I don't know any easy way to put this, so I'm just going come out and say it: Your academic program has brainwashed you! Follow the treatment recommendations below:

Just because there are flaws in some studies, if there are enough studies demonstrating the effectiveness of a therapy, there is probably a reason that those studies are coming out in favor of this therapy.

What you are talking about is outcome reliability in research settings, not real world validity. Efficacy research almost always requires an absence comorbid disorders; this does not happen in the real world. Many studies also fail to consider the amount of patients that may have dropped out of treatment and who did not benefit from treatment. In short, these studies fail to represent the real world and they should not be thought to provide validity.

You also can't say that psychodynamic approaches are not valid based on the fact that they don't follow a simple "cookbook" approach, such as CBT that lends itself to efficacy research. People, and their problems will not always be solvable in cookbook fashion.

Just because science is not perfect does not mean that you have the ability to pick and choose whatever you feel like, even if the science speaks against your choice of therapy. For example, psychodynamic therapy should never be used to treat OCD or MDD.

Actually we should be able to pick and choose whatever therapy modality we think will best help the patient. We have theory and a lot of education and training to guide us in this decision. We are not technicians - we are human beings, and so are our patients. We cannot treat them all the same based upon their presenting symptoms. You should know that similar symptomatology can have different underlying causes - it is our job to use critical judgement to decide what will be best for a given person. This is not to say that we can go about using any wackjob approach out there, so yes, science has its place, but you need to recognize its limitations in these efficacy studies. I can also think of instances where MDD would be better treated with a psychodynamic approach (than say CBT) - it depends on presentation and the individual.

 

[toby jones]

I think Linehan was onto something when she said that she had no earthly idea why DBT did okay in the couple of studies that it did and that it was perfectly possible that DBT simply provided a way of energising therapists.

Here is a saying: If you do what you have always done then you will get what you have always got.

Are the current therapies 100% effective? If not then why aren't we working on improving on them rather than simply doing what has been validated already (with no understanding of the mechanisms of change)?

One concern that I have is that a lot of the research is on kinds of DSM disorders. There is often more variability in symptoms between patients of the same diagnostic category than between patients of different diagnostic categories, however. If people were their disorders then I suppose it would be perfectly appropriate to treat people on the basis of their disorder. People aren't disorders, however, people are people with things that they find problematic (which may or may not correspond to the improvements psychologists like to talk about in their outcome studies).

For example, with respect to DBT most patients (I really hate to do this) rank 'feeling bad' as the most problematic aspect for them. Does DBT help them feel better? It does not seem to. Yes it helps them spend less days in hospital (see why the insurance companies love this) and yes it cuts down on ER visits for self harm (is there a common theme here?)

How about help with what the patients wanted help with?

I'm fairly interested in some of the work that has been done on mentalization based treatment for BPD...

 

[Dr.JT]

Actually we should be able to pick and choose whatever therapy modality we think will best help the patient. We have theory and a lot of education and training to guide us in this decision. We are not technicians - we are human beings, and so are our patients. We cannot treat them all the same based upon their presenting symptoms. You should know that similar symptomatology can have different underlying causes - it is our job to use critical judgement to decide what will be best for a given person. This is not to say that we can go about using any wackjob approach out there, so yes, science has its place, but you need to recognize its limitations in these efficacy studies. I can also think of instances where MDD would be better treated with a psychodynamic approach (than say CBT) - it depends on presentation and the individual.

How do you reconcile this philosophy with the research on clinical judgement?

 

[Logic Prevails]

How do you reconcile this philosophy with the research on clinical judgement?

Touche. However I am not arguing against using research to guide treatment. I just don't think we should assume all "Empirically Validated Treatments" to be truly valid in the real world and to the exclusion of other treatment modalities that don't lend themselves well to research. I think there needs to be some wiggle room for theory and training to guide treatment, perhaps within the slew of "Epirically Supported Treatments."

 

[Dr.JT]

Touche. However I am not arguing against using research to guide treatment. I just don't think we should assume all "Empirically Validated Treatments" to be truly valid in the real world and to the exclusion of other treatment modalities that don't lend themselves well to research. I think there needs to be some wiggle room for theory and training to guide treatment, perhaps within the slew of "Epirically Supported Treatments."

