Why do psychologists reject science???

[Psy01]

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I thought I heard him say that he developed CT because his experiment on depressed subjects did not reveal them to have "anger directed inwards" that his training (psychoanalysis) presummed to be responsible for the disorder. In fact, in comparison to control subjects, chronic depressed patients seems to have less hostility. Rather, their dreams and thoughts consisted of irrational and distorted beliefs. He picked up on this and developed CT from there....

Maybe there is more to the story, including a phobia....im not sure.

Yes, I've read that too.

Here is another bit to the story that I found in an article about Steve Hayes:
Beck's biographer, Brown psychologist Marjorie Weishaar, writes that in his younger years, Beck had public-speaking anxiety and a phobia about tunnels. He solved both problems by correcting misimpressions he had developed: "One day, approaching the Holland Tunnel, he realized that he was interpreting the tightness in his chest as a sign he was suffocating," Weishaar writes. He wasn't, of course, and when he "worked that through cognitively," the phobia vanished. Similarly, his stage fright eased "with continued practice and challenging his automatic thoughts."

http://www.time.com/time/magazine/article/0,9171,1156613-4,00.html

Interesting though - I forgot about that last sentence there. Was it really challenging his thoughts, or was it the continued practice that did it?

 

[Psy01]

Jacobon and Dimidjian's BA study is excellent. It was a well controlled RCT which included a well known CT proponent, Steve Hollon, as a contributor. While I agree that this study questions the underpinnings of the cognitive model, it is only one study. To note, behavioral activation could induce cognitive change on its own, thus leading to reductions in depression.

Indeed, and that's the point. What value does cognitive challenging really hold?

I saw an interesting case study a couple months ago about a guy for whom CT did not help at all, and the cognitive work seem to just get him even more mired within his thoughts than previously. The authors tried out BA, and his depression significantly improved.

 

[zenman]

As far as using EBP and not relying on clinical judgment, you are preaching to the choir. My point was that we need to acknowledge that science is less clear in some areas than in others, and research that moves beyond pure efficacy studies to test effectiveness is still in its infancy. I'm trying to find some middle-ground with the folks who aren't as big on EBP, but apparently I'm just putting myself against both sides🙂

Is therapy an art or science? I admit I'm right-brained, don't like rules and regs, plus I'm a smart-a** and suffer from genetic hilarity. I don't know as much about research as you guys do and I'm all for someone else doing all the research they want. But, I think I have to lean to the art side. Do I need therapy to handle this

 

[Shatani]

I should clarify, when I said we shouldn't be encouraging people to "pick one" I was not referring to doing so on a case-by-case basis. I was referring to the (relatively) pervasive attitude in the field of deciding if you are a "CBT" therapist or a "psychodynamic" therapist and never deviating from that. I agree with you that say for depression, we don't have much beyond clinical judgment to indicate where we should be doing IPT, CBT, Behavioral Activation, couples therapy, ST psychodynamic treatments, etc. I'm not convinced we'll never get there, but we certainly aren't there yet. My argument is that we need to be training people as evidence-based practitioners, who are keeping up on treatments, are critical consumers of research, etc. In other words, we should be training psychologists, not "CBT Therapists" or "Psychodynamic therapists". Very different things in my eyes.

i dont disagree with anything youve said, but i dont think that having a theoretical orientation is a hindrance unless the person is unwilling to consider anything else when it comes to treatment. if im psychodynamically oriented yet well-trained in EBTs, i dont see a problem.

the way i see it, your theoretical orientation governs the way in which you take in the problem but it doesnt necessarily have to govern the output (treatment provided)....i can see things psychodynamically and still know that the best treatment to alleviate the symptoms is ERP, for example, and be able to do that. doesnt have to be mutually exclusive...

