Thursday, December 31, 2009

Post-Christmas Elliott Clan Gathering in Murray Creek

Entry for 27 December 2009:

Boxing Day isn’t celebrated in the US, but the Day After Christmas is typically one of the busiest shopping days of the year, as people return gifts they don’t want, spend their gift cards, and buy the things they wanted but didn’t get for Christmas. I like to shop, but … would rather see family, so instead, Kenneth, Diane and I headed up to Murray Creek in the foothills of the Sierra Nevada. It’s been a couple of years since I’ve been able to get together with all my siblings at one time, perhaps since my dad died almost 4 years ago. The other five get together a couple times a year, most often for my mom’s birthday in April and for Dam Building (to create a swimming hole on the Murray Creek) in May, and then for significant birthdays involving multiples of 10. Over the years, the significant birthdays have developed a theme concept, like Lord of the Rings, the 1950’s etc. My youngest sister Louisa is really into this and is currently redecorating her house as a Wild West saloon/brothel in preparation for a Wild West-themed celebration for her partner in the Spring of 2010. Some of us think that this is getting a bit carried away, but it is hard to deny the energy behind it.

It was a lovely, sunny December day as we drove over Altamont Pass and down into the Central Valley, crossed the Valley, and continued on up into the Mother Lode Country. We arrived about noon. My siblings and their partners and children were scattered here and there: We’d passed Ebru (Joseph’s partner) and her mom Guler, out for a walk, on our way up the Murray Creek Road; Willy and Jim (Anna’s partner) were cutting firewood, chainsaw making a growly roar in the distance; Anna was up the hill in my mom’s house checking her email; Louisa and Steve, and Joseph and his baby Ayla were out for separate walks somewhere (Murray Creek Valley is great for walks); my mom, Conal and Holly, Katie (Willy's partner) and my nephews Aidan and Luke were hanging out in the lower, guest house, where Holly (Conal’s partner) and Joe (Louisa’s lodger) were working on their parts of dinner. (I’ve probably got this wrong; it’s really hard to keep track of them all, and they kept moving around!)

The big family dinner had been planned for 1pm; however, things are generally fairly fluid with my family, and Joseph and Ebru were having trouble getting Ayla to take a nap, so the plan kept changing. Instead of dinner we eventually all (except Willy, who came tailing in partway through) collected ourselves in the upper house to unwrap presents. Over the years, my siblings have mostly settled into sensible, reliable modest forms of gift giving, emphasizing do-it-yourself handicraft: Joseph makes a quite a professional-looking family calendar; Conal and Holly give baskets of honey, soap etc; Anna makes her famous almond roca and spicy pistachios; Willy makes a big square of shortbread; Louisa often makes scarves or something similar but this year surprised us with olive oil and balsamic vinegar from her partner Steve’s sister’s ranch. My mom gives everyone whatever cutting edge interesting thing she is into on a given year, always a surprise: This year it was a container of hemp seed, the latest nutritional wonder food (guaranteed THC-free!) and copies of Daniel Quinn's Beyond Civilization: Humanity's Next Great Adventure, her latest fave thinker. Diane and I don’t do so well, not being so handy and also being stuck in a more commercial/conventional Christmas present cultural scheme; since moving to Scotland we have been able to rely on Scottish Tourist Stuff: quaichs, whiskey, celtic pewter pieces, Elliott tartan stuff etc. This year it was a mixture of stuff, such as Scottish artisanal chocolates, celtic music, tartan tights… and a kilt towel for Willy, who showed it off in great style.

The Red Book. The high point, however, was presenting our mom with a copy of Carl Jung’s long-suppressed, just-published The Red Book, produced by Jung during his time of difficult and occasionally psychotic self exploration 1914-1930. My mom is a devoted Jungian; I can remember from my childhood how excited my mom and grandmother were when Jung published his paper on the archetypical significance of flying saucers. Over the years, my mom worked her way through most of Jung’s later work, and has been especially keen on his work on alchemy. Holly (Conal’s partner) had spotted news of The Red Book’s imminent publication last September and we had jumped at the chance to get this for our mom.

I’d read about Jung’s notebooks, but had no idea that they were so powerful and beautiful: This facsimile edition of The Red Book is physically quite large and imposing, with reproductions of Jung’s gorgeous, colourful symbolic paintings of mandalas and other archetypes and dream images, together with his elegant calligraphy in German, Latin and Greek, with translations in the back. This work is the legendary source of everything that Jung did for the remainder of his life. Our mom was indeed surprised, overwhelmed and pleased. She put it in a place of honor on a low chest in her sun porch, windows on three sides, overlooking Murray Creek. I can now imagine the sun porch as a kind of chapel, with The Red Book as a kind of sacred scripture, illuminated, timeless like the Book of Kells.

