Understanding Research in Clinical and Counseling Psychology

Jay C. Thomas, Michel Hersen

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781136831188
• Edition: 2
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Understanding Research in Clinical and Counseling Psychology, Second Edition, is written and designed for graduate students in the psychology and counseling fields, for whom the value of psychological research is not always readily apparent. Contributed to by experts in their respective fields, this text presents research as an indispensable tool for practice, a tool that is used every day to advance knowledge and improve assessment, treatment choice, and client outcomes. The book is divided into four logical parts: Research Foundations, Research Strategies, Research Practice, and finally, Special Problems. Included is a chapter that addresses one of the most important controversies, the distinction between realistic and "gold standard" efficacy studies. The remainder of the book addresses salient issues such as conducting research in various cultures, operating an empirically-oriented practice, and performing research with families, children, and the elderly. Students and professors will find the coverage ample and penetrating, without being too overwhelming.

I

Research Foundations

1

Introduction

Science in the Service of Practice

JAY C. THOMAS and JOHAN ROSQVIST

Contents

The Case of Sue

The Role of Research in Treatments for Obsessive-Compulsive Disorder (OCD)

Scientific Method and Thought

Objective, Systematic, and Deliberate Gathering of Data

Generating and Testing Hypotheses

Replication of Research Findings

Modification of Theories Using Findings

Clear and Open Communication of Methods, Data, and Results

Theory of Causality

Mill’s Requirement 1: Cause Must Precede the Effect

Mill’s Requirement 2: Cause and Effect Must Covary

Mill’s Requirement 3: There Must Be No Other Plausible Explanations for the Effect Other Than the Presumed Cause

Science in the Service of Practice

The Local Clinical Scientist

Skepticism, Cynicism, and the Conservative Nature of Science

References

Note

Today, psychologists are called on to help solve an ever widening scope of personal and social problems. It has been recognized that a large proportion of the population can benefit from psychotherapeutic services. Current estimates of the prevalence of mental disorders indicate that such disorders are common and serious. The National Institute of Mental Health (2009) estimates that up to one in four American adults suffer from a diagnosable mental disorder. The provision of psychotherapy services is a multibillion-dollar industry (Sexton, Whiston, Bleurer, & Walz, 1997), with certain very common phenomena (i.e., anxiety disorders) representing economic burdens to a tune of $42.3 billion annually of the total U.S. mental health bill of $148 billion (Greenberg et al., 1999). In addition, clinical and counseling psychologists are asked to intervene in prevention efforts and in situations involving individuals and families, prisons, and schools, along with playing their role in industrial and organizational work settings.

When so many people trust the advice and assistance of psychologists and counselors, it is important that professionals rely on a foundation of knowledge and evidence that is known to be tried and tested. Many students in clinical and counseling psychology wonder about the relevance of research courses and of research in general pertaining to their chosen profession, which mirrors a field in which science and practice of psychotherapy almost invariably inhabit different worlds (Lebow, 2006). These students often primarily value the role of the psychologist as helper and expect to spend their careers “helping” clients in dealing with important issues. This is indeed a very worthy ambition, but we argue that “effective” helping can occur only when the best techniques are utilized, and that it is only through scientific research that we can determine what is “best.” We illustrate this point through a brief history of treatment for obsessive–compulsive disorder (OCD) in which a client, Sue, received the assistance she needed through the systematic, targeted application of an empirically based treatment.

The Case of Sue

Sue, a 28-year-old married woman, was engaged in a broad range of avoidant and compulsive behaviors (Rosqvist, Thomas, Egan, Willis, & Haney, 2002). For example, she executed extensive checking rituals—hundreds of times per day—that were aimed at relieving obsessive fears that she, by her thoughts or actions, would be responsible for the death of other people (e.g., her one-year-old child, her husband, other people whom she cared for, and sometimes even strangers). She was intensely afraid of dying herself. She also avoided many social situations because of her thoughts, images, and impulses.

As a result of these OCD symptoms and the resultant avoidant behavior, Sue was left practically unable to properly care for herself and her child. In addition, she was grossly impaired in her ability to perform daily household chores, such as grocery shopping, cleaning, and cooking. Her husband performed many of these activities for her, as she felt unable to touch many of the requisite objects, like pots and pans, food products, cleaning equipment, and so on.

Additionally, Sue was unable to derive enjoyment from listening to music or watching television because she associated certain words, people, and noises with death, dying, and particular fears. She also attributed the loss of several jobs to these obsessions, compulsions, and her avoidant behavior. Sue reported feeling very depressed due to the constrictive nature of her life that was consumed with guarding against excessive and irrational fears of death.