 

[KGZotU]

Is therapy an art or science? I admit I'm right-brained, don't like rules and regs, plus I'm a smart-a** and suffer from genetic hilarity. I don't know as much about research as you guys do and I'm all for someone else doing all the research they want. But, I think I have to lean to the art side. Do I need therapy to handle this

Maybe it's an art wrapped in a science. Science can suggest new therapies to develop. Science can also help us know which therapies, when applied, produce the best results and how often. Apply therapy as an art, but take advantage of science's tools for projecting respective outcomes.

 

[Ollie123]

i dont disagree with anything youve said, but i dont think that having a theoretical orientation is a hindrance unless the person is unwilling to consider anything else when it comes to treatment. if im psychodynamically oriented yet well-trained in EBTs, i dont see a problem.

the way i see it, your theoretical orientation governs the way in which you take in the problem but it doesnt necessarily have to govern the output (treatment provided)....i can see things psychodynamically and still know that the best treatment to alleviate the symptoms is ERP, for example, and be able to do that. doesnt have to be mutually exclusive...

Interesting point. The purpose of conceptualization (at least as I see it) is to inform treatment. It seems somewhat odd and counterintuitive to me to conceptualize it in a way that doesn't seem to jive with the treatment and I think would make feedback and explanation of the treatment plan to the client kind of awkward. I could see other possible problems as well, but it is still an interesting question. In one sense, if the conceptualization is just what is going on in the back room and isn't actually changing what is happening in therapy then it shouldn't matter whether we attribute the disorder to interpersonal processes, biology, faulty cognition, or fuzzy pink bunny rabbits fighting in someones head. Though if that is the case, I wonder why bother conceptualizing beyond the diagnostic label in the first place.

My suspicion (which I openly admit, I have no evidence for) is that while this sounds okay in theory, I'm not convinced its realistic in practice and I'm really struggling to even picture how this would look.

 

[futureapppsy2]

Interesting point. The purpose of conceptualization (at least as I see it) is to inform treatment. It seems somewhat odd and counterintuitive to me to conceptualize it in a way that doesn't seem to jive with the treatment and I think would make feedback and explanation of the treatment plan to the client kind of awkward. I could see other possible problems as well, but it is still an interesting question. In one sense, if the conceptualization is just what is going on in the back room and isn't actually changing what is happening in therapy then it shouldn't matter whether we attribute the disorder to interpersonal processes, biology, faulty cognition, or fuzzy pink bunny rabbits fighting in someones head. Though if that is the case, I wonder why bother conceptualizing beyond the diagnostic label in the first place.

My suspicion (which I openly admit, I have no evidence for) is that while this sounds okay in theory, I'm not convinced its realistic in practice and I'm really struggling to even picture how this would look.

Yeah, I have same question... well-said, Ollie.

And now I really want to find a "fuzzy pink bunny rabbits" theoretical orientation!

I've never heard of them or that "degree".

I looked it up, and it appears only they and their Vermont affiliate offer it. It's interesting to look at the program, though--it seems pretty typical for a clinical PsyD program until you get to the "research" and "research training" (or lack thereof--a case study is an acceptable dissertation!--though some students do a bit more).

 

[Neuropsych2be]

This is why I always say "Evidence" is my primary therapeutic orientation. Telling students to "Pick one" strikes me as an immensely lazy approach.

I agree that it is inappropriate to say that theoretical orientation should guide treatment. My program requires students to declare an orientation and then demonstrate clincial skills in that area. In the real world where most of us operate, we do what works. If I were treating a phobia or OCD I would cognitve behavioral techniques rather than psychodynamic approaches even though dynamic approaches are closest to my orientation. My actual theoretical orientation is integrative (with a bent towards psychodynamic) and I feel that the debates between the various orientations is a waste of time. To often these debates are a dialectic with no one invested in a resolution. I am fond of general systems theory as a framework for an overarching metatheory for psychology. I agree that asking us to pick one of the three major schools is an intellectually lazy approach.

 

[GiantSteps]

Based upon many of the comments, the state of psychology as a science, at least clinical, seems dismal.

1. Working within a theoretical orientation in terms of research will most likely lead to nothing other than studies aimed at supporting that theoretical aproach. Then, when a problem comes along which the theory can not exlain, a new theory arises, often from someone outside the field, and the whole process starts again. Read Thomas Kuhn.