After gifts, we eventually did get dinner, a hectic, somewhat chaotic affair, with 15 or so different dishes, many of us squeezed in around the big table in the porch, the rest spilling over into the living room. After that, people began to leave, to go home or on to other commitments. We’d gradually collected here in Murray Creek, then we had a few hours all together, and now we began to leave again, starting with Joseph and his family, Louisa and her entourage that evening. There is a rhythm to these gatherings, which I like to watch, like the tide coming in and going out. When will we all be together again? Perhaps next August: At dinner, we agreed to a date for my 60th birthday party in early August. The theme? Scotland, of course! That will also give me an excuse to wear my kilt; let’s hope for cool weather!

The Role of Qualitative Methods in Research on Psychotherapy Effectiveness

Entry for 28 December 2009:

Last month Louise Silverstein, of Yeshiva University in New York City, asked me if I would be willing to present as part of a panel on the use of qualitative methods for providing evidence for psychotherapy effectiveness, to be submitted for presentation at the American Psychological Association conference in San Diego next summer. I wrote back as follows:

Do you mean using qualitative methods alone without any quantification? Or using qualitative methods to complement, question, elaborate and/or explain quantitative methods? It seems to me that change in therapy, and therefore by extension effectiveness, is a matter for both quantitative and qualitative data collection and analysis. I am willing to argue along this line for the essential role of qualitative methods in research on the outcome and effectiveness/efficacy of therapy, alongside quantification of amount of change. Would this be of interest or value for your panel?

Fortunately, Louise was happy for me to do this, and I produced the following summary, which I think is worth posting here because of its topical interest, regardless of whether the panel is accepted or not:

* * *

In this presentation I argue that qualitative data collection and analysis methods have several essential roles to play in research on psychotherapy efficacy and effectiveness:

First, qualitative methods enable us to identify the full range of effects of psychotherapy, beyond those assessed by the outcome measures used in any given study (=qualitative outcome research). This allows us to validate, interrogate, elaborate and deepen quantitative outcome findings on the effectiveness of therapy.

Second, qualitative research on what clients find helpful (or hindering) in their therapy provides a basis for making causal inferences about psychotherapy effectiveness and efficacy (=helpful factors research). Client post-therapy (or post-session) accounts of the aspects of therapy they used to change themselves provide one of several genres of psychotherapy change process research (Elliott, 2010).

Third, qualitative methods allow us to construct case studies to exemplify our quantitative outcome findings (=illustrative narrative case studies). Such narrative case studies make quantitative findings available and appealing to practicing therapists, thus enhancing the persuasive appeal of outcome studies.

Fourth, qualitative methods make it possible for us to evaluate effectiveness and efficacy at the single case level (=interpretive or pragmatic case studies). Qualitative methods are essential for constructing rich case records that provide the basis for drawing causal inferences about the role of psychotherapy in client change, as illustrated by Hermeneutic Single Case Efficacy Design studies (Elliott, 2002).

To sum up, it seems to me that establishing the effectiveness of psychotherapy requires mixed methods designs: Quantitative methods are good for measuring the amount of change and its probability, while qualitative methods excel at defining and describing what has changed and providing causal accounts of how change has come about.

Sunday, December 27, 2009

Christmas in Northern California

Entry for 25 December 2009:

After another very early start from Toledo, we land in San Francisco about 10.30am on Christmas Eve day. The weather is gorgeous and there is even more daylight (9 hrs 40 min) than in Ohio. It is a secret known only to natives that December is typically the nicest month in San Francisco. As we drive across the San Mateo Bridge, the sun is shining, the air clear, and we can see Mount Diablo. Black shore birds rest in the cement bases of the electricity pylons, waiting out high tide, frozen into odd positions; Kenneth and Diane are convinced that they are statues.

In Pleasanton, the weather is so lovely that Kenneth and I decide to go out for a run. It’s almost 60 degrees F (+15 C), with a light breeze. It feels like summer in Scotland!

