The American Psychological Association recently recommended only one form of treatment for people with post traumatic stress disorder, saying that it is the only one that is “evidence based.” Jonathan Shedler, the author of the following article, is a renowned researcher on therapeutic outcomes and a harsh critic of APA’s recommendation, as well as much of the empirically weak base for much of what is supposedly “evidence based.” I recommend this clear little article by Shedler, with whom I could not agree more.
Cost-effectiveness of psychological services:
a summary review of the literature
Presented to Dr. Sam Knapp,
Director of Professional Affairs, Pennsylvania Psychological Association
March 1, 2013
Roger Brooke and Jeremy Axelrad, Duquesne University
Jeremy Axelrad is a doctoral student in clinical psychology at Duquesne University. While authorship is to be acknowledged, readers may forward and distribute this paper at their pleasure.
(Citation is this web page.)
The following is a summary reporting of well designed studies in articles in peer reviewed journals (only one is a book chapter) which address the cost effectiveness of psychological interventions. Throughout the paper, we have kept in mind the proposed readership: intelligent readers who are probably not professional psychologists but who are interested in the relationship between psychological services, outcomes, and cost.
Roger Brooke, Duquesne University, Pittsburgh
The recent (winter 2001) annual conference of the Council of University Directors of Clinical Psychology (CUDCP), held in Santa Barbara, was a celebration of clinical psychology. The meeting deserves comment because it identified the two dominant themes of the future of clinical psychology and because CUDCP represents and comprises the most powerful clinical psychologists in America and Canada: the Directors of Clinical Training, who put their mark on the next generation of clinical psychologists. Despite the voluminous recent literature on multiculturalism, and on scientific method, in American Psychologist and elsewhere, there seemed to me to be a certain naivete among my good colleagues that is more problematic than they recognize and that, in the long run, will be self-destructive to our discipline. It is as though we as professional educators have not adequately taken to heart the implications of what we ourselves are saying about multiculturalism. At worst, we could be charged with using the rhetoric of multiculturalism as an instrument of cultural oppression. We shall be guilty as charged if we think of multiculturalism simply as a matter of adding “other cultures” (foreign and domestic) to our fields of research and care: clinical psychology would then be colonialism with a warm heart and an EVT (empirically validated treatment).
The first day of the Conference celebrated the scientist-practitioner model of training, which is now finding its fulfillment in empirically validated treatments (EVT’s) – those treatments, oriented towards the latest DSM, that have been experimentally and statistically validated. The second day celebrated multiculturalism. Professor Derald Sue gave a brilliant speech, and managed to say, without giving offense, that all White people were racists. He was, of course, not accusing anyone in personal terms at all; he was pointing to the way in which we psychologists impose on people from “other cultures” a whole range of assumptions which define for us (mostly White Americans) the nature of social and psychological reality, that is, assumptions about the nature of human beings which we fail to recognize as cultural.
After the seminar on multiculturalism, during discussion time, I suggested that, within the latencies of our celebration, there was looming a Clash of the Titans. The previous day’s Titan was the scientist-practitioner model of training; today’s was multiculturalism.
The challenge of multiculturalism, as an ethical and political obligation, is that there is little point in learning about so-called “other cultures” if our way of knowing is singular and has already colonized in advance what we know. Multiculturalism, as Professor Sue argued, needs to be approached not as an accumulation of already colonized “facts” but epistemologically, as ways of knowing and self-understanding.
However, the scientist-practitioner model is not merely a model of training but an epistemology, a way of organizing our experience within the culture of clinical psychology. As an epistemology it defines for us the nature of psychopathology, symptom, cure, evidence, validity, and even professional legitimacy and competence. Through its defining language it reaches into our professional identities and collegial relations. Clinical psychology is, therefore, an epistemology, not as some abstract philosophy, but as an embodied and organizing, political culture. The scientist-practitioner model of professional psychology is a cultural and political force. That is not to criticize it, but only to name it. Clinical psychology is, after all, part of my cultural identity, and I have thrived within it.
I suggested that we try to be a little more self-reflective and circumspect in our adoption of the scientist-practitioner model of training. We should not be its servant but its critical master.