2. Basing one's applied work on what works is not science. It is guess work. Sure you can try to pick a treatment you think might work and be right 25% of the time. That is great, except that a monkey can be right 25% of the time (Not that monkeys can't do other things well, such as playing in a band!). A scientific clinician must use his/her research based knowledge to improve the odds of blind guess work which is nothing more than monkey business. Now, I am not implying that many of you are not so high up on the evolutionary chain, but right now many of you have adopted what I will now call the 'banana based orientation"! Maybe you should all just see you clients up in the trees!

3. Within the area of pure research psychology, psychology needs to regain control of the variables and stop covering up variability in statistical tests of significance and large samples which creates distributions of behavior functions and processes but not real behavior of individuals.

4. One revolution of importance, that may advance psychology as a science is the moving away from null hypothesis testing to other forms of data analysis. As journals battle this out, it will be interesting to see what happens.

 

[Ollie123]

I agree the state of science in psychology is far behind what has been achieved in other domains. I think it is understandable as I'm hard-pressed to think of anything more complicated than the human brain. That's part of the fun🙂

I agree that theoretical work has often been misguided. That is actually a major point of my argument. I don't think the iterative process of building theories is bad, provided we move progressively closer, but that often doesn't happen. The big issue as I see it is that psychologists tend to ignore the other sciences. Relatively few theories truly integrate biology, neuroscience, chemistry, etc. A truly comprehensive theory should work across all levels of explanation. Obviously, this is ridiculously hard to do and probably not something we'll see in any of our lifetimes, but I think we need greater recognition that it should be the goal.

Totally on board with the problems of null hypothesis testing. Failure to report effect sizes frustrates me. p values have their place, but abuse is rampant and this needs to change.

I understand your point about the need for clinical judgment. However, I think its important to recognize that there is a big difference from saying "I'm not sure which of these works best, but in my opinion A seems most appropriate" and saying "I'm not sure which of these works best, so I'm just going to make some stuff up and hope for the best". I don't know anyone who denies the need for clinical judgment. I do think people overestimate its success...humans are pretty crummy decision-makers, and depending on what is used to make the decision I think that 25% is as likely to go down as it is to go up.

Please elaborate on your point #3. I agree with much of what pure behaviorists have to say, but there's some aspects of it I think are WAY off the mark and from that statement I can't tell which camp you fall in😉

 

[Therapist4Chnge]

2. Basing one's applied work on what works is not science. It is guess work. Sure you can try to pick a treatment you think might work and be right 25% of the time. That is great, except that a monkey can be right 25% of the time (Not that monkeys can't do other things well, such as playing in a band!).

You are dating yourself with that reference. 😉

 

[futurepsydoc]

Based upon many of the comments, the state of psychology as a science, at least clinical, seems dismal.

Agreed. Its a shame.

1. Working within a theoretical orientation in terms of research will most likely lead to nothing other than studies aimed at supporting that theoretical aproach. Then, when a problem comes along which the theory can not exlain, a new theory arises, often from someone outside the field, and the whole process starts again. Read Thomas Kuhn..

I think Kuhn's work should be mandatory in all doctoral programs.

2. Basing one's applied work on what works is not science. It is guess work. Sure you can try to pick a treatment you think might work and be right 25% of the time. That is great, except that a monkey can be right 25% of the time (Not that monkeys can't do other things well, such as playing in a band!). A scientific clinician must use his/her research based knowledge to improve the odds of blind guess work which is nothing more than monkey business. Now, I am not implying that many of you are not so high up on the evolutionary chain, but right now many of you have adopted what I will now call the 'banana based orientation"! Maybe you should all just see you clients up in the trees! .

I think the theme of the above commentaty is best explained by Paul Meehl and his findings on clinical versus actuarial prediction. Exposure to this work will be enlightening to those who see "experience" as the key to making clinical decisions.