Kenneth, Diane, her mom Gladys, and I have a pleasant, low-key Christmas Eve dinner of lasagna and salad. I put together a Christmas playlist… and discover my dad’s huge treasure of Christmas music of all different sorts. I end up with a playlist of almost 1000 songs, more than enough to keep us going into next year. We go to the 9pm service at Gladys’ Methodist church, sing Christmas carols, try to stay awake when the jet lag hits us. Afterwards we go home and finish wrapping Christmas presents. When Marjorie and Kris finally show up sometime after midnight, we are sound asleep.

On Christmas morning, there is the usual ritual of handing out and opening presents, followed by breakfast, with special breads. Before and afterwards, we hang around: Kenneth plays with his new Japanese Pokemon game. This is my year for music, so I get busy transferring my new CDs into iTunes, plus Kenneth’s “dinner playlist” of videogame music that he wants me to have so that I can play music he likes during dinner.

Friends of Gladys and Marjorie and Kris arrive about 2pm for a variation on a classic American Christmas dinner: The center of the meal is a large platter of ham and turkey, with side dishes of strawberry-spinach salad, a big bowl of asparagus buttered and sprinkled with bits of bacon, sweet potato and pineapple casserole, rolls. Afterwards there is apple pie with ice cream and Christmas cookies over tea/coffee. When the guests leave about 7pm, it feels like the middle of the night, and people more or less collapse.

I think about these rituals of the season, repeated in various permutations and combinations, year after year: The pressure of the preparations leading to a series of moments, followed by… not exactly a let down, but at least a kind of exhaustion, of wanting to simply kick back and relax, unwind, be unproductive, read that new graphic novel or simply to escape from Ordinary Time. It is a kind of Between Time, like the Romans marking an intercalendary period at this time of year. The different layers of the holiday overlap and intertwine: the spiritual/mythic woven together with the domestic/practical and the personal/emotional, as we do our tasks, remembering previous Christmases or being brought up short by expectations or disappointments. Archetypes play with and against household tasks, while old patterns and issues re-emerge. When I was a kid, my dad was often ill at Christmas, on a couple of occasions gravely so. As a result, Christmas still feels like a risky time, a time of danger, a season of light and dark, joy and sorrow, mixed together. The sun shining brightly, candles burning in the midst of the green Advent wreath, in the dark time of the year.

Friday, December 25, 2009

Glasgow to Toledo

Entry for 20 December 2009:

Up at 3.30 am, dead of night. At 4.30 we go out to meet the taxi; overnight, the slush has turned to ice, but main roads are fine. Long lines at the airport. We find out that our Amsterdam-Glasgow flight no longer exists (retrenchment in the airlines) and we’ve been booked onto a later flight without having been told. It’s snowing in Amsterdam, unusual for December, and everything is moving in slow motion. We end up spending 8 hrs in Amsterdam, as long as our flight to Detroit: waiting to board our flight, sitting on the plane waiting for to permission to push off, waiting for 2 hrs in a queue to have our plane de-iced, and finally an hour taxiing to our runway. After finally taking off, more than 3 hours late, our captain comes on the intercom to say that he’s been flying this route for 19 years and this is longest taxi he’s ever experienced.

We both have sleep deprivation headaches. I alternate between working my way throught the draft of John McLeod’s brilliant book on case study research, reading Fantasy & Science Fiction, napping, and eating. The entire flight happens in the dark, hour upon hour.

In Detroit, at immigration, we notice two things: First, US citizens no longer get their own lines/queues; we share the long lines with everyone else. Second, over our heads on the monitors, instead of warnings, they are playing a video of happy Americans saying, “Welcome!” Apparently, we are no longer in the Bush Era of Fortress America… and, with the economy still in a mess, Americans have finally realized that it would be a good idea to encourage more tourists. Even the immigration person is friendly. It’s nice to be home!

Diane has put down that we’ve been on a ranch or farm on the general assumption that we must have run across some sheep during one of our Saturday adventures over the past 4 months, so as usual we are diverted to agricultural inspection. The x-ray machine detects what looks like a contraband piece of fruit in Diane’s suitcase, and the customs guy goes rummaging around until Diane asks him what he’s looking for and then shows him... a chocolate orange. He lets us keep it.

Our housesitter Linda is waiting for us when we emerge from customs and go out to the curb. She offers to share her family’s dinner with us, but we are too exhausted to socialize more than a couple minutes, so we leave her where she is staying and head home to collapse. We’ve been up for almost 24 hours, and are happy to be home again, like Mole in The Wind in the Willows, coming upon his old home on Christmas, exhausted, overwhelmed, and happy.