Sue eventually became a prisoner of her own thoughts and was unable do anything without horrendous feelings of fear and guilt. For all intents and purposes, she was severely disabled by her OCD symptoms, and her obsessions, compulsions, and avoidant behavior directly impacted her child and husband.

In fact, her fears were so strong that she eventually became uncertain that her obsessions and compulsions were irrational or excessive and unreasonable (i.e., she demonstrated “poor insight”). She strongly doubted the assertion that her fears will not come true, although she had little, if any, rational proof for her beliefs. She was unsuccessful in dismissing any of her obsessive images, impulses, or thoughts and beliefs. She had very little relief from the varied intrusions, and she reported spending almost every waking hour on some sort of obsessive-compulsive behavior. She felt disabled by her fears and doubts, and felt that she had very little control over them.

Obviously, Sue was living a life of very low quality. Over the course of some years, she was treated by several mental health practitioners and participated in many interventions, including medication of various kinds, psychodynamic, interpersonal, supportive, humanistic, and cognitive behavioral therapies, both individually and in groups, as both an inpatient and an outpatient. However, Sue made little progress and was considered for high-risk neurological surgery. As a last-ditch effort, a special home-based therapy emphasizing exposure and response prevention (ERP) along with cognitive restructuring was devised. This treatment approach was chosen because the components had the strongest research basis and empirical support. Within a few months, her obsessive and compulsive symptoms remitted, and she eventually became sufficiently free of them to return to work and a normal family life. Thus, by the application of research-based treatment, Sue, who was previously considered “treatment refractory,” was effectively helped to regain her quality of life.

The Role of Research in Treatments for
Obsessive-Compulsive Disorder (OCD)

OCD has a long history. For example, Shakespeare described the guilt-ridden character of Lady Macbeth as prone to obsessive hand washing. Other, very early, descriptions of people with obsessional beliefs and compulsive behaviors also exist, such as people having intrusive thoughts about blasphemy or sexuality. Such people were frequently thought (both by the sufferer and the onlooker) to be possessed, and they were typically “treated” with exorcisms or other forms of what would now be deemed torture.

Obsessions and compulsions were first described in the psychiatric literature in 1838, and throughout the early 1900s, it received attention from pioneers such as Pierre Janet (1859–1949) and Sigmund Freud (1856–1939); however, OCD remained virtually an intractable condition, and patients suffering from it were frequently labeled as psychotic and little true progress was thought possible. That was until the mid 1960s, when Victor Meyer in 1966 first described the successful treatment of OCD by ERP (Meyer, 1966).

Since Meyer’s pivotal work, the behavioral and cognitive treatment of OCD has been vastly developed and refined. Now, it is generally accepted that 60%–83% of patients can make significant improvement with specifically designed techniques (Foa, Franklin, & Kozak, 1998; Salomoni et al., 2009). Also, patients who, initially, prove refractory to the current standard behavioral treatment can achieve significant improvement with some additional modifications. In any case, OCD does not appear to be an incurable condition any longer.

This change has been made possible only by the systematic and deliberate assessment and treatment selection for such patients. That is, interventions for OCD, even in its most extreme forms, have been scientifically derived, tested, refined, retested, and supported. Without such a deliberate approach to developing an effective intervention for OCD, it would possibly still remain intractable (as it mostly was just 35 years ago). In truth, recalcitrance is largely a myth promulgated by people who drift away from science-informed or evidence-driven treatment (Waller, 2009).

The empirical basis of science forms the basis for effective practice, such as what has made OCD amenable to treatment. Such empirical basis is embodied in the scientific method, which involves the systematic and deliberate gathering and evaluation of empirical data, and generating and testing hypotheses based on general psychological knowledge and theory, in order to answer questions that are answerable and “critical.”

The answers derived should be proposed in such a manner that they are available to fellow scientists to methodically repeat them. In other words, science, and professional effectiveness, can be thought of as the observation, identification, description, empirical investigation, and theoretical explanation of natural phenomena.

Ideally, conclusions are based on observation and critical analyses, and not on personal opinions (i.e., biases) or authority. This method of reaching conclusions is committed to empirical accountability, and in this fashion, it forms the basis for many professional regulatory bodies. It remains open to new findings that can be empirically evaluated to determine their merit, just as the professional is expected to incorporate new findings into how he or she determines a prudent course of action.

