Name That Therapy

Or, Therapy Names as Currency

When my client says “Therapy sucks—I tried it and it didn’t work!” there are a number of things this could mean.

“The therapist I had was of a personality that did not mix with my personality well. I felt invaded and condescended to and it was deeply unpleasant.”

“The therapist tried a specific therapy: psychodynamic or DBT or narrative therapy, and it was [not my cup of tea/definitely making it worse/seriously not feasible for my life or personality]”

“Therapy as a modality is not very compatible with me. We should pursue alternate things like medication or structuring parts of my environment to decrease symptoms or finding me a support group.”

I am uncomfortable with you, New Therapist, and expressing it via saying that therapy sucks.

The thing is, I have none of that information, just that the client is not pleased about interacting we me and has low expectations. Though my next question is almost always going to be “can you tell me more about why it sucked for you?” Even presuming they answer and follow that line of questions (and this is not guaranteed), I won’t have a ton of information.

So this is a plea/suggestion/blog post request for therapists to err on the side of telling their clients what the heck they’re doing.* And a second suggestion for clients to ask their therapists what the plan is.

Consider this situation: you, client-named-Jeff, are going to therapy for the first time. You don’t have any prior interaction with psychotherapy, nor do you read blogs like this. Your therapist focuses on cognitive distortions and sends you home with homework, and you just hate it. It feels like being a kid, and you really wanted to figure out why you’re feeling so anxious all the time (you’ve wondered if it comes from having to move around so much when you were growing up).  You never end up with rapport with the therapist, and given that trusting and liking your therapist is an important component of therapeutic success…you decide that the cost of seeing a counselor is ridiculous, and leave.

Two years later, your anxiety is severely impairing your ability to function at work. The company you work for is small, and they offer to pay for therapy instead of asking you to resign, hoping that it will allow them to keep an employee who has a history of loyalty and service. So you end up in my office. “Therapy sucks,” you say. We spend a good deal of time trying to figure out what things you hate and what things I can do that don’t make you feel patronized. Eventually we build some kind of trust, but your opinion remains that most therapists are incompetent. Lots of time is wasted in hit-and-miss appointments.

Or, consider this scenario: you, client-named-Jeff, are going to therapy for the first time. Again, you don’t have prior info about what therapy is like. Your therapist tells you do that they do Cognitive Behavior Therapy. They focus on cognitive distortions and sends you home with homework, and you just hate it. As in the previous story, it feels silly and childish and you’re more interested in discussing how you ended up where you are and building from there.  The therapist hears your complaints, but for some reason doesn’t deviate much from the CBT framework.

Now two years later, I see you. In the course of trying to figure out why you think therapy is hell served in fifty minute portions, you mention that your previous therapist did CBT. Now, I have some pretty damn useful information. I can ask you what things you didn’t like about it. If you’re able to give me concrete answers, I can avoid those things.

If I end up believing that some part of CBT really would make an impact, even if it annoys you, I can convey that! “I know you didn’t like getting homework because it felt childish, but I think I could help you much more if I had a sense of what triggers your anxiety at home, and I wouldn’t be surprised if you learned something about yourself too. Would you be willing to do a trial period of documenting your panic day to day?”**

Even better, you’re getting information that lets you self-advocate in future therapy settings. If your first therapist tells you they were CBT-focused, and I tell you that I’m mainly doing narrative therapy, you get to convey what worked and what didn’t to any future mental health professionals. If you end up needing some immediate help, or can’t afford an appointment, you’ve got a starting point for googling. You’ll know that Feeling Good is less likely to work for you than Retelling Our Stories, because you can read the flyleaf and compare it to your experiences.

But perhaps most importantly, giving clients information about a treatment plan or orientation can prevent them from generalizing one therapeutic orientation to the profession at large. A client knows that you’re doing one thing under the umbrella of therapy. It’s much easier to say to a therapist “this specific thing seems to fail” than “I think the thing that is your profession (therapy) doesn’t work for me”

*I recognize that sometimes telling certain clients (for instance) that you’re trying solution-focused brief therapy is going to derail the crisis work you’re doing, or going to paint you as an ivory tower academic who doesn’t understand.

