facilitated communication

When I saw facilitated communication (FC) listed as a probably harmful therapy in Lilienfeld's article, I knew I wanted to write about it in my blog. From my "confines [in] the Ivory Tower", I had thought that FC was pretty much dead. There was convincing empirical evidence that (to use Matt's extremely apt analogy), facilitators were essentially using nonverbal children with autism as Ouija boards, and none whatsoever that the "therapy" was actually helping these children to communicate anything other than the facilitators' own messages.

Then I went and saw Autism: The Musical, and was horrified to see FC apparently live and well, as two parents practically wept to hear a fluent message conveyed to them from their previously nonverbal child. A closer look at the child himself revealed him struggling against the facilitator's grasp on his wrist and paying little to no attention to the keyboard. While I do believe that persons with autism may often have better receptive than expressive language abilities, I have little confidence that anyone, autistic or not, could point to the correct letters to spell out a coherent message without actually looking at them.

Later, after the movie, I heard that the parents were apparently continuing to take their son in for regular sessions of FC. I have attached a link to a YouTube video in which you can listen to what I heard: a speech, ostensibly dictated by this child, on the occasion of his bar mitzvah. Slide it up to about the 3:45 mark and listen if you like.



After hearing such an eloquent and moving speech, you will have little trouble understanding what you might not have before: why people get taken in by PHTs, especially ones revolving around developmental disabilities, and why once taken in, they will do almost anything to retain their belief. What parent would want to think that their son did not have that secret gem hiding inside him? Who would want to give up that comfort once they had obtained it?

Lilienfeld lists as the potential harm of FC, "false accusations of child abuse against family members." Obviously, this risk is very serious. But for me, the "indirect" opportunity costs exacted by FC--and by other "fringe" therapies directed at individuals with developmental disabilities--are much more serious than the opportunity costs exacted by ineffective treatments for other classes of disorders. I say this because delaying effective interventions for pervasive developmental disorders has a cumulative cost; developmental achievements build upon each other and failure to achieve some milestone early on may disrupt later progress in a host of other areas. While a client with acrophobia who wastes decades on ineffective treatments may later be able to resolve the issue in 3 hours using an effective strategy, an individual with autism who is denied early effective treatment is unlikely to achieve to their full potential. In the case of treatments for developmental disorders, opportunity costs should not be excluded from the consideration of potential for harm.

blithe assumptions

So, I did a little perusing of the personality disorders section of the DSM, and I was amazed by some of the language that I found there. Linehan's article ought to have tipped me off, but it wasn't just the description of borderline personality disorder that used pejorative language and descriptions that were "confound[ed] [by] motivational hypothes[es]" (p. 14). Here's a sampling (all italics mine):

Histrionic Personality Disorder-

"they commandeer the role of 'the life of the party'"

"their emotions often seem to be turned on and off too quickly to be deeply felt"

"they often act out a role (e.g., "victim" or "princess") in their relationships"

"seek to control their partner through emotional manipulation or seductiveness"

"at increased risk for suicidal gestures and threats to get attention and coerce better caregiving"

Narcissistic Personality Disorder--

"they may blithely assume that others attribute the same value to their efforts..."

"sense of entitlement"

"contemptuous and impatient"

"Arrogant, haughty behaviors characterize these individuals. They often display snobbish, disdainful, or patronizing attitudes"

"very sensitive to "injury" from criticism or defeat"

"overweening ambition"

"[differs from] Histrionic, Antisocial, and Borderline Personality Disorders, whose interactive styles are respectively coquettish, callous, and needy..."

Obsessive-Compulsive Personality Disorder

"oblivious to the fact that other people tend to become very annoyed"

"stubbornly and unreasonably insist that everything be done their way"

"Individuals with this disorder may be miserly and stingy"

The language used to describe these individuals is certainly not scientific or objective; rather, it's the kind of subjective, emotional language you might use to describe anyone you didn't like. The diagnostic criteria seem more to be criteria for unlikeableness (if that's even a word) than impaired functioning and clinically significant distress. If this is the best we can do, it's no wonder a large portion of the world describes us as "quacks" and "shrinks." No meaningful therapeutic progress can be made if the clinician conceives of their client in such pejorative terms and ascribes motives to their behaviors (i.e., rapid fluctuations in expressed emotion) that may, in fact, have more to do with our cultural "common sense" about what such behaviors mean (i.e., "turned on and off too quickly to be felt"), and less about their actual origin and function (perhaps limbic dysregulation?).

