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FAQ: Psychotherapy and Science, the Disconnects

Question:

This message was posted anonymously: Issue 1, Regarding who are good counselors (cute title for issue):   "We can’t ‘Just Go With The Best’ UNTIL We can Determine what CONSTITUTES "the Best" and make sure we know where to concentrate training to make "THE Best" otherwise we won’t really have the best and won’t really get the best. Okay ?"   [Let me deal with your confusion from my title (above) by trying to state the issue still briefly, but more simply:  If you don't know what good peer counselors can do or what they can easily be trained to do and handle, you will not know where you really need SPECIALLY trained (long trained) individuals or the problems that they especially need to be trained for.   Trying for ten words or less:  "If you don't make comparisons with regular good people, you don't know what you got."  (scientically speaking) (Sorry, 15 words.)] Ok,  Let’s take a look at this specific issue in a little more detail: A major set of FOUNDATION research studies for the counseling/"therapy" field has not yet been done. AND indeed, ONLY 3 CONTROLLED studies (the last in 1979 !) have been done comparing the effects of counseling from professionals *with* counseling from "other reasonable helpers" (with no professional grad. training). THIS, in spite of the fact that these best studies in the area essentially show that other REASONABLE helpers do as well for arguably a broad range of problems. These studies, at the same time, indicate the other helpers are an ethical comparison group, having been found *good* for a broad range of problems for which counseling is most often sought. More recently much research shows peer counselors in colleges to be VERY helpful (though their performance is NOT directly compared to that of professional helpers in these studies). ANYWAY, these studies are NEEDED to show where professionals ARE really needed AND where treatments need to be developed (as is, this situation REMAINS VERY UNCLEAR). These studies might well also indicate the desirability of other mental health care provider roles (like well selected and well-trained peer counselors and/or more extensively trained paraprofessionals). Now to the "ethics" matter (the first defense of the many backing the status quo in the field): Not only have other reasonable helpers been shown effective for a broad range of problems in past studies, BUT ALSO: "other helpers" (peer counselors or "paras"), used as a comparison group to professionals (professionals who are licensed & grad.-trained), would ETHICALLY only have to be NO WORSE than the NO TREATMENT groups (or waitlist control groups) used today OR NO WORSE than the placebo controls used today for the study to be considered ethical. *AS WITH* the types of studies now done, clients treated by peer counselors OR "paras" could be offered professional care AFTER the study. (Today waitlist people wait up to around 3 months for treatment — they just wait until the other exactly equivalently disturbed group is treated.) AGAIN: Without these studies we do NOT KNOW where professionals are really needed or most needed. Areas where treatment developments are most needed are not being identified. (I hope readers appreciate these and other LIKELY negative effects ON CLIENTS of an inexcusable LACK of work in certain, basic areas of FOUNDATION RESEARCH.) Also, a reasonable, delineated mental health care SYSTEM (with a variety of helpers or at least specializations) is NOT being developed. IT REALLY CAN’T BE FROM ONE STANDPOINT: *BASIC FOUNDATION* RESEARCH IS *NECESSARY*.  There are many things about which one cannot conclude without clear research. ——— Issue #2:  (not so cute title): "If you want to have a good classification system (and you MUST if you want to be any kind of scientist), THEN you must do work on making your diagostic (or classification) system understandable.  You must at the most basic level set up definitions so people show agreement on diagnoses (or formal classification)"  This requires research DEVELOPING interrater reliability SURROUNDING the specific diagnostic criteria (PER SE) — i.e. as written — between each "revision" of said criteria.  