**For the curious, this is the worksheet I was thinking of.

About Face (Validity)

So say you’re looking to measure depression. It’s very important that the people in your research are depressed, rather than anxious or sad or grieving, but you don’t have time or money to pay a psychiatrist to spend hours interviewing each person who requests participation in your study.

Being an enterprising sort, you decide to create a scale—a questionnaire that you can distribute to everyone who responds to your generic Participate In Interesting Research About Stuff flier. Participants who score in the Depressed Zone will then get an interview with a psychiatrist, thus decreasing the total number of hours of her time that you pay for. You understand Likert scales and careful item selection, and you run a few pilot tests, and in the end, you have this:

Screen Shot 2014-10-15 at 9.48.10 AM

We now take a brief detour to explain reverse scoring. Some of the items (psychspeak for each question/statement) would be scored backwards. Answering ‘Strongly Disagree’ to items #1 and #2 would be in direct conflict with strong disagreement with item #3. So to score this test, we don’t just count up the number of answers in each category—we reverse the coding system for items. People who agree that they are equal to others, have a number of good qualities, and disagree that they’re a failure will all go in the Probably Not Depressed basket. People who don’t agree with the first two statements and agree with the third go in the Probably Depressed, Seek Help basket.

This is a common technique to force the participant to read each question, and give additional information to researchers. In a questionnaire without reverse coding, when you have someone who has Strongly Agreed with every statement they could have actually agreed strongly with each component (suggesting they’re severely depressed). But they could also be one of those jerks who just answered every question the same.  Reverse-coding controls for jerks.

But enough about this picky detail of psychometric design. You have a measure for depression!

Except, this isn’t a measure of depression. It’s a measure of self esteem. Rosenberg’s Self Esteem Scale, in fact.

Which brings me to the other picky detail of psychometric design I want to talk about: face validity. I’ve usually heard face validity  explained as the answer to this question:

On the face of it, does this scale measure the actual thing we’re trying to measure?

Having low self esteem does correlate with depression, sure. We might even go as far as to say that ‘has lack of self esteem’ is often a component of being depressed. But measuring self-esteem is not the same as measuring depression. Okay, but mental health is fairly fuzzy in terms of definitions. Let’s get more concrete.

Having low social economic status (SES) tracks very closely with poor diet. If find a group of people with very low income, they’re almost definitely going to have poor nutrition. But, if you spend ten minutes asking adults about their monthly income, you have not collected data on their nutritional intake. You’ve got priors and you can speculate with some amount of surety, but the thing you have measured is still monetary. Additionally, if you write a paper about the relationship between income and method of transportation, and your data for income sounds like “eats more than two fruits per day” the reviewers will giggle and write sarcastic notes when they return your study.

Returning to Rosenberg’s Self Esteem Scale, what we have is something that seems to be face invalid. If you have some amount of psychopathology (psychspeak for mental illness) training and you’re asked if it seems like the scale above is measuring depression, you’d probably say no, or not quite.

And of course, you could do some amount of empirically testing the scale too. You could see if it correlated with other measures of depression: with Becks Depression Inventory, or the HAM-D. You could see if it was uncorrelated with things that aren’t depression. You don’t want your measure of depression to be correlated with being sad (a brief state, where depression is more like a trait). But in the end, it’s possible that both of these could be true, and you’d still have a measure that answered in terms self-esteem, rather than depressiveness. That’s where face validity comes in. Is it all those things: uncorrelated with unrelated concepts, correlated with related concepts and measures, and does it sound like it’ll measure the thing we want?

And…I promised myself I would make this post more than just geeking out about psychometrics, so here we are. I think the issue of face validity is what a bunch of non-specialist arguments over psychology boil down to. Some people look at an IQ test and say, no, that’s not measuring intelligence, intelligence clearly includes all these other components! To which pro-IQ test people fold their arms and glare back with no, that stuff is outside the concept-space of intelligence, this is just measuring intelligence. Or, “that’s not measuring for ADHD, it’ll catch any hyper kid!” vs. “This is about ADHD, those kids you think are ‘just hyper’ have pathological attentional issues!” And at some further point, everyone’s stomping around arguing about which is the map and which is the territory and I start to have sympathy for Szasz.

