perception

One theme arose repeatedly in both of our articles today--and it wasn't "it's the relationship, stupid!" No, what I heard was, "it's the perceived relationship, stupid!"

Given that the client's perception of the therapeutic relationship seems more predictive of outcome than "objective" measures of therapist and alliance qualities, I wondered about the degree to which variables like therapist empathy and collaboration in the therapeutic relationship affect clients whose perception of the world is in some way disordered. In many situations the difficulties clients are encountering in daily living may be directly related to the way in which they interpret others' social cues. Clients' affective states may also contribute to their "read" on their interpersonal relationships in general as well as their relationship with their therapist specifically. This is part of what really irks me with the "common factors" argument, which we saw rearing its head in the Kirschenbaum & Jourdan article--such an argument, which has alliance quality and the Rogerian core conditions doing all the heavy lifting, completely fails to take into account the fact that many clients may present for treatment with conditions that bias their perceptions. It is possible that in some cases the link between perceived alliance quality (or perceived therapist empathy, positive regard, or congruence) and positive outcome may occur because clients who successfully learn to interpret cues from their environment (particularly their social environment) in a more "realistic" manner are both doing better at recognizing positive elements of the therapeutic relationship and are using their newfound skills to achieve a higher level of overall functioning. This does not indicate that the effective elements of psychotherapy are essentially equivalent; indeed, different clients may require very different treatment approaches to help get to this point.

This is not to say that I do not believe empathy and positive regard and affectively positive, collaborative alliances are not extremely important. Indeed, I believe that treating patients/clients in this manner is our ethical obligation--such practices demonstrate respect for the dignity of all persons. However, we cannot ignore client factors that influence their perception of the therapeutic situation--and the empirically supported strategies that best help patients with particular constellations of factors--if we wish to help them achieve the best possible outcomes.

humility

St. Teresa of Ávila once wrote that humility was the root of all other virtue. Now, if she--and you--may pardon the analogy, it occurred to me in reading Sechrest & Smith's article that humility may well lie at the root of scientific progress as well. Perhaps, I thought, we ought to think of humility as a scientific virtue as well as a personal one.

What do I mean by humility here? I mean a willingness to engage with experts from diverse areas and diverse fields, even if doing so means violating the strictures of "disciplinary apartheid." When we become overly attached to our own "disciplinary specialization," we are easily drawn into a win/lose, us/them mentality, "compet[ing] with each other for preeminence, rather than trying to learn from each other" (p. 13). This competitive mindset in turn impels us to rely primarily or even solely on statistical methods (like hypothesis testing) that focus more on a significant/nonsignificant (i.e. win/lose) p-value judgment rather than methods that focus on exploration, model building and refinement, and pattern recognition (with the determination of p-values used only as one tool in a large and varied toolbox). By working to prove our own preeminence, we're engaging in a kind of scientific hubris that can distract us from seeing the unexpected and making new discoveries. As any Greek tragedy could tell us, hubris ultimately leads to catastrophe--or, in our case, stagnation and the preservation of overly simplistic models of psychopathology.

If we are humble, on the other hand, we will not hesitate to seek advice and support from experts from different areas, and we will not avoid entertaining ideas that conflict with our pet theories as though they were some kind of personal threat. When I think about my own area of interest, autism, all I seem able to think about is how silly it is that any of us should attempt to approach the problem from only one discipline's perspective. We need not just clinical folks, but developmental, social, cognitive, quantitative, neuro, and community folks as well. So many research areas are split by discipline rather than topic, such that important crosstalk and debate never happens. Everyone from one theoretical perspective is grouped together, and there's no one there to say, "Hey, let's approach this problem from an utterly different direction!"


\begin{rant supporting my own disciplinary orientation as a supplement to other theoretical positions}
I think it's quite possible, for example, for researchers of certain disciplinary heritages to think of autism as "developmental" only in regards to its classification as a pervasive developmental disorder. Too few theorists, in my opinion, are familiar enough with normative developmental processes across a range of domains to begin to think seriously about how early disruptions may have cascading effects in multiple domains that are usually not thought of as so closely intertwined. (For example, disruption of connective pathways between the cerebellum and the cerebrum might lead, in the case of stroke in older patients, to aphasia via diaschisis...if these connections were disrupted in early infancy, we might see far more profound and far-reaching impairments due to the interrelatedness of many areas of development. However, theorists are often unwilling to entertain such notions, dismissing them because we know that certain kinds of trauma in older individuals lead to different symptoms than those we're concerned about in autism. [I'm not sure that digression made any sense at all.])
\end{rant}

So, glossing over developmental processes and cognitive models, social researchers might focus on problems of social relatedness, and develop interventions only for those problems. And cognitive researchers might focus on a linguistic model and develop language interventions, while doing a pretty little dance away from social issues. And so on...while all the while information from differing disciplines is begging to be put together as a coherent (I might even say integrated) whole.

Phew. Reading over this, I see many places in which this blog entry is very un-integrated. But I'd like to go to bed now, so I will. I look forward to a rousing debate with you all on Wednesday!

all must have prizes

There is the real possibility that practitioners and students in mental health fields accept the Dodo bird verdict simply because it appears to be generally and uncritically accepted by others. - Hunsley & DiGiulio, 2002, p. 13

Wow. How distressing is that idea? Therapists and researchers and students, all eagerly swallowing a particular verdict on a subject, simply because they've heard it repeated enough times, not because they've actually seen a preponderance of empirical evidence to support it.

I have to believe that adherence to the notion of psychotherapy equivalence cannot possibly be all that widespread--even though I heard it declaimed to me as fact during my undergraduate experience. I would certainly doubt that most persons who assent to the notion of psychotherapy equivalence have really thought through what this would mean.

Given that most clinicians (and research groups!) have definite allegiances to particular classes of therapy, such allegiances would suggest a belief that certain types of therapy are more efficacious, effective, and/or efficient than others. I doubt that many who maintained such an allegiance could really bring themselves to wholeheartedly endorse every other possible kind of therapy as well. Hunsley and DiGiulio seem concerned that proponents of "esoteric" therapies might use the Dodo bird verdict to their advantage by "claim[ing] clinical legitimacy for their treatments by relying on the results of research conducted on other forms of psychotherapy" (2002, p. 17). However, anyone promoting their "pet" therapy based on the claim of psychotherapy equivalence would be undermining such a claim in the moment they made it--if all psychotherapies are equivalent, why develop new ones? Why attempt to develop more efficient and effective forms of treatment? If the therapeutic alliance is the only important element, why not just throw all clients in with kindly college professors?

Whether we own up to it or not, I'd say that very few of us actually believe in psychotherapy equivalence. Propagating the myth of equivalence might be more a way of ducking the time- and resource-consuming realities of empirically validating a treatment than anything else.

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Picture from Project Gutenberg.