 

[Therapist4Chnge]

I was just speaking to my supervisor about an article he was floated about the role of intuition on decision making. I should be getting a copy later in the week, and if it is any good I'll post the reference.

 

[cara susanna]

According to Kuhn's theory, though, psych isn't even a science.

Philosophy of science is very interesting but IMO not very realistic.

 

[Shatani]

Interesting point. The purpose of conceptualization (at least as I see it) is to inform treatment. It seems somewhat odd and counterintuitive to me to conceptualize it in a way that doesn't seem to jive with the treatment and I think would make feedback and explanation of the treatment plan to the client kind of awkward. I could see other possible problems as well, but it is still an interesting question. In one sense, if the conceptualization is just what is going on in the back room and isn't actually changing what is happening in therapy then it shouldn't matter whether we attribute the disorder to interpersonal processes, biology, faulty cognition, or fuzzy pink bunny rabbits fighting in someones head. Though if that is the case, I wonder why bother conceptualizing beyond the diagnostic label in the first place.

My suspicion (which I openly admit, I have no evidence for) is that while this sounds okay in theory, I'm not convinced its realistic in practice and I'm really struggling to even picture how this would look.

well, lets say i am a person who considers herself oriented towards, say, object relations. and i am working with an addict of some sort. in my mind im thinking, well, crappy childhood environment, not great introjects, and so on and so forth. that would be how i conceptualize the case. but more and more studies are showing that motivational interviewing is the best treatment for addiction (hypothetical, i have no study to back this up, im just giving an example)...i know that, im trained to do that, and i see my client and give that person the treatment regarded as most likely to be helpful.

so, in an instance like this one, yes, i have a theoretical orientation. yes, in my mind ive conceptualized it as such. but no, it doesnt prevent me from (competently) administering EBT for the disorder that sits in front of me. i cant say it doesnt inform treatment in any way at all, but it doesnt need to dictate it.

maybe i just live in a world of sunshine and lollipops.

 

[Shatani]

i would like to point out that my program has never insisted anyone "pick one," i think that as you learn you generally develop one....some things make sense to you, some things dont jive as well...

 

[Ollie123]

"pick" was not necessarily meant to be literally a forced choice by the program🙂 More the metaphorical idea of choosing a camp based off personal preference, rather than what is necessarily best, and potentially closing yourself off to new ideas. That isn't a knock against the psychodynamic crowd, because CBT has plenty of mindless-drone religious adherents too.

I understood what you meant originally, but the example you gave still baffles me how that could be functional in practice. The entire purpose of conceptualization is to flesh out the treatment plan beyond just "X sessions of Y therapy". For example, if I'm coming at it from an MI framework, my conceptualization would likely involve a focus on reinforcing aspects of their lives, opposing cognitions about their substance use behavior, and other such areas that directly relate to and inform what the implementation of MI would look like. The orientation/conceptualization isn't just my take on what causes the disorder, its sort of the halfway point between cause and treatment. Maybe I'm just weird, I don't know. Is that how others conceptualize? I admittedly haven't had a great deal of clinical experience, but that's how I usually go about thinking through the process.

 

[Shatani]

i see your point and agree. maybe i need to distinguish between case conceptualization and Case Conceptualization (like trauma and Trauma). because i generally see a case through the lense of my specific orientation, its not an active effort, it just is. but knowing that a style/orientation/technique other than what i would tend to do instinctively is "prescribed" for this type of disorder and having been trained to do it, i would Conceptualize and plan treatment in the way you described. i suppose ive never seen the two activities as being mutually exclusive, but i most certainly have met clinicians who were slaves to their orientation and either unable or unwilling to consider that something else might work or *gasp* might work better.

 

[Therapist4Chnge]

Has anyone noticed a drecrease emphasis for case conceptualization, particularly in regard to examining the dynamics of the person's presentation, in addition to their symptomatology?

It seems that in the rush to apply many EBTs, true case conceptualization has given way to, "Dx is XYZ, therefore the treatment is ABC." Maybe it is just my hesitancy to hand things over to a more manualized (or over-manualized) treatment protocol.