Related: Streetlight Psychology

Rosenberg, M. (1965). Society and the adolescent child. Princeton, NJ: Princeton University Press.

Confounds, Damned Confounds, and Depression

[Content note: death, aging, dementia. It’s a cheerful post.]

As the Baby Boomers age, there’s simultaneously a large population of people to study and a vested interest in knowing a whole lot more about aging. This in turn, results in books like Depression in Later Life: A Multidisciplinary Approach, which I just finished. Eldercare and geriatric therapy is a field I’ve essentially never interacted with before grad school, so I’ve been reading whatever I can get my hands on.

One of the indications of depression in elders is executive dysfunction. Executive function is this collective name for the ability to anticipate the outcome of your actions,hold multiple threads  of knowledge in your head, and generally coordinate your behavior. Someone who anticipates a busy Tuesday and Wednesday, does their housework on Monday for a house party on Thursday is displaying executive function. Someone who forgets about the roast in the oven and sets the kitchen on fire because they went to start the laundry is exhibiting executive dysfunction. [Here’s the Wikipedia article  but, in a painful twist of fate, it’s horribly disorganized.]

So, elders with executive dysfunction might have depression. But, says you, this sounds like aging! This sounds like memory concerns. Couldn’t my grandma who forgot the roast in the oven have forgotten it? What makes this depression. Good point, says I. Let’s look at other commonly cited symptoms.

Hallucinations or psychosis can be a sign of depression in the elderly. Psychotic depression isn’t restricted to those with gray hair, but it’s more common as a component of depression in elders than in the young and middle-aged. Sure, fine, but paranoia and delusions are also a core sign of ongoing dementia! (And it’s hard to disentangle paranoia from pure hallucinations; when someone says there was a man trying to attack them, you usually can’t find that man to inquire if he was nice and well meaning or imaginary.)

Okay, but all that aside, there’s another piece of depression in the elderly. Declining social interactions! Of course, this could also come from dementia-driven or aging-driven means. I’m sure you can imagine that if your friend group began to die or move into assisted living situations, you might suddenly be somewhat less social. That the work of making new friends to replace ones you’d had for years or decades could be a little bit overwhelming, even unappealing. Alternately, dementia and Alzheimer’s come along with a less known symptom of irritability or outbursts of rage. This, you know, could result in either less social interaction by choice or by driving others away. Declining social interactions in your elderly client? Could be dementia…or it could be depression. Back to square one.

But what about insomnia? Insomnia is a common symptom of depression in young and old. This sounds like a more quantifiable sort of measure. “How are you sleeping, ma’am?” and bingo, we have a lead. Except (because there’s always an except), sleeping patterns change over the lifetime. Sleep research is generally terrible, but one thing we have established with a modicum of replication is that the elderly don’t sleep as much, and might not need to.

Okay, says you. How the hell am I ever supposed to determine what’s aging, what’s dementia/Alzheimers, and actually, why would I care outside of research interests? After all, if what you get is symptoms entirely indistinguishable from dementia and memory loss from aging—so indistinguishable as to make research bafflingly confounded—if what you see is an elder with psychosis and executive dysfunction and declining social interactions, isn’t it a walks-like, quacks-like duck situation?

Well, no. Because in one of those circumstances, in some of those people who show up in front of you with those ‘classic’ symptoms of dementia, in some of those cases the things are depression, and depression can be fixed.

And this was sort of stunning to realize. I been doing the opposite of what I described here. I sort of meanedered along assuming that if it looked like dementia, it was. In practice, this can, and probably does, have awful results.

Imagine (and I know some of you won’t have to imagine) you woke up one day with depression. You were stuck in this dark hole, and cut off from social connection and having trouble sleeping and struggling with memory issues. And then, everyone just sort of nodded sadly and conceded that this was tragic, but it was part of your inevitable decline. They never really considered therapy or treatment, because it was obviously an incurable, progressive, cognitive disease. Maybe, depression being what it is, you found yourself agreeing with them; that it was hopeless and probably not something you could stop.

And what if that wasn’t true?

Help-Seeking, Housekeeping

1. I am alive! I’m also still adjusting to grad school and having ten hours of commuting a week. Actual regular blogging is forthcoming as I wrap up and copy edit posts written in scraps between classes and in trains.

