Thursday, November 17, 2022

Therapy or Training?

By David S. Prescott, LICSW

A recent article titled, Accelerating the development of effective psychological interventions has become the source of some discussion within our field and beyond. In it, the psychology researchers describe using a “leapfrog” method for developing treatment approaches to combat depression. It has implications for professionals working in abuse prevention. Central to the authors’ argument is that traditional approaches to research can take a long time, and it often becomes apparent that changes to an approach are needed even before the results are published. Their leapfrog method involves being able to tailor approaches as the research is happening. While the fields of psychology, criminology, education, and medicine have long emphasized the importance of maintaining the highest standards of research, this article offers an alternative perspective on treating depression based on the lack of availability of mental health treatment for the masses.

With respect to the study itself, the authors have developed an online training program for people who suffer from depression. Because it is online, it can be delivered inexpensively to those who have internet access. It is not difficult to see how this could be a helpful triage for a lot of people, and these efforts are certainly worth pursuing. The authors make cogent observations about some of the most important characteristics of depression to treat and have certainly been creative in their approach. When it comes to conditions that rise to the level of public-health crises, innovations are welcome for consideration. Nonetheless, it seems that there are still many other factors to sort through before this can be meaningfully replicated and implemented with the public. Despite the attempt to streamline research, it seems that much further study is needed.

In fairness to the authors, the intent of their study was to investigate the feasibility of their approach more than to develop an effective treatment methodology. Just the same, there may be implications of this work that are worth considering. Not only does our field focus on preventing harm, we also need to ensure that our research and practice methods don’t cause further harm along the way. New ideas are welcome as long as we also guard against their potential misuse.

Unfortunately, much of the premise for this approach appears confusing. The authors make the point that there is a need for new treatments, as if there aren’t already many evidence-based approaches to mental health conditions such as depression. At the front lines, it seems that the problem isn’t that new treatments are desperately needed, it’s that access to the many existing treatments is limited by factors outside of the office. These factors include ease of access to treatment (including finding therapists, parking, transportation, insurance considerations, and the stigmas involved in getting help).  With respect to stigma, it often seems that one needs a confidential source simply to find the person to whom one can speak confidentially.

Interestingly, the authors don’t call what they’ve created treatment or therapy. Instead, it’s called training. This leads one to question whether we are giving up something that has a far deeper evidence base than online training programs. 

Setting aside the empirical underpinnings of their methods (and whether they’re the best approach in this case), there are still questions and concerns in resorting to this form of approach to depression. To start, there is much we still don’t know about the etiology of depression (and many other conditions), leading to confusion about the purpose of this training (for example, some research has found a link between inflammation and depression in some circumstances). Further, the current training seems not to account adequately for the depressing and anxiety-producing situations that people find themselves in during the current era. Again, some kind of self-study training in these situations could be welcome, but maybe it’s not prudent to consider it a full-blown intervention. A reading of the article showed no place for a licensed, responsible professional.

Thinking of the lessons we’ve learned in our field, consideration of the principles of risk, need, and responsivity suggest that this training is far from an actual treatment package. How does a one-size-fits-all training account for variations in risk for depression to continue? How is it tailored to address differences in depressive symptoms among individuals? And how is it adjusted to meet the specific-responsivity needs of clients, such as intelligence, learning style, or comorbid conditions?

Further, ethical considerations abound. Given that it is an online training and not interactive, where will responsibility lie when clients kill themselves? Will there be any feedback measures to ensure that the clients feel they are being helped and that the method is a good fit for them? Or will the measures used only examine symptom reduction? In some cases, will it not be even more depressing for clients that they have no one to talk to beyond the online training? One is reminded of comedian Rodney Dangerfield saying, “I called suicide prevention, but they put me on hold.”

Hundreds of research studies into “what works” in psychotherapy would also call this approach into question. The work of countless researchers, including Bruce Wampold, Zac Imel, Michael Lambert, Scott Miller, Jeb Brown, and many others, shows us that factors such as the therapeutic relationship, building hope and expectation that positive changes are possible, and ensuring that the goals of interventions match the client’s aspirations are critical components in efforts at change.  While any “training” is welcome, it seems that it can only fall short unless used in conjunction with an actual therapist.

A major reason to consider these issues is because similar efforts have taken place in the treatment of justice-involved individuals. One university developed treatment curricula that are so highly scripted that professionals administering them do not need a high level of education or experience. Common questions for which there have been few answers have included, “if it is this scripted, how do we tailor this curriculum to meet the needs of individuals in adherence to the principle of specific responsivity?” At the same time, it is also true that some organizations have developed self-help resources when no other options are available. “Helpful” is in the eye of the service user.

In line with the authors’ arguments, however, the trend in general psychotherapy seems to be in the direction of further medicalization. Fewer people look for therapists online than ask their physician for a referral. And that is against a backdrop of insurance companies that have so clearly prioritized profits over people in their business practices.

My hunch is that this approach will not bear fruit in the long term. Just because someone is trained does not mean that they will benefit in the long term from that training. It seems that the axiom most often forgotten in these endeavors is, “tell me and I’ll forget.  Show me and I’ll learn. Involve me and I’ll understand.” It’s easy to forget that people most often change not so much because of the insights they may gain from a book or training, but more through a relationship experience in which they can reflect on their lives, enact new skills, and build new futures.

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