Wednesday, December 23, 2009

The Gloaming

Entry for 20 December 2009:

The Gloaming is commonly defined as the time of day after the sun sets and before it becomes completely dark (also the symmetrical time in the morning before sunrise). Scotland is famous for its gloaming, a poetic and romantic time. The gloaming in Scotland is longest near the two solstices, about an hour on each end of the day. So while we watched the daylight shrink to a couple minutes less than 7 hours this week, the relatively clear weather (up until yesterday, that is) gave us generous amounts of gloaming. In the evening the sky shades gradually to midnight blue; in the morning we wake up at 8am to the half light, on weekends laying in bed to savour it. A small but noticeable compensation for the short days of the Dark Time, and something worth learning to appreciate, it now seems to me.

Tuesday, December 22, 2009


Entry for 20 December 2009:

Yesterday, it appeared that our preparations for our travel back to the USA were far enough advanced that we could afford the time to squeeze in one more Saturday excursion. We were running low on Historic Scotland destinations that were open and feasible for a short day trip, so I pulled out my Loch Lomond region tourist map and began looking for likely targets. The Auld Kirk Museum in Kirkintilloch sounded interesting, so we set off for it. Kirchintilloch is only 9 miles from Hyndland, has a Glasgow postal code, and is only 2 miles more than I had run that morning, but to Glaswegians it is a foreign country, a place you hardly ever go to. Nevertheless, we were there about half an hour later, on a cold December day.

It turns out that the name Kirkintilloch has nothing to do with churches old or new, but is a Gaelic-Welsh hybrid meaning “fort on the head of the hill”. The Romans built one of their Antonine Wall forts here on the hill, and later there was castle, long since pulled down. The Antonine Wall ran through what is today the Auld Kirk Museum.

After lunch at a little Italian restaurant around the corner, we made our way to the museum. It had started snowing while we ate our calzone and insalata mista, and the pavement was quite slippery.

The Auld Kirk Museum is a quaint little municipal museum in what is, strangely enough, an old Presbyterian church, laid out in the shape of a Greek cross of equal-length arms. A series of displays depicted the history of Kirkintilloch, from the Romans through the medieval castle and market town to the industrial revolution, when the canal and then the railroad made the town a centre of weaving and ironworking, to the present situation of being a bedroom community for Glasgow. The church was very similar in design to the one we saw in Carmunnock, with balconies on three sides for the gentry, who entered by separate outside entrances.

After talking to one of the docents, we wandered up the hill. It was 3.40pm and the sun had already set, but there was a lovely view of the Campsie Fells away to the north The long early winter gloaming was upon us and the slushy snow was quickly icing up underfoot. We walked carefully down to the canal, took photos of it in the failing light and walked back to the car. The trip back to Hyndland took almost an hour due to the weather conditions and repeatedly missing our turns as we desperately tried to avoid being pulled into the black hole of the Glasgow city centre. After this, 9 miles did seem like a long way from home!

Sunday, December 20, 2009

Whatever Happened to Dolly the Sheep?

Entry for 20 December 2010 (travelling back to Toledo):

After Craignethan, there were two more December Saturday Adventures. The first of these was a return visit to the Museum of Scotland in Edinburgh last Saturday. On our first visit, with Kenneth 18 months ago, we failed to make it out of the basement of the museum, the part dedicated to Prehistory (geological and human). This time, we were determined to see more of this 8-floor museum, but in fact didn’t do much better than last time. We hooked up with a “museum treasures” tour from one of the docents, who took us into a part of the museum that we hadn’t even realized existed when we were there last time:/ This consisted of a random collection of unusual items: A mounted baby elephant; a set of samurai armor; a 100-year-old collection of beautiful glass reproductions of invertebrate sea creatures; half(!) of a gold-painted dinner service of Napoleon’s (shared with the Louvre); and so on. There was a substantial collection of early steam-driven devices, like mostly engines and mine pumps, and so on and on. Once again, we saw only a tiny fraction of what was on display.

… But there in that large room we hadn’t even known existed last time, the museum treasures in the galleries above, was Dolly the Sheep, the world’s first mammal cloned from an adult cell. She was created (or whatever the proper word is) at Rosslyn Labs, a few miles south of Edinburgh, ironically close to the mysterious Roselyn Chapel. Stuffed and mounted, echoing the 200-year old baby elephant above, Dolly looks uncannily like her namesake, Dolly Parton. The signs around her case don’t say, but I seem to remember that she didn’t live that long, but she is fairly large for a sheep, so she clearly reached maturity. I don’t think we know whether the cloning was part of the problem, perhaps her telomeres were not up to the task. Now she has the privilege of rotating eternally in a glass case lit by little spotlights, frozen in time, gawked at by science fiction fans such as me. Is she a harbinger of a future of cloned humans? Do we see ourselves when we look at her?

