Why can psychological therapy be helpful?

24 10 2014

Research explaining how therapy might help is filled with very technical terminology, e.g., invoking “transference”, “extinction”, heightening access to “cognitive–emotional structures and processes”, “reconfiguring intersubjective relationship networks” (see over here for more).

Could simpler explanations be provided? Here are some quick thoughts, partly inspired by literature, discussions, and engaging myself as a client in therapy:

  • You know the therapist is there to listen to you — they’re paid to do so — so there’s less need to worry about their thoughts and feelings. One can and is encouraged to talk at length about oneself. This can feel liberating whereas in other settings it might feel selfish or self-indulgent.
  • The therapist keeps track of topics within and across sessions. This can be important for recognising patterns and maintaining focus, whilst allowing time to tell stories, meandering around past experiences, to see where they lead.
  • The therapist has knowledge (e.g., through literature, supervisory meetings, and conversations with other clients) of a range of people who may have had similar feelings and experiences. So although we’re all unique, it can also be helpful to know that others have faced and survived similar struggles — especially if we learn what they tried.
  • Drawing on this knowledge, the therapist can conjecture what might be going on. This, perhaps, works best if the conjectures are courageous (so a step or two away from what the clients says) — and tentative, so it’s possible to disagree.
  • There can be an opportunity for practice, for instance of activities or conversations which are distressing.
  • Related, there’s a regular structure and progress monitoring (verbally, with a diary, using questionnaires). Self-reflection becomes routine and constrained in time, like (this might be a bit crude but bear with me) a psychological analogue of flossing one’s teeth.
  • (Idea from Clare) “… daring to talk about things never spoken of before with someone who demonstrates compassion and acceptance; helpful because allows us to face things in ourselves that scare us and develop less harsh ways of responding to ourselves”
  • (added 27/10/2014) The therapist has more distance from situations having an impact on someone than friends might have so, e.g., alternative explanations for interpersonal disputes can more easily be provided.
  • (added 27/10/2014) It’s easier for a therapist to be courageous in interactions and suggestions than for a friend as — if all goes wrong — it’s easier for the client to drop out of the therapeutic relationship without long-term consequences (e.g., there’s no loss of friendship).

Some thoughts…





“How I became an analyst” by Arthur Valenstein

19 10 2014

Interesting multidisciplinary background — some excerpts from Valenstein (1995):

“When I was sixteen years old I built my own short-wave receiver and transmitter and became a ham radio operator. This bent towards electronics motivated me to enter the engineering school at Cornell University in 1931 with the intention of becoming an electrical engineer…”

“But those were depression years, and it seemed unlikely that I could make a sufficient livelihood as an electrical engineer.”

“… from early years I had been curious about people, how and why they were as they were. I was puzzled about myself as well, feeling myself to be something of an ‘outsider’ in school. As I learned later, this is one of the elements contributing to psychological-mindedness, a predisposition that is conducive to psychoanalytic inquiry.”

“I have always had one foot in hard science and one foot in literature and the humanities, and fortunately I don’t seem to have fallen between the two.”

“George Henry was carrying out a heavily funded research project on homosexuality. This opened a whole world to me that I had never known, especially the gay world, and I learned something about it, even getting to know some of its colloquial terms. Later Henry and his research assistant, who in retrospect I realize was homosexual, published several books on homosexuality from a descriptive point of view.”

“… I came to be in Boston, which I never left except for one year in neurology with Foster Kennedy (a colourful man, a Northern Ireland Orangeman of great sartorial splendour and the gift of marvellously eloquent, elegant speech) at Bellevue Hospital in New York, and my years in the military.”

“My initial exposure to the activities and ambience of the Hampstead Child Therapy Clinic [now the Anna Freud Centre] forty years ago, and my continued contact with it and with Anna Freud over many years, greatly influenced my identity as a psychoanalyst, both theoretically and clinically. Before my sabbatical in London in 1955, I had become interested not only in what nowadays seems to be called ‘cognitive developmental psychology’ and ‘attachment theory’, but also what might be termed ‘affect developmental psychology’.”

Reference

Valenstein, A. (1995). How I became an analyst. Bulletin of the Anna Freud Centre, 18, 283–291.





Politics

11 10 2014

In 1962, John F. Kennedy announces that “We choose to go the moon.” Seen as wonderful and achievable, even though JFK didn’t have the required knowledge and expertise to make it happen himself.

Zoom forward to the 21st century: the Green Party proposes that everyone should have a living wage and that we should strive for equality; that it’s unfair that a small minority of people whose job it is to move numbers between bank accounts should claim ownership of most of the world’s resources and that we need to and can change this. This is considered hopelessly utopian. How are they going to achieve that, people complain, their policies don’t spell out the details.

What’s going on? I’m too thick to grasp why the first is reasonable but the second irrational.