 

[KGZotU]

Perhaps there are a few conceptualizations of wide moderate utility, each having a few special domains of high utility. Having mastered one orientation, we can imagine that the marginal costs of mastering a second orientation might outweigh the benefits. That said, we can still grant that treatments developed by other conceptualizations within their domain of high utility could be more effective, even if we don't understand them completely down to the last inch.

This could be a rational explanation for practitioner behavior.

 

[futurepsydoc]

It seems that in the rush to apply many EBTs, true case conceptualization has given way to, "Dx is XYZ, therefore the treatment is ABC." Maybe it is just my hesitancy to hand things over to a more manualized (or over-manualized) treatment protocol.

I think you point out a serious concern. I think many people wanting to implement an EBT have/would/will rush to employ a manual (Tx ABC) if they are seeing a client with specific condition (Dx XYZ). Taking it a step further, these same therapists may jump right into the manual without much regard for the idiosyncratic nature of the patient's presentation. I whole heartedly agree that this approach sounds mechanical, simplistic, and out of touch with clinical practice as many of us know it.

However, I would argue that manual based CBT relies heavily on case conceptualization to inform the delivery of treatment. Cognitive-Behavioral interventions require the therapist to identify specific maladaptive behaviors, their frequency/intensity, the antecdents or triggers for that behavior, and the related maintaining mecahisms. These factors, while common amongst those with the same disorder, will be idiosyncratic to the individual client. Therapists using the manual have to integrate this information into a research driven formulation for the disorder in question. David Clark's Panic Disorder Treatment takes this approach, going so far as to share the case formulation with the patient. If I am not mistaken, Chris Fairburn's Tx Manual for Bulimia Nervosa operates in a similar fashion. I see this as a hybrid type of case formulation, as it uses idiosyncratic information about the client within a data driven model for the disorder, utlimately guiding a flexible and effective treatment protocol.

When I think of case formulations in a traditional sense, I see them as a hypothesis regarding the eitology of the client's disorder. So far as I know, we know very little about the eitology of most disorders, save to say that they are determined by a variety of factors that interact and play off of one another (e.g., truama, abuse, genetics, other environmental factors). We cannot change the past. If anything, I think a more traditional case formulation could help facilitate a better understanding of the person, aid the therapeutic alliance, and help validate the patient's past experiences. Clinical treatment decisions based off of this type of hypothesis is not that sound, scientifically speaking. Why not rely on treatment manuals informed by clinical trials, abnormal psychology research, and more basic science (e.g., cognitive science, decevelopmental psychology). What is the point of all this research if we are going to ignore it.

Thats my, possibly incoherent, .02

 

[Psy01]

[FONT=verdana, arial, helvetica, sans-serif] National Survey of Psychotherapy Training in Psychiatry, Psychology, and Social Work . [FONT=verdana, arial, helvetica, sans-serif] Myrna M. Weissman, PhD; Helen Verdeli, PhD; Marc J. Gameroff, PhD; Sarah E. Bledsoe, MSW; Kathryn Betts, DClinPsy; Laura Mufson, PhD; Heidi Fitterling, BA; Priya Wickramaratne, PhD .