I think right now the common factors approach is the best interpretation of the empirical literature. Although, included in this view is the importance of an overarching theory of behavior change and techniques that follow from that theory to elicit change. This is why the "eclectic" approach is somewhat troublesome to me. It boils down to people doing whatever they want and justifying it with their clinical judgment, which at best is poor.

Personally, I am of a CBT orientation which works well for me with the medical populations I work with. I borrow interventions from other domains, but always within a CBT context. I have no issue with psychodynamic approaches as long as they are the more modern versions (i.e. time limited). The only problem that sometimes arises is that dynamic therapists rely heavily on their judgment to chart patient progress. As Lambert has pointed out many times, 5-10% of patients get worse because of therapy and therapists are very poor at detecting these cases. I believe in ongoing assessment using objective measures, per Lambert's research, and this is sometimes an issue with psychodynamic therapists.

 

[Anon15]

I think Linehan was onto something when she said that she had no earthly idea why DBT did okay in the couple of studies that it did and that it was perfectly possible that DBT simply provided a way of energising therapists.

Not sure what you mean by this...

If people were their disorders then I suppose it would be perfectly appropriate to treat people on the basis of their disorder. People aren't disorders, however, people are people with things that they find problematic (which may or may not correspond to the improvements psychologists like to talk about in their outcome studies).

If you want to talk Linehan, she would argue that people aren't their "disorders" and in DBT treatment for BPD you are not treating symptoms but rather behaviors.

For example, with respect to DBT most patients (I really hate to do this) rank 'feeling bad' as the most problematic aspect for them. Does DBT help them feel better? It does not seem to. Yes it helps them spend less days in hospital (see why the insurance companies love this) and yes it cuts down on ER visits for self harm (is there a common theme here?)

I think it's fair to say that for a borderline patients "feeling bad" is the least of their worries. I think what you are failing to realize is that DBT is not about making people feel better but about how to teach people to better manage their self-injurious behaviors. Through the process of changing these types of self-injurious behaviors they then begin to feel better about themselves.

I.m fairly interested in some of the work that has been done on mentalization based treatment for BPD...

Check out the work of Bateman & Fonagy. However, there is no empircal evidence (unlike DBT) that mentalization works for BPD. In fact, it is very hard to train individuals (therapists) in this type of therapy.

 

[toby jones]

Do you mean you aren't sure what I mean by 'I think Linehan was onto something when she said that she had no earthly idea why DBT did okay in the couple of studies that it did and that it was perfectly possible that DBT simply provided a way of energising therapists'... Or that you aren't sure what I meant by 'if people were their disorders then I suppose it would be perfectly appropriate to treat people on the basis of their disorder. People aren't disorders, however, people are people with things that they find problematic (which may or may not correspong to the improvements psychologists like to talk about in their outcome studies)'?

With respect to the first interpretation the notion was that with respect to the mechanism of change Linehan said she had no idea why it was that DBT managed to outperform alternative varieties of psychotherapy on the couple of studies that it did. She said that one possibility was that the mechanism of change was that she had provided a new variety of therapy that energised and invigorated therapists. That it could be as simple as that. That as other people went on to write manuals for new varieties of therapies their studies would show that they outperformed DBT because they had provided a new variety of treatment for therapists to become excited and enthusiastic about and that the outperforming status of DBT could turn out to be very shortlived.

With respect to the second I was trying to get at the notion that generalisations from dx x to treatment y is most effective is a generalisation that works on the average patient with dx x. Who is the average patient with dx x? Some statistical or idealised notion. There is no such thing (in the world) as an actual patient that is patient x. Generalisations made over diagnostic categories are only as useful as the status of the category as a natural kind. Unfortunately the majority of DSM disorders do not pick out natural kinds as often there is more variation in behavioural symptoms (and inner causal mechanisms) between patients of the same dx category then there is between patients of different dx categories. Thus when you have an actual person in front of you and you are trying to decide what is most likely to help them the research on their dx is only likely to be applicable insofar as they approximate the idealised average of their dx. And how many patients do that? I thougth that dx of NOS was the most prevalent condition of all...

