#SeeingFurther: The Lancet Psychiatry Commission on Psychological Treatments Research

On Monday, 26^th March 2018 we had our second journal club session and we discussed the paper:

Holmes, E. A., Ghaderi, A., Harmer, C. J., Ramchandani, P. G., Cuijpers, P., Morrison, A. P., … & Moulds, M. L. (2018). The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science. The Lancet Psychiatry, 5(3), 237-286.

Here are some notes from thoughts shared in our discussion.

1. The group felt that a series of certain words captured the key messages from the document:

• Mechanisms
• Collaboration
• Methodology
• Training
• Combination of interventions
• Co-morbidity
• Therapeutic alliance
• Internet-based intervention
• Innovative treatment
• Public policy
• Assessment

2. General comments/thoughts:

We thought that this document was a useful resource for future directions not only in the development of research to improve psychological interventions, but it also highlights important considerations for the development of methodological and theoretical aspects of the field of mental health. Among several topics, our discussion focused mainly on the following three themes:

• • Authorship bias. This is not an uncommon issue when testing interventions. The group discussed the systematic review and meta-analysis by Kreplin et al (2018) [1] which analysed the effects of meditation interventions on pro-sociality in randomised controlled trials of healthy adults. Among the results, the authors of this study found that “… the moderation results showed that a significant increase in compassion only occurred if the intervention teacher was a co-author in the published study, but not when the intervention was delivered by other means (written/audio) or by a teacher that was not a co-author in the publication” (p. 6). The development of research (particularly randomised controlled trials) by independent research groups was considered extremely important to tackle this issue and to help the refinement of intervention packages.
  • Mechanisms. This stood out as a key topic of this report. Specifically, we discussed:
    • The differential meanings of the word “mechanism”, both between fields and possibly within the article. In the third section of the Part 1 – “What is the state of the field” (p. 242), the authors describe “pivotal evidence-based psychological treatments [that] have evolved by specifically targeting identified mechanisms of psychopathology”, mentioning the example of the treatment of panic disorder. The authors define mechanisms, using Kazdin’s (2007) [2] definition, as “the steps or processes through which therapy (or some independent variable) actually unfolds and produces the change. Mechanisms explain how the intervention translates into events that lead to the outcome.” We noted that this interpretation emphasises the increased ability to influence behaviour in desired ways, consistent with the behavioural tradition that Kazdin operates from. We noted that the majority of examples of successful interventions based on empirically evidenced mechanisms listed in the article (e.g., interoceptive exposure, instrumental reinforcement/exposure and response prevention, behavioural activation) come from the behavioural psychology tradition whose theoretical models were mostly developed through experimental methods with an emphasis on the prediction and influence of behaviour rather than the cognitive understanding of mechanisms. Furthermore, we considered that the behavioural tradition has made frequent use of single-case design studies. We discussed whether there was some tension between these different uses of the word “mechanism”, given that the examples of successful understanding employed the mechanism in the behavioural sense whereas the stated future directions employed the work mechanism in a cognitive or otherwise sense. Therefore, the theory behind different researcher’s understanding and use of the concept of mechanisms may be likely to impact future research and the success and applied utility of that research. In sum, we discussed whether all types of mechanism were equal, or whether important distinctions should be made.
    • The research method. Although randomised controlled trials (RCTs) are regarded a ‘gold standard’ method for testing interventions and have provided fundamental contributions to evidence-based psychological treatments, we understand that RCTs focus more on addressing the question of whether an intervention works or not. Understanding “why” an intervention works – the mechanism question – might be better addressed via other methodologies, such as qualitative, single-case design, EMA, or and experimental designs. In our discussion, two papers on single-case design were mentioned as examples: Rizvi & Nock (2008) [3] and Smith & Little (2018) [4].

• Therapeutic alliance and patients’ expectations. A very important aspect of assessing the effectiveness of a psychological intervention is related to the expectations that the patients have about the treatment, their level of engagement in the psychotherapy, and the quality of the therapeutic alliance (clinician-patient relationship/commitment). David Jobes [5] has been emphasising the importance of a collaborative approach in the treatment of suicidal ideation and behaviours. We thought that the success of a psychological intervention may also be moderated by the therapeutic alliance and the patients’ expectations/beliefs about the treatment. We believe these are fundamental variables to be assessed when testing the effectiveness of a psychological intervention.

References:

[1]. Kreplin, U., Farias, M., & Brazil, I. A. (2018). The limited prosocial effects of meditation: A systematic review and meta-analysis. Scientific reports, 8(1), 2403.

[2]. Kazdin, A. (2007). Mediators and mechanisms of change in psychotherapy. Annu Rev Clin Psychol 2007; 3: 1–27

[3]. Rizvi, S. L., & Nock, M. K. (2008). Single‐Case Experimental Designs for the Evaluation of Treatments for Self‐Injurious and Suicidal Behaviors. Suicide and life-threatening behavior, 38(5), 498-510

[4]. Smith, P. L., & Little, D. R. (2018). Small is beautiful: In defense of the small-N design. Psychonomic bulletin & review, 1-19

[5]. Jobes, D. A. (2016). Managing suicidal risk: A collaborative approach. Guilford Publications