After my remarks, the family therapists in the room would have noticed how the system immediately coordinated to nullify the intruder and to return to its prior comfort level. Of the comments I noted, then and later: science is culture free; it is not something to abuse people with, but to help them. We should not abandon science: mysticism, shamanic dance, and e.s.p. might be fine in other cultures, but this is America, and we have our own criteria for accountability. If we give up science we will not be able to know when we are wrong. More hopefully: science has many meanings.
The nullifying comments above should embarrass us for their epistemological and cultural naivete. The Clash of the Titans will not be averted so easily. A brief example might show how easily our colonialism can unwittingly slip into our science and care. A Taiwanese student is self-referred to the Student Counseling Center because she lacks energy and is unable to complete her dissertation. It is found that she has a history of traumatic loss and that she meets the DSM criteria for major depression. We are told that the Chinese do not have a concept of depression, so we have to “educate her about psychological constructs such as depression” (Grieger and Ponterotto, 1995, p. 362) before our treatment can make sense to her. These authors are well-meaning and sensitive, but the fact that the client was helped by “altering her world-view” to one that was more “psychological” (and biological, as she was referred for medication) was not critically examined. The authors do mention the debate about whether depression is universal or a cultural construct, but this debate is bypassed. It is taken for granted that the client must think like us if she is to be helped. But there are numerous cultural assumptions that have already colonized what it is that we scientist-practitioners think we know about this unfortunate young woman and her culture. It is assumed
that a billion Chinese misunderstand their own experience because they have not yet discovered what “depression” “is,”
that the human experience we psychologists and psychiatrists call depression is a pathological condition (rather than, say a spiritual malaise, like a dark night of the soul),
that this pathological condition is something an individual (rather than, say, a system) has,
that depression is a mental illness which, like a medical illness, has a set of defining symptoms,
that depression is caused by a combination of biochemical imbalances and dysfunctional thoughts (or unnamed grief, inner conflicts, etc.),
that the cure is to teach the client what depression “is,” and to change the mental factors that caused it (in CBT, to train her to think in ways we say are “realistic” and “functional”);
Most practicing therapists, I expect (or hope?), would approach this student with a humble and respectful desire to know how she understands her distress and organizes her experience in terms consistent with her cultural world. We would assume that we have at least as much to learn from the client as to offer her. We would approach her in the hope that, perhaps, on the bridge between her world and ours, with our human capacities and professional skills, we can find a way to meet that will be helpful to her. This seems to be good starting point for multicultural counseling: an awareness of both our common humanity and our cultural differences. The problem is that, for the scientist-practitioner psychologist, this approach might be creative, but it has not been validated and has no more status than homeopathic remedies have in medicine. Humble exploration based on respect for difference supposedly needs to be followed with experimentation as to the best approach to “treat depression.” The colonizing terms remain – and, of course, at our scientific best, we need to leave hanging in their misery a control group of unhappy Chinese students. (The health insurance companies are popping champagne, of course.)
I have no doubt that APA’s move towards multiculturalism is a genuinely ethical vocation and not merely a political feel-good. For Dr. Barbara Yutrezenka, the CUDCP panel’s host, multiculturalism is needed if our discipline is to avoid becoming obsolete. Yes, indeed! However, we need to take its ethical appeal to heart, knowing that, unless multiculturalism troubles us, we should be suspicious that our comfort might mask the complacency of a dominant culture. We need to allow for multiculturalism to change us, to make us more humble and self-reflective, and we should be vigilantly suspicious of any of new “knowledge” of “other cultures” if it serves to perpetuate our biases. We also need to be more systematically self-conscious and critical of the cultural assumptions that tend to remain unthematized in the conduct of our scientific research. We need to appreciate why, for some of our colleagues in the field, identifying clinical psychology’s care with empirically validated treatments is not only long term professional suicide but is culturally and politically oppressive, or even racist. Finally, we need to be more flexible in our understanding of science, and to include in our repertoire qualitative methods that are rigorous, self-reflective, and descriptive.
Reference: Grieger, I. and Ponterotto, J. (1995). “A framework for assessment in multicultural counseling. In J. Ponterotto, J. Casas, L. Suzuki, and C. Alexander (Eds): Handbook of multicultural counseling. Thousand Oaks: Sage Pubs.