I don't have a bone to pick with Linehan. I thought she did an amazing job of providing a treatment that was non-judgemental and her theory is likely to assist therapists considerably with respect to counter-transference issues.

> I think it's fair to say that for a borderline patients "feeling bad" is the least of their worries.

You are entitled to your opinion (and I do indeed have some sympathy with your opinion) but what I was getting at was that the majority of people with BPD (I hate to talk 'majority' but anyway) the majority of people with BPD rank that as their number one problem. That is their number one goal: to feel better. That is what they want help with: to feel better. We might think (and I do have sympathy for this position) that they need to reduce self harm and inpatient days in order to feel better but the trouble is that DBT hasn't been shown to outperform other varieties of treatment with respect to making patients feel better. I could be out of date with respect to the efficacy studies on DBT but last I heard only the first year had been shown to outperform other varieties of treatment for DBT and it only outperformed other varieties of treatment with respect to reduction of inpatient days, reduction in self harm behaviours, and a slight improvement in functioning. It was not shown to outperform other varieties of treatment with respect to patients feeling better even though that was commonly reported as the number one goal of patients with DBT. It would be like 'my variety of treatment has been shown to outperform treatment as usual... With respect to teaching patients how to juggle. In fact it *significantly* out-performs treatment as usual'. I can say 'my treatment is the scientifically validated one and it would be unscientific to practice anything else' but the fact is that what it helps with is irrelevant. I'm not saying reduction in self harm and less inpatient days is completely unrelated but I do think that taking that to be the measure of success with respect to the program being 'more scientific' is changing the subject slightly. It helps with what the insurance companies and clinicians want targeted but it doesn't help the patients with what they most wanted help with.

Which is of course why there are more phases of DBT than the first phase (the first year). I have found that some places only treat people with the first phase because they say that the other phases haven't been shown to be effective, however. That was never Linehan's intention. The intention was to stabilise patients in their first year so that they would be able to cope with the later hard work which she hoped would help improve their quality of life (or, help them feel better). With respect to length of treatment I'm not sure how DBT (with all the phases that Linehan intended) is shorter or cheaper than alternative varieties of treatment. I'm not sure that the studies have been done.

> Check out the work of Bateman & Fonagy. However, there is no empircal evidence (unlike DBT) that mentalization works for BPD. In fact, it is very hard to train individuals (therapists) in this type of therapy.

Thanks for the reference, I'll do that at some point. One must be careful to distinguish between 'there is a current lack of evidence because the studies have not been done' from 'there is evidence that this does not help'. I think that it is hard to train therapists in DBT too...

 

[Anon15]

Wow long post...

I have lots of thoughts about your posting...If you would like to start a BPD thread I'd be happy to chime in but I think we've gotten off the topic of theoretical orientaion a bit (I am guilt of this as well)!

 

[Therapist4Chnge]

Great idea Anon15, i'd like to hear more about this. We can put a link in here pointing over to the thread. I guess we could split out the applicable posts, though a link is probably easier. 😉

-t

 

[Anon15]

Great idea Anon15, i'd like to hear more about this. We can put a link in here pointing over to the thread. I guess we could split out the applicable posts, though a link is probably easier. 😉

-t

Thanks TFC, that sounds great. I will start a new thread tomorrow and prehaps you can create a link🙂

 

[Therapist4Chnge]

Sounds like a plan.

Now to get back to the OP....

Is anyone else having a hard time defining their theoretical orientation? I get the feeling that my inclination toward CBT may be premature as my experience is mostly in behavior modification and I don't have much experience exploring other models. Also, I expect my perspective to evolve while in graduate school (why else go?) Can anyone else relate to this? Care to share your story?

-t

 

[NYCPsych]

... any names to add besides Rutgers, Baylor, Indiana? I find that it can be difficult to learn about PsyD programs' theoretical orientations from their websites.

Thanks-

 

[Therapist4Chnge]

When I was looking, "The Insider's Guide to Clinical Psychology Programs" really help me. They gave %'s of orientation for the profs. It probably isn't 100% accurate, but will give you a decent idea.

-t

 

[NYCPsych]

thanks for the quick feedback! it's on my list!