Frankly, this section of the DSM seems like a holdover from the dark ages, and I'm horrified by the pseudoscientific veneer it lays over highly subjective diagnostic categories. After all, how is a clinician to operationally define, say, "fishing for compliments" (a behavior described in both the Histrionic and the Narcissistic sections)? Or, taking a look at the actual criteria , how is one to pinpoint which emotions are "shallow" (Histrionic)? How can different clinicians all arrive at the same definition of what is "theatrical" (Histrionic) or "haughty" (Narcissistic) or "perfectionis[tic]" (Obsessive-Compulsive)?

Furthermore, is a category of personality disorders even helpful? Defining these diagnoses as disorders of the personality suggests disorders of intrinsic, relatively stable traits; it implies resistance to treatment. If a clinician diagnoses a client as having avoidant personality disorder, it seems that there's little that can be done--her very personality is disordered! Yet give the same individual a label of social phobia, and it seems, instead, that change can be effected--the phobia can be tackled.

So, in all, this whole category has me steamed.

a little too close to home

Part 1: Anxiety and Parenting Practice

I got hit with a double whammy: a mother AND a father with an anxiety disorder. This had interesting consequences for me, because I had the definite genetic input, but I also had the environmental factors beating me over the head constantly. My mom still sends me articles clipped from the local newspaper about women being raped and murdered, along with advice about how not to have the same thing happen to me. Just last week she sent me a little internet film about kitchen grease fires, narrated by a woman who had had her face burned off: an awesome thing to find in one's inbox first thing in the morning. Don't get me wrong, I love my family, but we're also a nice little self-reinforcing kettle of neuroticism.

When you grow up in an anxious family, you get the genetic predisposition, but you also get the constant message that the world is Out to Get You (see also maternal lecture #347, "There Is Not a Man in the World Who Doesn't Want to Dismember You and Shove You in the Trunk of His Car"). I was consequently interested in Minecka & Zinbarg's suggestions (2006) for reducing the likelihood that children of anxious parents would grow up to have anxiety disorders themselves.

While I thought their suggestions were sensible, I felt that they would be almost impossible to implement without managing the parent's anxiety first. Particularly, Minecka & Zinbarg suggest that children be provided with experiences that "facilitate the development of mastery and a nonavoidant coping style" (p. 23). One might also infer from evidence cited earlier in the article that they might suggest that parents redirect or refrain from discussion of possibly dangerous or threatening events, as this may reinforce children's avoidant responding. These are all excellent, evidence-based suggestions; however, I wonder if Minecka & Zinbarg considered just how difficult it may be to get a parent with an anxiety disorder to avoid verbal instruction and rumination about threat with their children, and furthermore, to allow the child sufficient control over their choices and environment to develop a sense of mastery. All parents worry about the welfare of their children, but anxious parents may be more likely than others to experience uncontrollable worry leading to a restriction of their child's environment. This is a kind of avoidance-by-proxy, in which the parent prevents the child from engaging in more independent behaviors that cause the parent worry. Subsequently, the child both learns the parent's fears vicariously and loses the opportunity to engage in behaviors that would instill a sense of control--and immunize them against vicarious learning of the parent's fears and avoidant style. Therefore, I see addressing the parent's anxieties and fears as absolutely necessary to the implementation of prophylactic childrearing practices.

****

Part 2: The Problem with "Pathology"

I went to see Autism: The Musical and afterwards there was a Q & A session. One of the panelists was a 12-yr-old boy with autism. The moderator asked him, "what does it feel like to have autism?" The boy responded, "I never know how to answer that. It would be like asking someone who doesn't have autism, 'What's it like to not have autism?' A person with autism can't tell you what it's like to not have autism and a person without autism can't tell you what it's like to have autism. It's part of me, I don't know what it's like."

That's the problem with talking about these conditions exclusively as pathology. My anxiety is part of me and it would be silly even to consider who I would be without it. I want to manage it, so that I can function, but I don't actually want to erase it. It's helpful to a certain extent--it's part of the reason that I'm so perfectionistic about my work, and I like that. I like focusing on details and making my work beautiful, whether it's a knitted lace shawl or a sonnet or a term paper. That's the flip side of my anxiety. I don't want to be "cured." I don't want some tumor excised. I like who I am. It doesn't really feel like a disorder as much as a complex and integral part of my make-up, some parts of which I want to dampen and some parts of which I want to highlight. Lexapro helps me do that to a certain extent, but so does choosing environments in which I know I'm going to function better and avoiding environments (like big, loud, crowded parties) in which I know I'm going to function worse. And so does gently putting myself into situations within my proximal zone of development (like, say, calling up someone I don't know and asking them to let me come observe at their facility) and letting myself find out that I didn't die. And so does taking time to meditate and go hiking. We shouldn't focus so much on eliminating the disorder as on shaping the life.