Consider, for example, how the treatment of obsessions has developed over time. Thought stopping technique is a behavioral technique that has been used for many years to treat unwanted, intrusive thoughts. In essence, the technique calls for the patient to shout “stop” or make other drastic responses to intrusions (e.g., clapping hands loudly, or snapping a heavy rubber band worn on his or her wrist) in order to extinguish the thoughts through a punishment paradigm. It has since been determined that thought-suppression strategies for obsessive intrusions may have a paradoxical effect (i.e., reinforcing the importance and veracity of the obsession by specifically focusing attention and energy on it) rather than the intended outcome (Rosqvist, 2005). It has been established, through empirical evaluation and support, that alternative, cognitive approaches (e.g., challenging the content of cognitive distortions)—like correcting overestimates of probability and responsibility—are more effective in reducing not only the frequency of intrusions but also the degree to which they distress the patient.

An alternative to thought-stopping strategy, the exposure-by-digital-loop method, has been systematically evaluated and its effectiveness has been scientifically supported. In this technique, the patient is exposed to endless streams of “bad” words, phrases, or music. As patient’s obsessions frequently center on the death of loved ones, they may develop substantial lists of words that are anxiety producing (e.g., Satan, crib death, sudden infant death syndrome [SIDS], devil, casket, coffin, cancer). These intrusive thoughts, images, and impulses are conceptualized as “aversive stimuli,” as described by Rachman (Emmelkamp, 1982). Such distortions and intrusions are now treated systematically by exposure by digital loop (and pictures) so that the patient can habituate to the disturbing images, messages, and words. This procedure effectively reduces their emotional reactivity to such intrusions and lowers overall daily distress levels. Reducing this kind of reactivity appears to allow patients to more effectively engage in ERP (van Oppen & Emmelkamp, 2000; Wilson & Chambless, 1999; van Oppen & Arntz, 1994).

The point of this OCD example is to show that over time more and more effective methods of treatment are developed by putting each new technique to empirical testing and refining it based on the results. In addition, the research effort has uncovered unexpected findings, such as the paradoxical effect of thought suppression. The traditional thought-stopping technique is in essence a method of thought suppression, whereby the individual by aversive conditioning attempts to suppress unwanted thoughts, images, or impulses. However, systematic analyses have revealed that efforts at suppressing thoughts (or the like), in most people, lead to an increased incidence of the undesired thoughts. It is much like the phenomenon of trying to not think about white bears when instructed to not think about them; it is virtually impossible! What has been supported as effective in reducing unwanted thoughts, whether about white bears, the man behind the curtain, or about germs and death, is exposure by loop. This method does not attempt to remove the offending thought, but “burns it out” (i.e., reaction to specific content) through overexposure.

In light of this experience, it is prudent for the professional to incorporate these techniques into treating intrusive thoughts. Although a therapist may be very familiar with thought-stopping strategy, it is reasonable to expect that the scientifically supported techniques will be given a higher value in the complete treatment package. This follows the expectations of many managed care companies, and this also adheres to the ethical necessity to provide the very best and most appropriate treatment possible for any given clinical presentation. To do anything less would be a great disservice to the patient, as well as put him or her into possible jeopardy by providing substandard care.

In these days of professional accountability and liability for a product, it has become necessary to be able to clearly demonstrate that what we do is prudent given the circumstances of any particular case. Most licensing boards and regulatory bodies will no longer accept arbitrary, individual decisions on process; rather, they dictate and expect that a supported rationale is utilized in the assessment and treatment process.

With this in mind, it has become increasingly necessary, if not crucial, that the professional engage in a systematic method for assessment and treatment selection in order to create the most effective interventions possible (given current technology and methodology). Today, the empirical basis of science forms the basis of effective practice.

Scientific Method and Thought

Early in the twentieth century, the great statistician Karl Pearson became embroiled in a heated debate over the economic effects of alcoholism on families. Typical of the scientific battles of the day, the issue was played out in the media with innuendoes, mischaracterizations and, most importantly, spirited defense of pre-established positions. Pearson, frustrated by the lack of attention on the central issue, raised a challenge that we believe serves as the foundation for any applied science. “Pearson’s challenge” was worded in the obscure language of his day, and has been updated by Stigler (1999) as follows:

If a serious question has been raised, whether it be in science or society, then it is not enough to merely assert an answer. Evidence must be provided, and that evidence should be accompanied by an assessment of its own reliability (p. 1).

Pearson went on to state that adversaries should place their “statistics on the table” (Stigler, 1999, p. 1) for all to see. Allusions to unpublished data or illdefined calculations were not to be allowed. The issue should be answered by the data at hand, and everyone was free to propose their own interpretations and analyses. These ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Editors
• Contributors
• Part I Research Foundations
• Part II Research Strategies
• Part III Research Practice
• Part IV Special Problems
• Author Index
• Subject Index