Saturday, December 19, 2009

Saturday Adventures are Possible Even in December

Entry for 5 December 2009:

1. Lovely morning for a run: About +5 degrees Celsius and no rain (for a change), I passed 10 other runners. Running along the River Kelvin, at about mile 5 of a 6-mile run, I passed an elderly couple by the Ha’ Penny Bridge. The man, speaking Glaswegian Scots, called out something to me that didn’t register. His tone was friendly though, so I smiled and waved to him. As I ran over the bridge, however, I retrieved his comment from temporary auditory memory, played it back to myself a couple of times, and discovered that what he’d said was, “Impressive, young man, impressive!”

2. Craignethan Castle is probably the last of the major nearby castles, and it’s a good one, too. Perched high overlooking a bend in the River Nethan, we approached it from behind. When we arrived about 1 in the afternoon, there were no other cars in the car park/parking lot. A surveillance camera surveyed the otherwise empty lot. The castle lay below us, with a series of defensive structures to protect from attackers coming from this direction. We descended to the entrance to the outer wall. The steward/keeper greeted us cheerily as we entered the shop/office. We asked her how many people she’d had today. “Counting you… two!”, she said. She lives in the 17th century house built into the outer wall from the ruins of the high inner wall that (like most true castles in Scotland) had been pulled down to diminish the castle’s military significance.

After chatting with her for a bit and getting advice about the best bits to see, we began our ramble about the castle. By the this time, we have perfected a standard sort of castle ramble, wandering around the outer castle yard (or bailey), exploring all available nooks and crannies, wandering up and down narrow spiral stairs and dank basements, dripping in the rain, reading all the signs, taking pictures of every potentially interesting sight, trying to imagine what life there must have been.

About halfway through our damp ramble, we looked up the hill and saw another car and a couple coming down the path carrying a baby. In spite of the baby, they were moving much faster than we and soon caught up with us. They turned out the be fellow Americans, based in the Lake District and up for a day of castles: Craignethan was their third castle of the day (after Dumbarton and Bothwell). Apparently, only Americans are crazy enough to wander around damp and derelict Scottish castles in December! Well, there really aren’t too many castles in North America, so we have to make up for it while we’re here.

As I said to Kenneth later on Skype, Craignethan is a serious defensive castle worth a closer look, especially in nicer weather, featuring the latest in 16th century military defensive technology. In the late autumn, with the trees nearly bare and the river rushing below, we enjoyed its somber desolation, then went into the shop to warm up with a cup of hot chocolate and another chat with the steward.

Sunday, December 06, 2009

Emotion-Focused Therapy Classified as Counselling by NICE

Entry for 5 December 2009:

In my comments at the New Savoy Conference on Psychological Therapies in the NHS, I gave a version of my rant about the new Revised NICE Guidelines for Treatment of Depression, which had been thoughtfully placed in all delegate packs. What I said was:

(a) there is a need to relook at NICE’s weighing of the evidence, such that it gave infinite weight to RCT’s and zero weight to everything else; and (b) NICE wasn’t even following its own evidence guidelines, as witnessed by their not even looking for studies on Person-Centred or Emotion-focused therapy in their computer-based search strategy, and then ignoring perfectly good RCTs on Emotion-Focused Therapy even after these had been brought to their attention.

I based my comments on having revised the summary recommendation document. The final published version of the recommendations on Counselling has been reformatted (mainly by lumping it together with brief psychodynamic psychotherapy) but is unaltered from the draft version distributed earlier this year for comment. It reads as follows: For people with depression who decline an antidepressant, CBT, IPT,

behavioural activation and behavioural couples therapy, consider:

counselling for people with persistent subthreshold depressive

symptoms or mild to moderate depression

short-term psychodynamic psychotherapy for people with mild to

moderate depression.

Discuss with the person the uncertainty of the effectiveness of

counselling and psychodynamic psychotherapy in treating depression.

Based on this, I mistakenly assumed that the NICE reviewers had totally ignored the vigorous commentary from BACP, which included the evidence on EFT for depression that I had provided.