This is rarely done. Regarding the therapists’ major guide for objectivity, the Diagnostic and Stat. Manual of the Amer. Psychiatric Assoc.: It is without question that one could develop criteria-through-procedures that show MUCH better inter-rater agreement than the DSM. The last time the Amer. Psychia. Assoc. published and reported COLLECTED reliability data (within the DSM itself (DSM III)), there was only a r=.7 correlation between clinicians AS TO WHETHER a client had a disorder in the Mood Disorder GROUP (or NOT). SIMILARLY, there was an equally low level of agreement on whether a client had a disorder in an Anxiety CATEGORY (or NOT) (quite inadequate!!). (Often there is disagreement on whether a disorder is an Anxiety Disorder or a Mood Disorder.) AND this is all beside the issue that today’s "diagnoses" are possibly good for very little and possibly often more destructive than constructive. VERY VERY little work was done investigating the inter-rater reliability of criteria *between* DSM-III and the meeting of the DSM-IV committee to define "new" diagnostic "options." In fact, only 14 of the top 40 diagnoses had ANY inter-rater reliability data generated on their criteria in the 15 years since DSM-III (source: DSM-IV Sourcebook, Vol. 2). Judging by the "new" ICD-10 criteria and their inter-rater reliabilities, we can expect the DSM-IV diagnostic criteria to show little better inter-rater reliabilities than DSM-III (the DSM-IV criteria were made to be very similar and consistent with ICD-10). To comfort us in some way a number of therapists say "we don’t like diagnoses either." A GOOD RETORT: I don’t care about diagnoses, but you still need good definitions THROUGH THE PROCEDURES YOU USE within an agency to have the minimum science standard — decent inter rater agreement. Otherwise you cannot discuss anything clearly with any others (you can’t communicate). I am in no way comforted by the INDIVIDUAL therapist making his decisions in idiosyncratic ways, with way too little accountability. (It is a principle: power corrupts. Without accountability or communication you will have an inappropriate degree of power BECAUSE it is in no way appropriately negotiated, sanctioned, or scientifically monitored.) I am quite aware that "therapists" often do not use the DSM.  They VERY often do not use ANY proven diagnostic OR CLASSIFICTION sysem.  They think what ever they want and do whatever they want.  I can’t believe that people can possibly be given doctorates in this area (esp. given I have well shown that clinicians are in NO real sense whatsoever "science-practitioner"  –  in NO sense at all). See http://homepages.go.com/~psycadvoc/it.html   for more. —— Issue #3:  (not cute at all) : "Claims of Being "Science-Practitioners" are Fraudulent, Misleading and Scientifically Unethical" People of science should do the main basic science practices when and where they can (e.g. in their own local agencies or professional group).   To be a "science-practitioner" you must do some science practice, not just read science (or in this case read a hodge-podge of poor science and speculatively "extraoplate"). To be a "science-practitioner" you must clearly and regularly engage in some science procedure.   Extrapolating from studies done in the irony tower is NOT practicing science.  In fact, it is doing NOTHING special OR professional at all.  Such a person is acting just as a lay reader of science and unless the practitioner uses the results of the single study (or much more rare, a study program) *directly* and in a controlled manner, he is only speculating. In NO substantial way is their any truth to the claim that clinical psychologists, etc. are science practitioners.  Clinical psychologists do not have the discipline to establish good operational definitions WITHIN AGENCIES (e.g. for defining (i.e. diagnosing) personality disorders). NO PROGRESS CAN BE MADE UNDER THESE CIRCUMSTANCES (and many other similar problems-in-science cases). Because they are not scientists they cannot progress OR really work well together. They cannot self-evaluate. DSM criteria are so far from good operational definitions, I would not dignify them with the word "criteria." I know of no counselor or agency that has made any credible attempt at scientific respectability (or any that could be argued to be doing such). It is simply pitiful and inexcusable. Practice, as is, is actually an abuse of power and taking advantage of vulnerable populations. Someday such practice may result in law suits. Using diagnostic procedures that do lead to excellent inter-rater agreement is certainly possible today, not only at some level but at a useful level. At present counselors and therapists don’t even respect each other. Since I am trained in psychology myself I know what is meant when it is said that therapists are "trained in scientific methods." Trouble is they engage in no regular (much less integral) scientific PROCEDURES in the normal or typical conduct of their work. This is true to such a degree it is unacceptable. And it is true of all therapists I know of. Again, their failure to develop operational definitions of personality disorders that at least show excellent within agency inter-rater reliability is an excellent illustration. There is correspondingly a lack of proven agreement on the application of procedures (loosely called "therapies") and on the assessment of results IN actual practice. The field itself recognizes deficiencies in how "therapies" are considered "validated." (Obviously with this problem most treatments should NOT be termed "therapies.") The fact that the idea … read more »

Response:

Issue 1, Regarding who are good counselors (cute title for issue):   "We can’t ‘Just Go With The Best’ UNTIL We can Determine what CONSTITUTES "the Best" and make sure we know where to concentrate training to make "THE Best" otherwise we won’t really have the best and won’t really get the best. Okay ?"   [Let me deal with your confusion from my title (above) by trying to state the issue still briefly, but more simply:  If you don't know what good peer counselors can do or what they can easily be trained to do and handle, you will not know where you really need SPECIALLY trained (long trained) individuals or the problems that they especially need to be trained for.   Trying for ten words or less:  "If you don't make comparisons with regular good people, you don't know what you got."  (scientically speaking) (Sorry, 15 words.)] Ok,  Let’s take a look at this specific issue in a little more detail: A major set of FOUNDATION research studies for the counseling/"therapy" field has not yet been done. AND indeed, ONLY 3 CONTROLLED studies (the last in 1979 !) have been done comparing the effects of counseling from professionals *with* counseling from "other reasonable helpers" (with no professional grad. training). THIS, in spite of the fact that these best studies in the area essentially show that other REASONABLE helpers do as well for arguably a broad range of problems. These studies, at the same time, indicate the other helpers are an ethical comparison group, having been found *good* for a broad range of problems for which counseling is most often sought. More recently much research shows peer counselors in colleges to be VERY helpful (though their performance is NOT directly compared to that of professional helpers in these studies). ANYWAY, these studies are NEEDED to show where professionals ARE really needed AND where treatments need to be developed (as is, this situation REMAINS VERY UNCLEAR). These studies might well also indicate the desirability of other mental health care provider roles (like well selected and well-trained peer counselors and/or more extensively trained paraprofessionals). Now to the "ethics" matter (the first defense of the many backing the status quo in the field): Not only have other reasonable helpers been shown effective for a broad range of problems in past studies, BUT ALSO: "other helpers" (peer counselors or "paras"), used as a comparison group to professionals (professionals who are licensed & grad.-trained), would ETHICALLY only have to be NO WORSE than the NO TREATMENT groups (or waitlist control groups) used today OR NO WORSE than the placebo controls used today for the study to be considered ethical. *AS WITH* the types of studies now done, clients treated by peer counselors OR "paras" could be offered professional care AFTER the study. (Today waitlist people wait up to around 3 months for treatment — they just wait until the other exactly equivalently disturbed group is treated.) AGAIN: Without these studies we do NOT KNOW where professionals are really needed or most needed. Areas where treatment developments are most needed are not being identified. (I hope readers appreciate these and other LIKELY negative effects ON CLIENTS of an inexcusable LACK of work in certain, basic areas of FOUNDATION RESEARCH.) Also, a reasonable, delineated mental health care SYSTEM (with a variety of helpers or at least specializations) is NOT being developed. IT REALLY CAN’T BE FROM ONE STANDPOINT: *BASIC FOUNDATION* RESEARCH IS *NECESSARY*.  There are many things about which one cannot conclude without clear research. ——— Issue #2:  (not so cute title): "If you want to have a good classification system (and you MUST if you want to be any kind of scientist), THEN you must do work on making your diagostic (or classification) system understandable.  You must at the most basic level set up definitions so people show agreement on diagnoses (or formal classification)"  This requires research DEVELOPING interrater reliability SURROUNDING the specific diagnostic criteria (PER SE) — i.e. as written — between each "revision" of said criteria.  This is rarely done. Regarding the therapists’ major guide for objectivity, the Diagnostic and Stat. Manual of the Amer. Psychiatric Assoc.: It is without question that one could develop criteria-through-procedures that show MUCH better inter-rater agreement than the DSM. The last time the Amer. Psychia. Assoc. published and reported COLLECTED reliability data (within the DSM itself (DSM III)), there was only a r=.7 correlation between clinicians AS TO WHETHER a client had a disorder in the Mood Disorder GROUP (or NOT). SIMILARLY, there was an equally low level of agreement on whether a client had a disorder in an Anxiety CATEGORY (or NOT) (quite inadequate!!). (Often there is disagreement on whether a disorder is an Anxiety Disorder or a Mood Disorder.) AND this is all beside the issue that today’s "diagnoses" are possibly good for very little and possibly often more