So there.

the siren song of the linear model

Prepare for a really dorky blog entry.

I was very struck by Kendler, Kuhn, & Prescott's 2004 article--not necessarily because of their conclusions about risk factors for depressive episodes but because of how they got there. In other words, I appreciated their approach to various statistical issues, especially model building and the use of raw probabilities. Admittedly, I am still a quantitative infant, but I particularly appreciated their deliberate decision to compare additive versus multiplicative models of risk. It is often tempting to try to fit any dataset to a linear model, not for any theoretical reason, but simply for reasons of convenience. Much can be gained, however, from considering the implications of fitting data to different mathematical functions; in this case, for instance, fitting a multiplicative model of risk suggests processes that differ in important ways from the ones that would operate in an additive model of risk. Just because linear models are easy to construct and analyze does not mean that they are the best way to understand our data!

I also appreciated Kendler et al.'s discussion of their decision to use raw probabilities as opposed to transforming them, perhaps to log(raw probability). Using a logarithmic transformation may indeed have made the process of statistical analysis easier but it also would have disguised one of the most interesting features of these data, which is the nonlinear relationship between risk of a depressive episode and contextual threat X neuroticism. I agree with the "public health argument" and I also think that it would have been much more difficult to interpret log(hazard ratio) than it is to interpret the raw probabilities. Despite the statistical convenience that transformation to a log scale can provide, it can lead to results that are difficult to interpret. Here, sticking with the raw probabilities makes the patterns Kendler et al. wish to highlight much more clear.


P.S. Jim--you wanted me to remind you to get me the reference(s) on doing meta-analyses of single-case studies.

me and my incoherent brain

While reading Voelker's brief article on proposed links between sleep disruptions and depression in college students, I flashed back to vivid memories of college friends dealing with depression who felt unable to get up in the morning despite multiple alarm clocks--who stayed asleep in bed until 4 or 5 pm, missing all their classes. Their problems with depression seemed intimately tied to abnormal sleep patterns and an inability to establish a healthy sleep-wake rhythm. Sleep problems can be devastating to individuals' daily functioning (lost jobs, failed classes...), so I'd be interested to know the statistics on abnormal sleep patterns in persons with depression. [Armitage's observation of poor coherence during the sleep of some individuals with depression was certainly provocative, but I'd be interested to see the findings replicated.]

Thinking along these lines, it seems to me that incorporating sleep hygiene goals in a behavioral activation therapy program for depression could be highly useful. Bootzin & Epstein discuss establishing appropriate discriminative stimuli for falling asleep by reserving the bed and bedroom for sleep only; along with establishing appropriate cues for sleep, they recommend certain daytime activities as well: avoiding naps, engaging in light, regular exercise, and exposing oneself to bright light. It seems to me that the stimulus control instructions would mesh well with goals for behavioral activation; developing simple goals early in therapy such as "I will not stay in bed for more than 15 minutes after waking in the morning" and "I will not use my bed for purposes other than sleeping (or sexual activity)" and moving on to more challenging goals such as "I will avoid naps" and "I will spend 15 minutes a day doing [fill in form of light exercise here]" as therapy progresses could help the client both to "activate" and to resolve sleep disturbances--which, in turn, would likely assist the client in activating yet further.

Certainly, resolving sleep problems will not automatically resolve depression, but it seems to me that these issues may, for many individuals, have a reciprocal relationship; anxiety or catastrophizing may feed insomnia, but then insomnia may further feed anxiety. Certain depressed persons might be predisposed to certain kinds of sleep disturbances, and these sleep disturbances may lead to impaired performance at school or at work--which may worsen a depressed individual's perception of their own efficacy. It seems to me that it would only make sense to tackle these problems together. I'd be interested to see any research that tackled this question empirically.

