Check out this opinion piece (rebuttal) published in Psychology Today by Jonathan Shedler. It challenges the notion that randomized control trials (RCTs) are the “gold standard” to determine the best forms of treatment in the real world. While RCTs can answer certain questions, he argues they cannot answer the most important questions. As a result, the APA recommended treatments are all short-term treatments but will not be able to tell us whether those who undergo the treatment really get better and what options are available for those who drop-out of treatment (there is a significant drop-out rate with several of these recommended treatments).
For those interested in this controversy, I’d like to find out if you have (a) heard anyone challenging Shedler’s criticism and (b) what alternatives are offered by them. I’ve seen zero challenges to his piece to date.
Thanks to a friend I read this essay today about a possible way to model PTSD formation–by considering what does or does not happen in the trauma victim’s social environment after the trauma experience. The article discusses 2 different studies, one animal and the other human.
The animal study concludes that kidnapping a mother rat from her pups for more than 15 minutes will result in anxious activity upon reunification in the same cage where the trauma happened. Mother and pups will continue to be over-reactive well beyond the event. However, if mother and pups are reunited in a new environment, the trauma reactions (racing around, stepping on each other, aggressive behaviors) seem not to be present. Might it be that they have a shared job of exploring the new environment?
The human study points to the importance of having reunification symbols or rites of re-entry when bringing child soldiers back into the community. This appears to have value over just quietly pretending that nothing happened.
This month’s edition of American Psychologist has several interesting articles about the negative effects of therapy. The article by David Barlow, “Negative effects from psychological treatments”, provides a good overview of the effectiveness research controversies. But instead of focusing on how best to collect data about the benefits of a treatment, he gives some attention to looking more clearly at who benefits from a treatment and who is made worse (using dismantling type studies).
The next article (by authors Dimidjian and Hollon) gets at the definition of harm. Defining harm is rather complex. That a client may not get better from a treatment or may get worse during a treatment is not necessarily evidence that the treatment caused harm. And true to form, we have to accept that some treatments may both harm and help (they give the illustration of a nursing mother on medications: it may help her and yet harm her baby). Or, a treatment may make someone worse at first but then help them later on. Or, the treatment may be just fine but the practitioner may use it in a way that is good or bad. Finally, a treatment may be thought of as harming a patient when in fact what is seen is the normal trajectory of the disease.
So, how do you get at understanding whether a counseling treatment harms? They offer a number of methods for research which I won’t get into here.
Finally, the last article covers training implications (Castonguay et al). They cite therapists’ frequent underestimation of treatment failure and client deterioration. Looks like about 5-10% of clients get worse in treatment. If one wants to train counselors to avoid more failure how might one do that? Castonguay et al suggest that one do so by beefing up (a) proper therapy skills, and (b) skills to identify potentially harmful treatments. On p. 45 the authors include a table of training recommendations, which include
- expose trainees to list of potentially harmful treatments
- help trainees monitor change and deterioration
- enhance relationship skills
- learn and practice interventions that are empirically supported
- prevent and repair a variety of relational pitfalls
- adjust treatment choice, expectations, etc. based on client characteristics
- Address trainee’s issues (anxiety, hostility, defensiveness, naiveté, etc.) that may hinder counseling
Every counselor fears harming another; fears not helping enough. And it is often unclear whether our work is having its intended impact in the moment. However, there are things we can do to keep the communication lines open and thus listen to our clients about what is helping or not helping. This is what keeps us on our toes. What works for one person harms another. We must not get wedded to one way of helping.
Ever wondered if your counselor really knows what is in the Diagnostic & Statistical Manual (DSM, ver. 4TR)? Or do they just do the flip and dip method (let the large book open to any page and blindly point to a spot on the page)? Let’s hope not. Well, some professors are trying to increase the accuracy of their students via video vignettes.
One such person, Dr. Aaron Rochlen of U. Texas, has a website with 5 video vignettes available on his website (http://www.edb.utexas.edu/psychopathologypractice/index2.html) for students to watch and then try their hand at giving a DSM diagnosis.
Warning. Site is free. There are no answers given so don’t bother submitting your diagnostic considerations as they won’t go anywhere unless you send them to someone. Second warning: At least one of the “clients” uses some curse words.