2. Recently I started reading some academic texts on depression in older adults. Holy mother of confounds, y’all. It could be dementia, or it could be depression with psychosis! It could be health and digestive concerns, or it could be a the anorexia/depression combination! It could be pre-dementia, showing as a mild cognitive impairment, or it could be executive function difficulties from depression! But I’m learning some really interesting things, and a post will be forthcoming.

3. MealSquares, which I’ve been trying out, are so good for my brand of badbrains. So. Good. They’re low-variance, so when I’m trying to over-optimize food and overwhelmed by different options, I can make the decision as basic as “Which of these two square things looks like it has more chocolate chips? This one? Okay, I’ll eat that one.” And then when I eat that one, it’s likely I’ve eaten something nutritionally complete, and I can stop thinking about it.

4. Help-seeking: based on a discussion had recently with classmates, I’m wondering if some readers could help me out. Do you have expressive or receptive language difficulties? Other language processing concerns? Lots of therapist skills are geared towards specific movement, speaking, and expressive cues. We’ve noticed that this can break down in interacting with language processing problems. But we don’t have better rules of thumb to replace in such instances. If you imagine yourself talking to a therapist or having a therapist talk to you, what would you prefer they did? What makes things harder for you?

Befriend A Swing Question Today!

I’ve been reading through my textbooks before I start grad school (I know, I know) and especially struck by the  Clinical Interviewing book.*

I mean, who couldn’t appreciate passages like this?

Several factors dictate seating-arrangement choices, including theoretical orientation. Psychoanalysts often choose couches, behaviorists choose recliners, and person-centered therapists use chairs of equal status and comfort.[…] Generally therapist and client should be seated at somewhere between a 90-and 150-degree angle to each other during initial interviews.

While I strongly discourage trying to be a therapist to your friends, (It will be exhausting! It will fail to meet your needs! They might begin to find every interaction too invasive!) this book has some work-throughs of conversational strategy that generalize.

Most people have heard of open and closed questions. The tl;dr of it is that open questions mean people can answer (and are encouraged to answer) in paragraphs, and closed questions allow (and encourage) short answers.

What adventures did you have today?

(Answer: Some story, or some reason why today was bad. In theory will capture narrative, mood, and current emotional state, plus give lots of jumping-off points for conversation to spring from.)

Did you have fun today?

(Answer: Yes/No, any elaboration is icing on the cake, and liable to be shorter than the open version of this question.)

Here’s the Advanced Version(tm): Swing Questions.

Again, back to the book:

Swing questions usually begin with Could, or Would, Can, or Will. For example:

  • Could you talk about how it was when you first discovered you were HIV positive?
  • Would you describe how you think your parents might react to finding out you’re gay?
  • Can you tell me more about that?
  • Will you tell me what happened in the argument between you and your husband last night?

Ivey, Ivey, and Zalaquett (2011) wrote that swing questions are the most open of all questions: “Could, can, or would questions are considered maximally open and contain some advantages of closed questions. Clients are free to say ‘No, I don’t want to talk about that.'” (p. 85)

Okay, so these sound a touch trite or overly solicitous. But we can work with this! Step one: bury the lede. Instead of opening with “Can you tell me more about X” try “I think I’m still missing something, can you tell me more about X?” (Important: you have to actually be missing something. This technique is to help conversations about difficult issues, not to teach insincerity.)

Alternate constructions:

I’m not sure I agree that he was being deliberately mean, but I don’t know if I have enough information about the argument. Will you tell me more about it?
Mmm, say more about that if you want to? (the can/would is more implied than stated here)
Would you be willing to explain what that was like? I’m not sure I’ve had any experience like that. (In theory, someone could respond with “Yes.” However, you’ve now indicated that you want them to talk more, and everyone wants to avoid the awkward pause that single-word answers cause.)

Step two: convey uncertainty!
You don’t want in any way to make this sound like a command (“Tell me your deepest secrets! Confess your distress!) and questions asked without a veneer of deference can be unintentionally pressuring. The fastest way to is to have increasing tone and pitch towards the end of the question. Depending on personal style and skill, raising one or two shoulders and/or tilting your head can also add effect.

