Pygmalion Revisited

Carol Dweck was honored for her Distinguished Scientific Contribution in the 2012 Awards Issue of the American Psychologist.  This was for her work on Mindsets and human nature: Promoting change in the Middle East, the schoolyard, the racial divide, and willpower.  She summarized her work and other research in an article in the same publication (Dweck, 2012) that demonstrates how our beliefs about human traits and attributes, like intelligence and personality characteristics, can change and are subject to, what in the past was referred to as the Pygmalion effect (Rosenthal & Jacobson, 1968); basically a self fulfilling prophecy set forth by priming.  The Rosenthal & Jacobson research did indeed show that students of teachers primed with higher expectations for them actually performed better, or up to those higher expectations in comparison with a control group of students of equal ability and equivalent historic performance.  The suggestion is that the teachers in this case unknowingly treated the higher expectation students differently than equivalent students where no or a lower expectations were set. 

Dweck reviewed a series of studies that showed that, not only do beliefs about whether people’s traits and attributes guide expectations and behaviors, but also that beliefs and related expectations and behaviors are subject to change via priming. 

In the experiments Dweck described, baselines were set by assessing whether subject mindsets were fixed or open, for example with regard to whether people can change or not, and their subsequent thoughts and behaviors with respect to subject-others or their personal characteristics.  As expected, findings indicated that those with fixed mindsets tend to avoid challenges, show less resilience in the face of setbacks, tend to rapidly judge individuals and groups, and generally reject information that is contrary to held beliefs.  This is in contrast with those with open mindsets that tend to seek challenging opportunities; show greater resilience in the face of setbacks; tend toward understanding peoples behaviors as being situationally or contextually driven, as opposed to being the result of psychological traits; and, that are less likely to affix labels and more likely to update impressions in the face of new information.  

Baselines were followed by experiments where subjects were primed with reading materials that either reflected a fixed or open mindset; for example evidence that groups and individuals that are evil or aggressive will always be that way, vs. evidence that groups and individuals are not inherently evil and can learn from new information or experience respectively. 

A promising result came from a study involving Israeli and Palestinian attitudes toward one another where those with seemingly intractable baselines, from both sides, who were primed with an open mindset article, developed more favorable attitudes toward the other side and became more open to actions and compromises for resolving disputes.  This was also the case with a study involving adolescent bullies and victim aggression where adolescents provided with a personal rejection scenario and subsequently primed with an open mindset article, assigned 40% less retaliatory measures and wrote more pro-social notes about their experience to the aggressor in the scenario.

Individual beliefs about whether willpower or energy are limited, or non-limited were also found to be predicted by mindset.  In the last study Dweck summarized a limited mindset predicted worse self regulation in the last weeks of final exams (unhealthy eating, more procrastination vs. studying) at a university.  In the same study, providing sugar to those who believed that sugar would help restore energy (limited glucose theory) was only helpful to those who believed in limited willpower.  In fact those with limited willpower beliefs showed restored performance when they thought they ingested sugar even though they did not.  This placebo effect is consistent with studies indicating that a significant percentage of the effectiveness of medications is dependent upon who gives it to you (McKay, Imel, & Wampold, 2006; Wampold, & Brown, 2005).

And so I must ask myself, what is the role my mindsets play with respect to the outcome of the individuals in my care?  How are mindset and priming incorporated into organizational cultures; and, what role might priming play in building individual self-efficacy and patient outcome.  How can organizations in treatment systems better serve patients by priming for the best of expectations when making referrals?      

    

"The Ghost in the Machine"

I just finished Atul Gawande’s book Complications: A surgeon’s notes on and imperfect science. Gawande highlights the very human nature of medical care and its influence on both the good and the bad outcomes of medical practice.  In vivid detail he describes cases that highlight the intended very mechanical and scientific nature of surgery and medicine in its practice, but inevitably calls attention to the role that “the ghost in the machine” (Gilbet Ryle, 1949) plays in influencing outcomes below the level of consciousness, the role of insights that come without conscious thought.  It was just a hunch given a 5% chance that Eleanor was infected with a deathly antibiotic-resistant, flesh eating bacteria that called for biopsy and immediate surgery, but it was this hunch that lead to saving her foot and leg, and perhaps her life.

While it may be an apparent “ghost in the machine,” Gawande’s work indicates that this ghost is not beyond influence and it becomes very clear that our ghost is largely trained by practice, experience and reflection that build neural maps to guide future automatic thought patterns and behaviors.  In Gawande’s case, if you want to be a great surgeon, do a lot of surgery and have a way of reflecting upon your work so that strengths are reinforced and shortfalls avoided; I would suggest that this rule applies to all endeavors to include psychotherapy.  It all comes back to knowing what we want to become and acting it out long before we get there; our humanity and the art always remain key to both science and practice.  