A few days ago, however, I received an email from Les Greenberg about a request for more information about these recommendations from Klaus Pederson, a Danish psychologist involved in setting policy for that country on treatment of depression. He wanted to know why EFT was lumped with counselling in the new NICE guidelines. That can’t possibly be true!, I thought, and went and downloaded the complete guideline from the NICE site.

Much to my surprise, I found the following in their review of the evidence for Counselling:

Page 219:

Three new studies (GREENBERG1998, GOLDMAN2006 and WATSON2003) that met the inclusion criteria were found in the update search. … Two studies, GREENBER1998 and GOLDMAN2006, are not listed in Table 52 given that these compare two different types of counselling.

Page 222-23:

The comparison of counselling versus CBT was included in one study (WATSON2003). There is insufficient evidence (only one small-sized study with wide CIs [=Confidence Intervals]) to reach any certain conclusion about the relative effectiveness of these two treatments (for BDI [=Beck Depression Inventory] scores post-treatment: SMD [=Standardized Mean Difference] 0.04; 95% CI -0.38, 0.47)…

Two studies, GREENBERG1998 and GOLDMAN2006, compared two different types of counselling (therefore are not included in the tables above). GREENBERG1998 examined the effectiveness of client-centered counselling versus process-experiential counselling. The evidence indicates that there was no significant difference between treatments in reduction of self-reported depression scores (SMD 0.13; 95% CI, -0.57, 0.82). GOLDMAN2006 compared client-centered counselling with emotion-focused counselling. The results favoured emotioned-focused therapy (BDI scores: SMD 0.64; 95% CI -0.02, 1.29). These two studies are small in size and therefore results should be interpreted with caution.

In addition to the limited data available for counselling interpretation of the results is complicated by the different models of counselling adopted in the studies. For example, Bedi2000 and Ward2000 follow a Rogerian client-centred model of counselling, Simpson2003 a psychodynamic model whereas the studies by WATSON2003, GREENBERG1998 and GOLDMAN2006 adopt a process-experiential/emotion-focused model which is compared in the latter two trials to the client-centred model of Rogers.

It is difficult to know what to say about this dismissal of the evidence for EFT with depression. The three RCTs were certainly enough to get EFT added to the list of empirically supported therapies in the United States, but here in the UK the NICE review committee has written it off as a form of generic counselling! The criticism of the different models of counselling in the last paragraph is particularly annoying because of course the NICE reviewers created the problem by lumping these therapies together in the first place.

I wrote the following back to Les:

I commented on an earlier version of this draft and supplied information on three RCTs on EFT for depression. I note that this revision appears to have been done hastily by throwing EFT in with a miscellaneous collection of studies of counselling. No other therapy for depression appears to have suffered this sort of indiscriminate treatment; the EFT RCTs are dismissed as involving small samples, even though this criticism has not been lodged against comparable CBT studies. … Having spoken with various people associated with the NICE work on this guideline, I can verify that it [the revised NICE Depression Guideline] is conceptually and empirically sloppy; [therefore,] the Danish Reference Program should not follow this. For example, they [NICE] do not distinguish different kinds of counselling and even include psychodynamic counselling along with EFT under the same heading. It is clear that the committee that did this work was dominated by CBT and psychopharmacology supporters, who do not really care to understand what humanistic therapy is or the nuances between different forms of either counselling or humanistic therapy.

I have two further comments at this point:

1. The Mental Health Providers Forum, a consortium of 60 mental health charities (including both counselling services and service user advocacy groups), has set in motion a process to investigate the process by which these and other NICE guidelines have been constructed and to develop alternatives. I have been invited onto the Scientific Committee of the Mental Health Providers Forum, a task force of psychotherapy and mental health services researchers led by Michael Barkham. We had our first meeting 10 days ago, the day before the New Savoy conference, and will be looking at the science end of things. But it’s now clear that science isn’t going to be enough here: The cavalier treatment of the EFT evidence makes it clear that the NICE review committee is perfectly capable of changing the rules on the evidence to suit the conclusions that they have already decided on. Scientific evidence is critical here, but so is political action!

2. Ironically, the end result of this biased review process is that counselling -- now explicitly including Person-Centred counselling and Emotion-focused Therapy – is nevertheless “in the NICE guidelines”. For example, in his speech at the New Savoy conference the Health Minister simply referred to treatment “recommended by NICE” without specifying what the level of the recommendation was, then referred to counselling as one of the treatments that now need more emphasis. Doubly ironically, UKCP’s Humanistic and Integrative Psychotherapy brand, which they have gone to great pains to distinguish from counselling, is not included.