What can happen when “real world” training meets academia

15 09 2014

I did my PhD research at a doctoral training centre. It was a wonderful, though often stressful, experience (and I still work in academia). One of the conditions for the programme was that we attended various transferable skills workshops. These workshops were often framed as being about making us more employable, even if we were to fall from the “ivory tower” (heaven forbid).

One workshop was particularly memorable: two days on creativity, organised by the funding body and run by a multinational company which claims to have helped corporations to be more creative. Students travelled from across the UK to attend and were doing research on a range of topics across the breadth of science.

First the positive. Although research conferences are a good way to meet folk from elsewhere, everyone tends to have a similar background, so it was great to chat with people who were doing radically different things and discover what we all had in common, for instance in terms of the day-to-day challenges of doing a PhD.

The creativity workshop itself was exceedingly painful and for most of the time felt like a parody. One of the PowerPoint slides was a picture of three (badly drawn) tunnels. You could see the light at the end of one of the tunnels, you could vaguely see around the second tunnel, and the third tunnel was totally dark. We were told to strive to fumble around in the dark tunnel as it’s in there we’d find the really exciting ideas. Another slide had a diagram showing how there is a continuum of ideas, bad ideas at one end of the continuum, good ideas at the other. We should be striving to move to the end where the good ideas live. There were motivational posters all around the room with quotes like, “Creativity is seeing relationships were none exist” (a platonic friend and I got our photo taken in front of this poster, holding hands, gazing longingly into each other’s eyes).

The “facilitators”, I discovered later via the web, were neurolinguistic programming (NLP) “Master Practitioners”. As far as I can tell, NLP has no evidence of efficacy. Guess what happens when NLP practitioners try to use corporate training techniques with science and engineering students…? By the end of the second day, there were 40 of us sitting looking miserable, arms folded. They presumably get paid rather a lot to deliver something devoid of any content and they didn’t give us any evidence whatsoever to support any of the claims they made.

So much for transferable skills.

Is it possible that PhDs already train people up on useful skills? Most people leave academia and get jobs elsewhere, i.e., are successful! I think having more highly trained scientists wandering around the world can only be a good thing. Imagine if government used more evidence for its policies, for instance, relying on scientific thinking rather than ideology and rhetoric.





A farcical proposal for mental health outcomes measurement

5 09 2014

If you’re going to develop a questionnaire for something resulting in a total “score” — quality of life, feelings, distress, whatever — you’ll want all of the questions for one topic to be related to each other (as a bare minimum). This questionnaire probably wouldn’t be very “internally consistent”:

THE GENERAL STUFF QUESTIONNAIRE

  1. How often do you sing in the shower?
  2. What height are you?
  3. How far do you live from the nearest park?
  4. What’s your favourite number?

(You might still learn interesting things from the individual answers.)

This one would:

THE RELIABLE FEELINGS QUESTIONNAIRE

  1. How do you feel?
  2. How do you feel?
  3. How do you feel?
  4. How do you feel?
  5. How do you feel?
  6. How do you feel?
  7. How do you feel?
  8. How do you feel?
  9. How do you feel?
  10. How do you feel?

However, you might wonder if questions 2 to 10 add anything… (So internal consistency isn’t everything.)

There are many ways to test the internal consistency of questionnaires, using the answers that people give. One is to use a formula by Lee Cronbach called Cronbach’s alpha. Answers run from 0 to 1. Higher is better (but not too high; see the second example above).

In England, it is now recommended (see p. 12 of Mental Health Payment by Results Guidance) to use scores on a “Mental Health Clustering Tool” to evaluate outcomes. I think there are at least two problems with this:

  1. It’s completed by clinicians. It’s unclear if service users even get to know how they have been scored, never mind to what extent they can influence the process.
  2. The questionnaire scores aren’t internally consistent.

The people who proposed the approach write (see p.30 of their report): “As a general guideline, alpha values of 0.70 or above are indicative of a reasonable level of consistency”. Their results: 0.44, 0.58, 0.63, 0.57. They also refer to previous studies showing that this would always be the case, due to “its original intended purpose of being a scale with independent items” (p. 30). So, by design, it’s closer to the General Stuff Questionnaire above: a list of “presenting problems” to be read individually.

Not only are clinicians deciding whether someone has a good outcome (are they really in the best position to decide?), but the questionnaire they’re using to do so is rubbish — as shown by the very people proposing the approach!

Undergraduate psychology students wouldn’t use a questionnaire this poor in their projects. Why is it acceptable for a national mental health programme?





No biomarkers

27 08 2014

There are no biomarkers
We can’t treat it
Not so! Said the psychiatrist
Here, we have tears
They are easy to treat
This pill dries them up

But that’s treating the
Symptom not the cause
Not so! Said the psychiatrist
Crying is diagnosed by DSM
You are Crying if
You are crying

Stop crying, pleaded the psychiatrist
Giving her a hug.





Advice to empiricists from Alan Grafen

20 08 2014

Spotted in Grafen, A. (1987). Measuring sexual selection: why bother.

advicefield








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