So, dear readers, can you tell me more about what makes this succeed or fail for you?

*Very, very good if you’re looking to be a therapist/helping professional.

NJRE Injury

On of the great quandaries of experimental design is how to put people into stressed states, without actually harming them. That is, how do we make people feel stress without say, going to the trouble of convincing their bosses to assign them extra projects or taking away their money or making their relatives ill?

A solution has been screaming babies.

Babies, when they cry, and especially when they do the shrieking, crying, colicky noise-making, are near-impossible to ignore.

No, really, they’re nearly impossible to ignore. This video is 1:32 minutes long, consisting entirely of one unhappy baby. Try listening to it all the way through at a normal noise level. The first time, I shut it off at 0:11 seconds when I noticed my shoulders crawling up to my ears. A canny professor teaching child development a few years ago forced our class to listen to two minutes of a screaming infant, then said flatly, “You will listen when parents tell you they’re overwhelmed.”

Babies distress-crying, unlike the whine of the A/C that you can tune out, or the car-horn that eventually stops demanding attention, are hard to push to the back of your awareness. This is good! The evolutionary adaptation that makes us care a lot (and not be able to sleep through) a crying child is quite adaptive! Parents do need to wake from a dead sleep to respond to their child.

In short, the success of crying baby sounds as an excellent in-laboratory mechanism for inducing stress is that they’re painfully uncomfortable to listen to, and you cannot tune them out.

Now, let’s talk about NJRE’s.

I came across Not Just Right Experiences in Stuff: Compulsive Hoarding and the Meaning of Things, and there was immediate recognition.

“not-just-right-experiences, or JFREs as some OCD researchers and patients call them, are relatively common, and not just among people with OCD. Like an itch, the sensations that one’s clothes don’t fit right, or the experience of seeing a crooked picture on the wall, NJREs violate our expectations for order.

Most of us learn to tolerate these violations and either don’t notice or feel nothing more than simple recognition that something is out of place or off-kilter. But for people with OCD, NJREs can be quite dramatic. I once consulted on a case of a young man who was completely incapacitated by various NJREs and had been hospitalized. For instance, he did not feel right when passing through a doorway unless his shoulders were equidistant from the doorjambs. The discomfort kept him trapped in his room.”

NJREs with obsessions and without are like the difference between the pen tapping in a meeting and a screaming baby. It’s this constantly present, mentally loud feeling of wrongness. You might notice that a picture is crooked, and it might hover on the edge of your awareness, I notice clothes fitting a certain way and I cannot carry a conversation; it’s so distracting. As described in Stuff, people with hoarding disorder get it with their items moved, particularly putting things in the trash. I’d bet people with misophonia have something similar with those sounds — hear someone chewing? It just. won’t. go. away. Every NJRE is the screaming baby.


One going theory is that it’s the anterior cingulate cortex, which we think might be used in detecting errors, but also handles emotional regulation and impulse control. What if this is what happens (speculative, oversimplified model):

At some point very early on in the development of the disorder in question, your ACC  screws up and shouts that things are wrong

You ended up flooded with distress. This is bad, and you want it to stop.

Because your first reaction is not that synapses in your brain might be misreporting, you look for what’s wrong.

A plausible explanation comes to mind (chewing noises! clothes fit more tightly! things are not symmetrically arranged!) and you go fix the thing or change clothes or drown out the chewing noise.

Your brain gets the message that you’re doing something to fix the Wrongness and quiets down a little.

Hey presto, you’ve just started conditioning yourself! For bonus points, the anterior cingulate cortex is also responsible for impulse control. Perhaps this plays into being unable to avoid responding to NJREs?

So, just not being obsessive? Just deciding to throw that stuff out? Just focusing? Imagine doing that with a screaming baby in your head.

Fergus, T. A. (2014). Are “not just right experiences” (NJREs) specific to obsessive-compulsive symptoms?: Evidence that NJREs span across symptoms of emotional disorders. Journal of Clinical Psychology, 70(4), 353-363.

Seeing the Ceiling

Say I want to settle the question of who’s more moral, atheists or the religious. I’ve got a lab and a grant and some spare time, (A girl can dream, can’t she?) so I set up the experiment that will solve the question once and for all.

