Wednesday, December 16, 2009

Reflections - synthesizing research with class topics

The assignment: Pick a topic from class and synthesize it with a peer-reviewed journal article.

Eliyahu N. Kassorla
Abnormal Psychology
Dr. A. Daniels
My education has been primarily research focused, and now I am looking at treatment options and outcomes. Being empirically validated means that a treatment is general enough to have broad implications, something that psychodynamic theories and psychoanalysis cannot do. In the search for emerging and empirically validated treatments, I have been looking at articles that branch clinical realities with cool research, despite a glaring lack of sharks with laser beams on their heads.
In class, Dr. Daniels (“you”), described schizophrenia as a disruption in the organization of the self, and as “a deterioration of the self.” You further stated that the ability to distinguish the difference between “me and not me” has been disrupted (Daniels). I found an article about integrative therapy and its use for sufferers of schizophrenia. The article was written by Paul Lysaker, Kelly Buck, and David Roe (“the authors”). Integrative therapy is a technique that combines many different theoretical orientations, “combining the best features of each, ignoring the theoretical inconsistencies to help the subject” (Garvey). The point is not to get an overarching conceptual framework of the mind, but to use what works to help a patient.
This article is meta-study, which means it does a review of many individual cases and studies. This article reviews the transcripts of “8 therapists serving 30 clients” (28). The authors “suggest that an integrative psychotherapy that focuses on narrative could be of unique use to persons recovering from schizophrenia by assisting them to construct a greater sense of personal continuity” (29). You stated that schizophrenics have deficiencies in organizing their sense experience, so maybe a narrative therapy may help put the experience back into the normal “subroutine” in the schizophrenics “main program code”. The authors state that “Impairments in encoding that may be a direct consequence of the underlying neuropathology of schizophrenia may also limit the accrual of autobiographic details following illness onset” (29).
What I think is great is the data section, which first describes the sample population:
“Clients were adults treated in an outpatient clinic of a medical center under voluntary and routine conditions. The average age was 44 (SD=4.4), and the average participant had 12.3 years of education (SD=1.2) and 10.2 lifetime hospitalizations (SD = 3.4). Twenty-eight (93%) clients were male and 2 (7%) were female. Two (7.3%) were employed full time, 1 (3%) was employed part time, 1 (3%) was a student, 7 (23.3%) were actively involved in vocational rehabilitation, and 19 (63.3%) were retired and lived off a disability pension. Twenty (67%) had never married, 7 (23%) were divorced, 2 (7%) were married and 1 (3%) was engaged to be married. Ten (34%) were African American, 18 (60%) were Caucasian, 1 (3%) was Asian and 1 (3%) was Latino. All but one client were prescribed antipsychotic medication. Clients’ participation in psychotherapy ranged from 3 months to several years.” (30).
These statistics are great because it humanizes the sample group, but also gives the readers a cross section of who the patients are. It shows how broad the touch of this disorder is: it can be anyone.
The methods section is also critically important. The authors describe their sessions to be broken into three phases: beginning, middle and end. The beginning phase was generally between one to five minutes, and consisted of “A signal of readiness to hear from the client, immediate placing of the client’s agenda as preeminent, attention to the client’s immediate experience, and showing an interest in the meaning of the client’s speech from the first utterance” (31). The middle phase has the therapist guide the client in a “reflection about the client as protagonist in the stories they tell, reflection about the therapist as an audience for the story, and a responses to client’s difficulties thinking of themselves, recognition of client’s right to have/create their own story, invitation to help link, filter, or change perspective, reflection of possible issues not mentioned” which generally lasted for fifteen to forty minutes (31). The end phase, generally five to ten minutes, made “Mention of sessions approaching end [and an] invitation for client to frame their experience of the session [, and a m]ention of scheduling of next session” (31).
In conclusion, the authors seek to make a point that a great way to have a positive treatment outcome is to keep the schizophrenic in touch with his sense of self, so a coherent narrative must be produced. This can organize the perceptual framework, helping to make sense of an already chaotic sensory experience. But don’t take my word for it:
“We assert that this treatment is potentially useful to individuals regardless of their phase of illness as long as they seek to make sense of what is and is not wrong in their lives, what they grieve and hope for, and what is to be done. Making sense of all of this seems likely to make it easier for individuals to navigate their way through the terror and losses of schizophrenia and find a way to live more personally satisfying lives. In this way, we may expect greater narrative coherence to be linked with better long-term outcomes” (34).
The authors note that the small sample size inhibits generalizability, but similar research on these foundations can help to either support or refute the contents of the article. They also note that they are uncertain if schizophrenics without a high level of intellectual functioning can benefit from this therapy.
“The elements outlined are well-recognized ones, and thus a new psychotherapy has not been invented. Instead, we have sought to spell out and make transparent an organization of established practices that could be applied to help persons recover a coherent sense of self” (34).
The authors, not inventing science, should be commended on this innovative fusion of existing techniques. Clinicians need always be on the lookout for new techniques and practices, regardless of theoretical orientation, in order to better suit their clients. It is their wellbeing, not a clinician’s ego, which must be the primary focus. If strictly cognitive, behavioral, or psychodynamic practitioners cannot be open to new information, then they are doing their clients a disservice, and fall into the confirmation bias.
Daniels, A. Abnormal Psychology. Fall 2009. New England College: Henniker, NH.
Garvey, Kilian J. Cognitive Psychology. Spring 2007. University of New England: Biddeford, ME
Lysaker, P., Buck, K., & Roe, D. (2007). Psychotherapy and recovery in schizophrenia: A proposal of key elements for an integrative psychotherapy attuned to narrative in schizophrenia. Psychological Services, 4(1), 28-37., doi:10.1037/1541-1559.4.1.28