New Savoy Conference Focus on Wellbeing

Entry for 27 November 2009:

A clear emerging trend at the New Savoy Conference on Psychological Therapies in the NHS was a greater focus on Wellbeing (WB), of particular interest for us in the Counselling Unit because of ongoing discussions about the possibility of a departmental restructuring plan that might have us as part of a Department (or something) of Health and Wellbeing. We heard about WB in the inspiring opening talk by Cary Cooper (current President of BACP). We heard about WB in a speech from Andrew Burnham, Secretary of State for Health. Lord Layard talked about WB. There was a workshop on WB, which I attended. There was a session on enhancing WB in children and young people. And finally there was a session on WB in older adults. So WB was a major focus on the conference. However, it was much harder to tell exactly what was meant by WB. On the one hand, all mental health problems were being put under the heading of WB, which simply amounts to a trendy repackaging of Business as Usual. On the other hand, some presenters tried to go beyond relabeling distress as (absence of WB) by pointing to early intervention and prevention.

The detection/prevention angle seems to me to be a more legitimate use of the term WB, but left me with two thoughts. First, I was left with a large sense of déjà vu: Haven’t we been here before? Wasn’t this the main point of the community psychology movement of the 1970’s? When I was in graduate school, a lot of very bright people like Seymour Sarason, Julian Rappaport, George Albee, and many others spent a lot of time talking and writing about things like primary prevention (preventing problems from emerging in the first place), secondary prevention (identifying emerging problems in at-risk populations and addressing them before they get worse), and, in distant third place as not very good at all, tertiary prevention, which is pretty much business as usual: Working with individuals with full-blown problems, presumably to keep them from getting even worse or recurring in the future.

Second, over the course of the conference, it became clear to me that most of the people talking about WB were of the first variety, the repackagers. That is, we (and I do include myself) don’t really have a clue about how to do prevention. We are experts at psychotherapy/counselling, that is, the poor cousin, the tertiary brand of prevention; this is what we do and this is what we are good at. Turn us loose on prevention programs and we are out of our depth and more likely to do more harm that good. For example, early identification programs can end up stigmatizing kids through singling them out for intervention. Even more disturbing is what happens when psychologists or others try to intervene without doing the proper research beforehand. Again I speak from experience, having worked for several years in Toledo on an ill-conceived school-based anti-violence program.

One of the few presenters who illustrated what I would consider to be a well-grounded approach to WB was Sube Bannerjee, Professor of Mental Health and Aging at King’s College London, who gave a wonderful talk on developing programs for people with dementia, based in part on research on the trajectories by which people end up in care homes for dementia. However, based on what I heard at the conference it seems to me that what is really called for are well-targetted systemic interventions to prevent the worst effects of dementia. I think that there is a role for us, but it begins to look like Dot Weak’s and Pam Courcha’s research on teaching Pre-Therapy Contact Work to nurses and caregivers makes more sense than conventional counselling or psychotherapy.

Saturday, December 05, 2009

Bridging the Research-Practice Gap with Systematic Methodological Pluralism

Entry for 27 November 2009:

For this year’s New Savoy Conference on Psychological Therapies in the NHS, Michael Barkham invited me to take part on a panel on evidence and the research-practice gap. As I thought about what I would say in my allotted 4 slides/10 min, I remembered a couple of lines from William Blake that I have loved since coming across them as an undergraduate in 1971. I looked the poem up and immediately realized how perfect the poem was for what I wanted to say. Here is the text version of my Powerpoint slides:

1. William Blake on Methodological Pluralism:

Now I a fourfold vision see,

And a fourfold vision is given to me:

'Tis fourfold in my supreme delight

And threefold in soft Beulah's night

And twofold always. May God us keep

From single vision and Newton's sleep!