good storytellers

Despite Jim's disclaimer in class last week, I really enjoyed this week's readings and they went by quickly. I was particularly interested by Jacobson, Martell, and Dimidjian's 2001 article on behavioral activation treatment for depression. Their focus on action, rather than cognition, intrigued me. "One of the primary goals of presenting the BA model," they state, "is to dispel the myth that changes in mood need to occur before changes in behavior" (p. 260). I put a little exclamation point next to this statement on my paper copy, because in making this claim, Jacobson et al. draw upon a large body of social psychology research that supports the notion that behaviors have the ability to change cognitions just as much as, if not more than, cognitions have the ability to change behaviors. If forced, for example, to choose between two equally appealing alternatives, we later devalue the one we did not choose and increase our evaluation of the one we did choose. A study I particularly like that illustrates our behaviors' ability to drive our judgment is one in which participants were asked to engage in an excruciatingly boring task for a long period of time. (For the life of me, I cannot remember who did this study!) Once the task had been completed, researchers either offered the participants $1 or $15 to tell the future participants that the task had been interesting. Participants who received $15 did so, but later rated the study as boring. Participants who received $1 also told others the study was interesting, but when privately rating the study, said they had actually found it interesting. Presumably, they could not justify lying about the study for just $1, and so explained their behavior by coming to believe that they had actually found the repetitive task interesting! This and other similar studies suggest that while we don't always know the reason for our behaviors, we're very good at coming up with plausible explanations after the fact.

Although we would like to believe that we are perfectly rational creatures, oftentimes our self-stories are used not to guide our behaviors but to make sense of what we do. By encouraging depressed individuals to engage in personally reinforcing activities, BA uses behaviors as a guide to change cognitions (i.e., "if I am choosing to get out of bed and engage in this activity, then I must be feeling more energetic"). I doubt that this would work if goals were not worked out collaboratively; if the therapist were more active-directive, I imagine that the client would then be able to attribute their actions to the "orders" of the therapist, and would consequently not derive as much benefit. I therefore see the program's emphasis on helping the client to select activities that they personally find reinforcing to be a plus. Getting the client to make choices about goals and carry them out independently as homework drives them to ascribe their positive behaviors to their own internal states rather than to the dictates of the therapist.

Overall, I found theirs to be an intriguing and potentially very useful perspective on the treatment of depression. Looking forward to hearing from everyone else on this!

a born demander

Is there any meaningful difference between REBT and other forms of CBT? Engels, Garnefski, and Diekstra (1993) seem as though they'd like to tackle this question ("The findings of ...quantitative reviews lead to the conclusion that cognitive-behavioral therapies show the highest overall effect sizes...of all treatment modalities under study, but the degree to which RET contributed to this result is unclear" [p. 1083]) but they find themselves unable to address this question due to lack of sufficient data. Instead, Engels et al. end up comparing RET to placebo, systematic desensitization, and combination treatments--a strategy that seems to me less than useful. Comparing RET to placebo tells us little about the therapy's incremental validity, while comparing it to "combination treatments" (i.e. RET plus "behavioral therapy such as group systematic desensitization, self-control desensitization, or behaviorally oriented assertiveness training" (p. 1085)) and to systematic desensitization seems too much like comparing the same thing. Desensitization is cropping up everywhere here!

I encountered an anecdote about Albert Ellis on Wikipedia (I know, I know) relating how, as a young man, he overcame his shyness around women by approaching 100 women in the Bronx Botanical Gardens and engaging them in conversation. This desensitization procedure that he developed for himself at the age of 19 seemed like a foreshadowing of his later formation of a therapeutic strategy that he described as "unusually forceful and emotive and uniquely behavioral with its emphasis on in vivo desensitization" (p. 154). (Italics mine). Given the role of desensitization in REBT, systematic desensitization, and these combination treatments, it seems like a finding of no significant difference among these conditions tells us very little--we might have expected that methods utilizing exposure & desensitization would be similar in their effects.

What would be really interesting to know would be the answer to that first question--is there any meaningful difference between REBT and other forms of CBT? Engels et al. describe RET as "distinguished from other CBT methods especially in its therapeutic goal: the client's achievement of a new philosophical outlook" (p. 1083). But does helping clients to achieve a more existentialist worldview produce any incremental improvement over any other form of CBT? Are there clients for whom a therapist's assumption "that imperatives lead to needless disturbance" would prove unhelpful (p. 157)? Is any form of "must," too strongly adhered to, considered unhealthy, or would only certain classes of "musts" qualify? I suppose I'm thinking here of dealing with highly religious clients. Would the REBT therapist classify the "musts" of the religion as too absolutistic to be healthy? Would any orthodox client be seen as necessarily unhealthy for holding such dogmatic beliefs? I don't entirely understand the full nature of REBT--what the essential components of it are as opposed to what are simply more related to Ellis's personal therapeutic style. I'm looking forward to discussing this further in class.

P.S. Interesting excerpts from Ellis's Overcoming Resistance: A Rational Emotive Behavior Therapy Integrated Approach:

Shame-attacking exercise

(And for Jim:)
On using obscenities