Eliyahu N. Kassorla
Abnormal Psychology
Dr. A. Daniels
Reflections Upon Class Topics
In class we discussed eating disorders. One group, more than others, stands out with high prevalence rates: adolescents. An article by Rhode, Gau, and Shaw explores a treatment known as “dissonance intervention”.
The article documents the effectiveness of a dissonance intervention treatment of eating disorders. This intervention begins with engaging the subject in “verbal, written, and behavioral exercises” in which they are meant to critique their ideal body image (Rhode, Gau, and Shaw, 2009, 825). The authors intend to create “psychological discomfort,” inducing cognitive dissonance; hopefully the subject will resolve their dissonance by rejecting the idealized thinness (Rhode, Gau, and Shaw, 825).
The article included three hundred and six subjects who met the DSM-IV criteria for the eating disorders of “anorexia nervosa, bulimia nervosa, or binge eating” (Rhode, Gau, and Shaw, 2009, 827). Of these, one hundred and thirty nine were assigned to the dissonance intervention; the remaining one hundred and sixty seven were assigned to the control group. The control group “received a two-page brochure” and psychoeducation. However, the authors state that “[…] there is evidence that receiving a psychoeducational brochure results in greater reductions in risk factors and eating disorder symptoms relative to assessment-only control conditions” (Rhode, Gau, and Shaw, 2009, 829). The authors note this, presumably to note that this control may provide a treatment outcome.
Dissonance intervention ran between one and four sessions. In these sessions, subjects were expected to “[…]apply the skills […] learned in the sessions (Rhode, Gau, and Shaw, 2009, 828). The first session was “interactive, with participant-driven discussions of the definition and origin of the thin ideal; how it perpetuated”, and the messages received from family and peers (Rhode, Gau, and Shaw, 2009, 828). Homework was given to the subjects, to “[…] write a letter to a hypothetical younger girl to discuss the costs of persuing the thin ideal and to examine their reflection in a full length mirror, recording positive aspects of themselves” (Rhode, Gau, and Shaw, 2009, 828). This is classic CBT at work: the subject is made to buy-in to negative feelings about the thin ideal, and eventually they will believe it. The subject is further made to make positive statements about their body image, eventually changing this positivity into what they really believe. These changes in the cognitions are expected to lead a positive change in behavior, further reducing negative feelings.
The second session reviewed the previous session, but made the subject make affermations out-loud. They were also involved in “counterattitudinal role-play”, where the subject must make statements contrary to their own belief (Rhode, Gau, and Shaw, 2009, 828). The subjects were also made to make a list of ten things people can do to resist the ideal.
The third session, again, reviewed the prior session, examined the pressures causing the subject to skew their idea of the ideal. The subjects were required to develop “quick comebacks that challenge thin-ideal statements made by peers (Rhode, Gau, and Shaw, 2009, 828). This typifies the inoculation-effect, where a subject is rehearsed in rejecting these socially-motivated cognitions in a controlled environment. This hopefully leads to them adopting the rejection attitude in the uncontrolled real-world social setting. Subjects were also primed to act in a way inconsistent with their previous body-issues, “e.g.: wearing shorts if they have avoided doing do because of body dissatisfaction” (Rhode, Gau, and Shaw, 2009, 828). This is also a key function in behavioral-activation therapy, where the behavior changes a cognition solely by doing the action.
Session four built upon the previous session, enabling the subjects to challenge themselves by allowing the subject to free-respond to statements, and then elaborating on how it “perpetuates the thin ideal” (Rhode, Gau, and Shaw, 2009, 828). Subjects were encouraged to “talk about their bodies in a positive, rather than a negative way” (Rhode, Gau, and Shaw, 2009, 828). Another letter to a “hypothetical younger girl” was written, this time on how to “avoid developing body image concerns” (Rhode, Gau, and Shaw, 2009, 828). The key these sessions built on is that they elicited subject buy-in, forcing them to take these thoughts, cognitions, emotions, and beliefs in.
The results indicated a positive outcome with dissonance-therapy, compared to the before condition as well as the control group. One year after, forty-two percent of the subjects continue to show “clinically significant change”, compared with only twenty-four percent of the control group. The authors described the effect size as medium; a medium effect size clearly shows promise as one type of possible treatments available to clinicians. There are other treatments available to clinicians, but many of those require many visits or inpatient treatment; both options are costly and long in treatment duration.
Clinicians should be very interested at using these cognitive mechanisms to effect change in client behavior. Although cognitive-behavioral models, as well as other paradigms, are in use, this one shows promise in being fast and potentially long lasting, at least a year with the medium effect persisting. Further, this trial was conducted with relatively inexperienced clinicians, themselves having “delivered the prevention program an average of only twice” (Rhode, Gau, and Shaw, 2009, 831). This is noted by the author, comparing this trial to one of their other trials, where the facilitator had presented an average of eighteen times. Using their treatment handbook exactly as described shows promise, so busy, or innovative, clinicians can quickly add this program to their repertoire. Further, the authors noted that their previous trial used an assessment-only condition for the control. In this trial, the authors used a psychoeducational brochure, possibly reducing the apparent effect size in this trial. This control condition seems better in a real clinical setting, where literature can be made available. I am interested in seeing a trial where the brochure is combined with these trials, seeing if the effect size increases. Clinicians can work with a client, but augment the care with the results of this trial.
Stice, E., Rohde, P., Gau, J., & Shaw, H. (2009). An effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescent girls. Journal of Consulting and Clinical Psychology, 77(5), 825-834.

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