[FONT=verdana, arial, helvetica, sans-serif] Arch Gen Psychiatry. 2006;63:925-934..
[FONT=verdana, arial, helvetica, sans-serif]
.
[FONT=verdana, arial, helvetica, sans-serif] Context Approximately 3% of the US population receives psychotherapy each year from psychiatrists, psychologists, or social workers. A modest number of psychotherapies are evidence-based therapy (EBT) in that they have been defined in manuals and found efficacious in at least 2 controlled clinical trials with random assignment that include a control condition of psychotherapy, placebo, pill, or other treatment and samples of sufficient power with well-characterized patients. Few practitioners use EBT. .
[FONT=verdana, arial, helvetica, sans-serif]Objective To determine the amount of EBT taught in accredited training programs in psychiatry, psychology (PhD and PsyD), and social work and to note whether the training was elective or required and presented as a didactic (coursework) or clinical supervision. .
[FONT=verdana, arial, helvetica, sans-serif]Design, Setting, and Participants A cross-sectional survey of a probability sample of all accredited training programs in psychiatry, psychology, and social work in the United States. Responders included training directors (or their designates) from 221 programs (73 in psychiatry, 63 in PhD clinical psychology, 21 in PsyD psychology, and 64 in master's-level social work). The overall response rate was 73.7%. .
[FONT=verdana, arial, helvetica, sans-serif]Main Outcome Measure Requiring both a didactic and clinical supervision in an EBT. .
[FONT=verdana, arial, helvetica, sans-serif]Results Although programs offered electives in EBT and non-EBT, few required both a didactic and clinical supervision in EBT, and most required training was non-EBT. Psychiatry required coursework and clinical supervision in the largest percentage of EBT (28.1%). Cognitive behavioral therapy was the EBT most frequently offered and required as a didactic in all 3 disciplines. More than 90% of the psychiatry training programs were complying with the new cognitive behavior therapy requirement. The 2 disciplines with the largest number of students and emphasis on clinical training—professional clinical psychology (PsyD) and social work—had the largest percentage of programs (67.3% and 61.7%, respectively) not requiring a didactic and clinical supervision in any EBT. .
[FONT=verdana, arial, helvetica, sans-serif]Conclusion There is a considerable gap between research evidence for psychotherapy and clinical training. Until the training programs in the major disciplines providing psychotherapy increase training in EBT, the gap between research evidence and clinical practice will remain..

 

[Ollie123]

Has anyone noticed a drecrease emphasis for case conceptualization, particularly in regard to examining the dynamics of the person's presentation, in addition to their symptomatology?

It seems that in the rush to apply many EBTs, true case conceptualization has given way to, "Dx is XYZ, therefore the treatment is ABC." Maybe it is just my hesitancy to hand things over to a more manualized (or over-manualized) treatment protocol.

I think there is some truth to this. We've barely touched on conceptualization in coursework, though we get a lot more of it through supervision.

I think there's good and bad to this. I'm all for a manualized approach, but I also think conceptualization is vital even for a strict manualized approach. CBT manuals walk you through the process of challenging thoughts, but they obviously can't give too much details about which thoughts are most important for the clients to focus on. To some degree, this comes out as part of the therapy process, but its helpful to identify them earlier on in the process to make sure the sessions stay on task. On the other hand, just as its possible to over-manualize I think its possible to over-conceptualize. I think one of the reasons traditional psychoanalysis took so damn long was because so much time was spent conceptualizing and re-conceptualizing rather than actually doing something.

 

[busi26]

[FONT=verdana, arial, helvetica, sans-serif] National Survey of Psychotherapy Training in Psychiatry, Psychology, and Social Work .[FONT=verdana, arial, helvetica, sans-serif]Myrna M. Weissman, PhD; Helen Verdeli, PhD; Marc J. Gameroff, PhD; Sarah E. Bledsoe, MSW; Kathryn Betts, DClinPsy; Laura Mufson, PhD; Heidi Fitterling, BA; Priya Wickramaratne, PhD .

[FONT=verdana, arial, helvetica, sans-serif]Arch Gen Psychiatry. 2006;63:925-934..

Amazing! Why are clinical psyc programs continuing to focus on substandard therapy methods. It is indefensible!

We know what tools work best, but don't teach our students how to use the most effective tools. How can this be?

Those who argue for using psychodynamic and other unproven treatments do so knowing that other treatments are better. Why do so many psychologists reject science?

 

[Psy01]

Those who argue for using psychodynamic and other unproven treatments do so knowing that other treatments are better.

Do they? I think a lot of them don't. For example, I've stumbled across a bunch of papers concluding that dynamic therapy is effective, and guaranteed the dynamic people really focus on those kinds of papers. Confirmation bias is pretty powerful.