Say I bring a bunch of religious people and a bunch of atheists into my lab. I’ve got two research assistants, one of whom plays as if they’re a participant too. So each time someone, religious or atheist comes into the lab, they sit down next to a stranger (my research confederate), and I call them both into the lab together. They sit down, sign lots and lots of consent forms, and do some silly tasks. None of these tasks matter, they’re just there to distract the participants from realizing what I’m actually paying attention to. At the end of doing all the questionnaires, the confederate stands up, and ‘accidentally’ lets and expensive looking watch fall. Without appearing to notice, they leave the room. I see the watch fall and in a distressed voice, ask the real participant if they don’t mind going to the next room and giving the ‘participant’ his watch back, since I’m so busy entering the data.

Now, the real participant could take the watch, walk into the next room, sprint past the fake participant, and leave with a nice new watch. They are, after all, holding onto a watch, I am looking at my computer and entering data, and the ‘participant’ appeared not to notice they’d dropped a watch.

They could.

But most of them don’t. It doesn’t matter if the participant is religious or an atheist, they tend to pick up the dropped watch, walk into the next room, and give it back to our confederate in this experiment.

Case closed, says I! Religious people and nonreligious people are equally moral! After all, they had equal rates of watch-stealing (that is, none at all).

Not so fast, says you. Practically nobody will steal a watch when you’re just sitting there watching* them! You’re there at your computer, the fake participant is in the next room, and you have their name from participant registration and the consent forms! This is a terrible measure of morality–you have to be fantastically immoral to fail this test! In fact, what you’ve done is determine that nonreligious people and atheists have equally low levels of Horribly Immoral and Brazen Watch Thieves.

In fact, says you (why you’ve come into my laboratory to shout at me, I’m unsure), atheists are more moral! If you made this study more complicated–made it easier to steal the watch without suffering consequences, fewer atheists would steal the watch. You’re wrong, says my religious lab assistant! Fewer religious people would steal the watch!

And all the while, I sit there in puzzlement, because I did this study, right? And I was testing for morality, right? Everybody agrees that stealing a watch is Bad and not stealing a watch is Good.** And my research assistants sit there in outrage, because OBVIOUSLY the [religious/atheists] would be more moral if you made the test harder!

This, dear readers, is the ceiling effect. My bar (or ceiling) for Moral Person is far far too low. Everyone returns the watches, but there’s no way to distinguish between the ones who give the watch back and then glare at puppies on the walk home and the ones who return the watch and wander over to the soup kitchen to volunteer.

Take another, real life example. Jacob says men are better at math than women. Elizabeth says this is clearly false. (Both of them are grievously oversimplifying ‘math’, but we’ll let them get away with it.)

Elizabeth points out that This Math Test (TMT, an official exam given to every high school student in our fictional universe) shows that men and women don’t differ significantly. Therefore, men and women are basically about the same in math ability.

Jacob disagrees. He claims that this test is too easy–that men and women do score the same on the TMT, but that doesn’t mean they have the same ablities–the test is too easy. After all, says he, standardized tests hardly examine the highest possible skill level–they cover basic material. He claims that Elizabeth is just demonstrating the ceiling effect–when you give people a really hard test, men outscore women. Jacob is actually right, but this gap is rapidly shrinking, and men also are overrepresented on the other end–with unusually low math performance.*** (Third section after the abstract, here)

And these ceiling debates play out in a number of parts of psychology research. (And in case you didn’t have enough architecture metaphors in your life, we also have the floor effect.) Here’s a more complicated version of the gender-ceiling issue. You can have sparkling methodology, a huge and representative sample base, but if you’re creating a test with a ceiling problem…you might get entirely unhelpful, or worse, misleading, answers.

This is the best and worst of psychology, for me. That there’s always just a little bit more than the research, always a little bit more to debate and argue and question. Maybe the study is too old, maybe you got a weird subset of the population. Maybe the rats are afraid of the gender you always use for research assistants. Maybe there’s a ceiling. Or a floor.

*sorry, this was unintentional.

**That one girl who stole the watch in order to sell it for medication to save her dying father was dismissed as an outlier. 

***Basically, men have higher variance of performance: they’re some of the best and worst performers. Women have a narrower bell curve of math performance.