destructive than constructive. VERY VERY little work was done investigating the inter-rater reliability of criteria *between* DSM-III and the meeting of the DSM-IV committee to define "new" diagnostic "options." In fact, only 14 of the top 40 diagnoses had ANY inter-rater reliability data generated on their criteria in the 15 years since DSM-III (source: DSM-IV Sourcebook, Vol. 2). Judging by the "new" ICD-10 criteria and their inter-rater reliabilities, we can expect the DSM-IV diagnostic criteria to show little better inter-rater reliabilities than DSM-III (the DSM-IV criteria were made to be very similar and consistent with ICD-10). To comfort us in some way a number of therapists say "we don’t like diagnoses either." A GOOD RETORT: I don’t care about diagnoses, but you still need good definitions THROUGH THE PROCEDURES YOU USE within an agency to have the minimum science standard — decent inter rater agreement. Otherwise you cannot discuss anything clearly with any others (you can’t communicate). I am in no way comforted by the INDIVIDUAL therapist making his decisions in idiosyncratic ways, with way too little accountability. (It is a principle: power corrupts. Without accountability or communication you will have an inappropriate degree of power BECAUSE it is in no way appropriately negotiated, sanctioned, or scientifically monitored.) I am quite aware that "therapists" often do not use the DSM.  They VERY often do not use ANY proven diagnostic OR CLASSIFICTION sysem.  They think what ever they want and do whatever they want.  I can’t believe that people can possibly be given doctorates in this area (esp. given I have well shown that clinicians are in NO real sense whatsoever "science-practitioner"  –  in NO sense at all). See http://homepages.go.com/~psycadvoc/it.html   for more. —— Issue #3:  (not cute at all) : "Claims of Being "Science-Practitioners" are Fraudulent, Misleading and Scientifically Unethical" People of science should do the main basic science practices when and where they can (e.g. in their own local agencies or professional group).   To be a "science-practitioner" you must do some science practice, not just read science (or in this case read a hodge-podge of poor science and speculatively "extraoplate"). To be a "science-practitioner" you must clearly and regularly engage in some science procedure.   Extrapolating from studies done in the irony tower is NOT practicing science.  In fact, it is doing NOTHING special OR professional at all.  Such a person is acting just as a lay reader of science and unless the practitioner uses the results of the single study (or much more rare, a study program) *directly* and in a controlled manner, he is only speculating. In NO substantial way is their any truth to the claim that clinical psychologists, etc. are science practitioners.  Clinical psychologists do not have the discipline to establish good operational definitions WITHIN AGENCIES (e.g. for defining (i.e. diagnosing) personality disorders). NO PROGRESS CAN BE MADE UNDER THESE CIRCUMSTANCES (and many other similar problems-in-science cases). Because they are not scientists they cannot progress OR really work well together. They cannot self-evaluate. DSM criteria are so far from good operational definitions, I would not dignify them with the word "criteria." I know of no counselor or agency that has made any credible attempt at scientific respectability (or any that could be argued to be doing such). It is simply pitiful and inexcusable. Practice, as is, is actually an abuse of power and taking advantage of vulnerable populations. Someday such practice may result in law suits. Using diagnostic procedures that do lead to excellent inter-rater agreement is certainly possible today, not only at some level but at a useful level. At present counselors and therapists don’t even respect each other. Since I am trained in psychology myself I know what is meant when it is said that therapists are "trained in scientific methods." Trouble is they engage in no regular (much less integral) scientific PROCEDURES in the normal or typical conduct of their work. This is true to such a degree it is unacceptable. And it is true of all therapists I know of. Again, their failure to develop operational definitions of personality disorders that at least show excellent within agency inter-rater reliability is an excellent illustration. There is correspondingly a lack of proven agreement on the application of procedures (loosely called "therapies") and on the assessment of results IN actual practice. The field itself recognizes deficiencies in how "therapies" are considered "validated." (Obviously with this problem most treatments should NOT be termed "therapies.") The fact that the idea of scientific procedure INTEGRAL in a therapist’s daily work makes no sense to many therapists is not surprising. THERE ARE NONE!! I would hope you could see a … read more »

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