Westen et al. article Flashcards
What do Westen et al. argue for?
A more nuanced story about efficacy and treatment of choice than sometimes seen in the scientific literature
Note: not claiming their own narrative is bias-free
Arguing that EST methodology assumptions are not generally valid - they apply to some instances but not to others
What do Westen et al. do not argue against?
Not advocating against evidence-based practice (but asking for a more nuanced story)
What are Westen et al. suggesting is time for in their article?
Time has come for a thoroughgoing assessment of the empirical status of not only the data but also the methods used to
assign the appellations empirically supported or unsupported.
How do Westen et al. argue for their point of view?
- they examine the empirical basis of the assumptions that underlie the methods used to establish empirical support for psychotherapies
- then they reexamine the data supporting the efficacy of a number of the treatments currently believed to be empirically supported
- they offer suggestions for reporting hypotheses, methods, and findings from controlled clinical trials and for broadening the methods used to test the clinical utility of psychosocial interventions for particular disorders
- arguing from data (how to collect and interpret the data, so that we maximize our chances of drawing accurate inferences)
What type of text is the Westen et al. article?
Critical towards the established “story” of efficacy and treatment choice
Arguing for a more nuanced story
What is the target audience of the Westen et al. article?
The scientific community
What happened in 1995 with the publication of the
first of several task force reports by the American Psychological
Association?
Suggested training professionals exclusively in the use of empirically validated therapies
The report distinguished ESTs from the less structured, longer-term treatments conducted by most clinicians
Which characteristics do ESTs and the research models used to validate them, share in common?
- treatments are typically designed for a single Axis I disorder
- patients are screened to maximize homogeneity of diagnosis, and minimize co-occurring conditions that could increase variability of treatment response
- treatments are manualized
- treatments’ duration is brief and fixed to minimize within-group variability
- outcome assessment focuses primarily on the symptom that is the focus of the study
These characteristics are aimed at maximizing the internal validity of the study (“cleanness” of the design)
What is considered a valid experiment according to the general assumption?
- randomization
- manipulating a small set of variables
- control of potentially confounding variables
- standardizing procedures as much as possible
–> drawing relatively unambiguous conclusions about cause and effect
What is the problem with ESTs according to Westen et al.
The use of RCT methodologies to validate
ESTs requires a set of additional assumptions that are themselves neither well validated nor broadly applicable to most disorders and treatments
For example:
1) psychopathology is highly malleable
2) most patients can be treated for a single problem or disorder
3) psychiatric disorders can be treated independently of personality factors unlikely to change in brief treatments
4) experimental methods provide a gold standard for identifying useful psychotherapeutic packages
What are the main assumptions of ESTs according to Westen et al.
1) Psychological processes are highly malleable
2) Most patients have one primary problem or can be treated as if they do
3) Psychological symptoms can be understood and treated in isolation from personality dispositions
4) The paradox of pure samples
5) Controlled clinical trials provide the gold standard for assessing therapeutic efficacy
Explain the assumption of malleability (Westen et al.)
- the assumption is implicit in the treatment lengths used in ESTs (6 to 16 sessions)
- exclusive focus on brief treatments: emerges less from any data on the length of treatment required to treat most disorders effectively and more from pragmatic considerations such as the need to avoid the confound of time elapsed
- another reason for short treatments: The longer the therapy, the more variability within experimental conditions; the more variability, the less one can draw causal conclusions.
Conclusion: the preference for brief treatments is a natural consequence of efforts to standardize treatments to bring them under experimental control (longer sessions pose a threat to internal validity)
What are Westen et al. arguments against the malleability assumption?
- it doesn’t rest on strong evidence
- even though brief interventions work for some disorders, a substantial body of data shows that with or without treatment, relapse rates are high (ex. repeated depressive episodes)
- the assumption is inconsistent with data from naturalistic studies of psychotherapy, which consistently find a dose-response relationship: longer treatments (1, 2 years) are more effective than shorter ones (ex. the finding from naturalistic samples that
substantial symptom relief often occurs within 5 to 16 sessions, particularly for patients without substantial personality pathology; however, enduring “rehabilitation” requires substantially longer
treatment, depending on the patient’s degree and type of characterological impairment) - meta-analytic data on ESTs suggest that most psychopathological vulnerabilities studied are in
fact highly resistant to change, that many are rooted in personality and temperament, and that the modal patient treated with brief treatments for most disorders (other than those involving specific
associations between a stimulus or representation and a highly specific cognitive, affective, or behavioral response) relapses or seeks additional treatment within 12 to 24 months - findings from research using implicit measures, for example the Stroop task, shows continued biases towards depressive words, even among people who are no longer depressed –> changes in state may or may not be accompanied by changes in diatheses for those states encoded in implicit networks + raising questions about the durability of change
- Beck studies + contemporary research in cognitive neuroscience: implicit associational networks, which reflect longstanding regularities in the individual’s experience, can be resistant to change, and likely provide a diathesis for many psychological disorders
Why are researchers focusing on patients with only one disorder?
- researchers are choosing relatively “pure” cases (without comorbidities) to avoid confounds presented by co-occurring disorders
- there is a requirement for research proposals to be tied to categories defined in DSM in order to receive funding –> focus on single disorders
What are Westen et al. arguments against the assumption that most patients have one primary problem or can be treated as if they do? (correlative assumption that the syndrome can be treated sequentially using different manuals)
- the empirical and pragmatic limits imposed by reliance on DSM diagnoses: 3 costs of linking research to DSM
- DSM diagnoses are created by committee consensus on the basis of available evidence rather than by strictly empirical methods; DSM categories not very well empirically supported –> empirically unsupported assumptions about psychopathology
- the implicit assumption that patients typically present with symptoms of a specific Axis I diagnosis and can identify at the start of treatment precisely which one it is, is not generally valid; the best available data from both naturalistic and community (catchment) studies suggest that between one third and one half of
patients who seek mental health treatment cannot be diagnosed using the DSM because their problems do not fit or cross thresholds for any existing category; funding only research focused on DSM has virtually eliminated research that once dominated psychotherapy
- unrealistic for therapists to learn the manuals for each disorder; considering that most patients do not respond to a first-line ESTfor most disorders –> having to learn 2 or 3 manuals for each disorder - the problem of comorbidity:
- single-disorder presentations are the exception rather than the rule (most Axis I conditions are comorbid with other Axis I or Axis
II disorders in the range of 50% to 90%)
- the methodology underlying the identification of ESTs implicitly commits to a model in which comorbidity is thought as being random or additive (that some people just happen to have multiple disorders, rather than their symptoms might be interrelated) –> thinking that the best treatment is with sequential manuals. HOWEVER sequential symptom targeting may not be an optimal treatment strategy in conditions in which: a. seemingly distinct Axis I symptoms reflect common underlying causes - the way different functions of assessing comorbidity in controlled trials and clinical practice may place limits on generalizability