(Letter to Thomas Butts, 1802)

2. Systematic methodological pluralism

a. Danger of “single vision”: Universal fallibility of knowledge practices

b. Points to need for multiple lines of evidence:

•To support practice

•To speak to different stakeholder groups

•To further science

c. Convergent operationism (Donald Campbell): Bringing multiple line of evidence to bear on a topic

3. Key Psychotherapy Research Methods Address Different Research Questions and Speak to Different Stakeholders

a. Randomized Clinical Trials:

•Research Questions: Test Causal models (internal validity)

•Stakeholders: Trialist Scientists (scientists who believe that RCTs are the one true way to evidencing a therapy; experimentalists)

b. Change process research:

Involves getting inside the “black blox” of therapy; including process-outcome, helpful factors, significant events and sequence analysis studies

•Research Questions: Develop causal models; Test causal models

•Stakeholders: SPR Scientists

c. Naturalistic effectiveness research:

Practice-based research (e.g., Michael Barkham and the CORE team)

•Research Questions: Establish generalizability to practice (external validity)

•Stakeholders: Policy-Makers/ Commissioners

d. Systematic case studies:

For example, Hermeneutic Single Case Efficacy Research (HSCED): looks at causality at the single case level

•Research Questions: Describe practice; Show what is possible; Test causal claims at an individual level

•Stakeholders: Practitioners

e. Qualitative/narrative research (first person accounts):

•Research Questions: Capture a sense of the lived experience of a therapy

•Stakeholders: Service Users

4. Blake’s Pluralist Epistemology Compared to Key Psychotherapy Research Methods

The Twofold Always:

1. Outer: Scientific-Objective-Observational: Randomized Clinical Trials; Naturalistic effectiveness research

2. Inner: Experiential-Subjective-Phenomenological: Qualitative/Narrative

The other forms of vision:

3. Unconscious: Interpretive-Tacit-Emergent : Change Process Research (getting inside the change process)

4. Transcendent: Spiritual-Immanent-Epiphanies: Systematic Case Studies (Most therapists are secular, so for them, the epiphanies occur with particular clients)

Commentary/further discussion:

1. Converging lines of evidence vs. range of convenience. In his presentation, Tony Roth, citing the American Psychologist George Kelly, raised the issue of the range of convenience of the different methods, suggesting some kinds of research may not be appropriate for addressing certain kinds of questions. This is certainly an implication of this framework. However, this turns out to be more complicated in actual practice: Thus, three different types of research all have a strong role to play in making causal inferences linking therapy to client change: (1) RCTs; (2) Systematic Case Studies (specifically, HSCED research; and (3) Change Process Research.

RCTs provide an operational method for justifying causal inference, but fail in themselves to satisfy the plausible explanation condition for causal inferences, and are subject to various ills ranging from differential attrition to researcher allegiance effects. Change Process research is actually a family of different types of methods that attempt to fill in the missing mediating processes linking therapy to outcome, or to test for the presence of hypothesized mediating processes. Systematic Case Studies (at least the HSCED variety) also seek to get inside the change process, but at the level of single cases.

Accumulating consistent evidence from these three different types of therapy research provides a set of converging operations that can provide a more solid basis for inferring psychotherapy efficacy, even though the questions they address differ. Beyond these, moreover, Naturalistic effectiveness research and Qualitative/narrative research can also play supportive roles in supporting causal efficacy claims for a psychotherapy: An efficacious therapy will show strong pre-post effects (especially persuasive with chronic problems) and will attract client narratives testifying to the experienced effectiveness of a psychotherapy. Each of these approaches provides evidence that bears on the broad question of effectiveness/efficacy, creating a network of linked evidence supporting the theory of a therapy’s effectiveness, what Cronbach and Meehl (1955) called a nomological net.

2. I got a real kick out of Roz Shafran, who teaches CBT at the University of Reading. In her presentation, she argued passionately that an excellent example of how to bridge the research-practice gap is work on key processes in Obsessive-Compulsive difficulties, including prolonged exposure and response prevention, thought-action fusion, contagion propagation, and the memory disrupting effects of repeated checking. These are all processes that were identified in practice, tested and refined through experimental laboratory research, and then fed back into practice as within-session therapeutic experiments. (These are analogous to EFT tasks.) During the question period, I said that I’d love to use change process research methods on this therapy, such as doing qualitative interviews. Roz responded, “Let’s work together!”, and I reached over and shook her hand; the audience applauded.

3. A few minutes later, someone in the audience, perhaps in an attempt to burst the panel’s bubble of pluralistic unanimity, asked the question that we’d all being avoiding: what we thought about NICE’s use of evidence. Although Tony ducked the question, Roz and I gave differing views, with her defending NICE and me criticizing its use of evidence. I’ve since learned that the situation with NICE is a bit more complicated, a topic that I intend to take up in a later blog entry. Shortly after that, the session ended, but the connection remains, and I look forward to further dialogue with Roz and others, such as Shirley Reynolds (who teaches at U of East Anglia and who I know from Sheffield days in the mid-1980’s).