Well, John, funny you should raise the issue of big picture stuff and the state of mental health and the relationship between science and practice. It has been very much on my mind, as I have been engaged in a spirited debate with a number of folks on this issue. The debate has been triggered by APA treatment guidelines for PTSD. The APA posted them last year, and there was a strong push to repeal them. Although the push generated a petition signed by almost 50,000 folks, and a petition in support of the guidelines only generated 3,500, yesterday the guidelines were upheld.

 

I signed neither petition and in many ways sit in a unique position relative to the debate. Here are some musings if you want to get a flavor. As with any complicated guild/institution, the issues are very complicated once you start getting into the specifics of the debate.

 

Anyway, this is just food for thought

 

Best,

Gregg

 

 

 

HI Unified Psych list,

 

I thought I would share with this list that I have been musing a lot about the whole science-practice thing lately. I spent the day sketching out the various pieces of the puzzle as I see them and as they have been floating around in my head. This is a major project and what I am sharing is more like a brainstorm than any specific argument. But I decided to share it here to let others know how I am kicking things around.

 

Fundamentally, I am trying to point out a couple of things.

 

First, there are at least three elements always going on in the science-practice divide. There is the (1) practice element (what one is doing in the clinic room), there is the (2) research element (what empirical studies have been done) and there is one’s (3) conceptual scheme that links the two and provides the basic interpretive frame for both.

 

Virtually ALL of my attention in my thinking and work is on the last part. That is, my mission has been to develop a conceptual scheme that is both up to the task of practice and assimilate and integrates research in a cumulative and workable manner. The Unified Theory/Unified Approach framework I operate from is the sense-making system I use for both science and practice.

 

In wrestling with the guideline debate, I keep coming back to the question, What is the larger conceptual scheme that the psychologist is operating off of that justifies the application of research (or not) in the specific instance of them treating a particular individual in a particular context?

 

I have been completely struck by the complete absence of this element in the PTSD Guidelines. Indeed, this is why I don’t think they are well-characterized as guidelines, but instead are essentially a literature review.  

 

The other thing that has launched into my consciousness in this debate is that I differentiate between levels of intervention and specifically between counseling, psychotherapy, and psychological treatment. I share this distinction in various ways and various times with my students, but it has emerged as important in this debate as I have dialogued with many folks about it. The attached document offers some reflections on such distinctions. The short of it is that when folks are dealing with full blown mental disorders, such that it is pretty clear that the disorder is a major problem rather than a symptom of the problem, then we do need a more structured, active, systematic approach, IMO. For example, when a client is in the midst of a MDD of moderate-to-severe levels, there are definitely things that NEED TO BE DONE. The situation is much less prescribed when dealing with adjustment disorder with depressed mood into MDD mild.

 

Another thing that this highlighted is that I do believe I am at a place where I am ready to delineate my general approach to psychotherapy with folks who I would classify as falling in the neurotic cluster (clinically sig negative affect, relational identity problems, seeking psychotherapy but not well-characterized by a full blown mental disorder…that is, an depressed/discouraged/anxious/low resilient/low self-esteem/isolated person). This starts with my Well-being check up system, and then leads into shared understanding of focus for enhancing adaptive living.

 

What is needed in next steps to dance with the conventual system is to systematize this approach, test it and show that it at least gets the normal standard good results of a bona fide approach and then have that be the control condition against which other conditions are measured. I acknowledge that a part of me resists this both because of the work (I am dispositionally more of a theorist than researcher) and I feel that a principled approach to treatment that is grounded in the best available evidence is all the justification that is needed for the approach.

 

I am also thinking that this general bona fide psychotherapy would not only be used for the neurotic cluster. But rather the vision I have is that it would become the control condition relative to specific psychological treatments for specific problems. If someone could beat my generic, principled approach to psychotherapy in a specified psychological treatment for a specific condition (e.g., bulimia, PTSD, OCD) then we could have high confidence that it was effective relative to effective practitioners general approach.  This, of course, points out one of the great weaknesses of ESTs. What they mean has everything to do with what they have been compared to. However, that is often not clear or not strong and thus the meaning of effect sizes are definitely up for debate in terms of what they should guide an experienced clinician to do. If though, as psychological treatment system could systematically outperform a generic bona fide principled psychotherapy, then I would be impressed and keen on learning it.

 

Well, that is how I have spent my Saturday. Perhaps folks less obsessed with our field are actually getting out and having fun 😊.

 

Please share thoughts if you have them.

Best,

Gregg