Paying Attention to Context

At the time of his retirement, a favorite professor from my past advised that I “always pay attention to context.”  His advice stuck with me over time and has proven to be sage given the growing body of research suggesting the important role that context plays in human health and happiness.  Context appears to influence both psychology and biology and the order of how and the degrees to which these influences are combined appears to be somewhat fluid. While research in this area is largely correlational, en masse it does point to the need for a greater emphasis on the role a context may be playing in the experiences and life outcomes of individuals and societies, and may raise the question of whether more concrete supports might serve as better and perhaps necessary and more cost-effective options for facilitating individual or societal life improvements.  While these more concrete supports may largely fall in the realm of public policy and how a society treats its marginalized or disenfranchised groups, this does not discount the fact that much can be done with individuals to alter contextual influences just by paying greater attention to them; paying attention highlights cognitive and behavioral choices.  

     

As recent examples of this line of research, there were three studies published in the recent edition of the journal Health Psychology (Volume 31, #4) that highlighted the role that childhood life context and related stressors play in the elevation of a stress related biological marker (C-reactive protein, or CRP) in adulthood, and the role that positive perceptions and non-work social ties play in a healthier lifestyle and lowered risk for disease.  Elevated CRP has been identified as a marker for elevated inflammation and increased risk for disease in adults. 

In the first article, Hagger-Johnson, Mottus, Craig and Starr ( http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2012-02775-001 ) modeled a life course pathway from childhood intelligence and parental social class that proved to serve  as a potential platform for unhealthy behaviors, low quality of life, high body-mass index and increased risk for cardiovascular disease as measured by CRP.  In the second, Appleton, Buka, McCormick, et al. ( http://www.ncbi.nlm.nih.gov/pubmed/22329424 ) found that childhood emotional problems on their own do not necessarily contribute to elevated CRP or the increased risk of disease in adulthood.  Increased risk for elevated stress (CRP) and adulthood disease was however found with children with emotional problems who were also exposed to the stress related to low socioeconomic status.  Both articles appear to point to the question of cost-to-society and the cost effective benefit of strategies targeted at altering the socioeconomic conditions that today appear to be growing the population of those in poverty in the USA.        

In a third study Ferris, Kline and Bourdage ( http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2012-00038-001 ) considered the more immediate contextual components of work (positive perceptions of job characteristics) and non-work social ties.  These predicted biopsychosocial health and a healthier lifestyle which predicted lower risk for cardiovascular disease.  This would suggest that we do have some control, to a point; is there a socioeconomic cut off where the choice or control is largely lost?     

Outside of the public policy arena (the realm of making things better for most) it would seem that Acceptance and Commitment ( http://contextualpsychology.org/act/ ), Cognitive (identifying more helpful ways of thinking about circumstances), and Behavioral (functional analysis and change of behavioral antecedents and rewards) (http://www.rebt.org/ ) therapies do present as options for reframing or even changing the context even where minimal resources are in play.  Sometimes however, it would seem that the larger context will have to change before that growing population below the socioeconomic cut are able to muster the resources, self efficacy and hope necessary for any therapy to work.          

The Therapeutic Alliance Supported and Reinforced

Two (2), what I think are important additions to therapeutic alliance literature appeared in the January edition of the Journal of Counseling Psychology (Vol 59, No. 1).  In the first, Fluckiger, Del Re, Wampold, Symonds and Horvath (How central is the alliance) completed a meta-analysis to see if there were moderators to the influence of the working alliance in the context of randomized clinical trials.  They found none with the exception of a slightly higher correlation between outcome and alliance with researchers with a specific interest in the alliance.  As allegiance to a therapy practice contributes to alliance development, this should not be surprising or at all troubling.  

The importance of this research finding lay with the primary role that the alliance plays in therapy outcome and alliance development as the central evidence based practice; if therapeutic bond and agreement on task and goals are not in alignment, it is unlikely that any evidence based practice, including the administration of psychotropic medication, is going to work. 

In the second, Fluckiger, Del Re, Wampold, et al. (valuing clients’ perspective) completed a randomized controlled study to see if inviting clients to provide their therapists with feedback about the therapy process (letter and phone call) would increase the quality of the therapeutic alliance developed; it did and it did over the full course of therapy.  The suggestion was that the feedback requests fostered enhanced client feelings that their therapists were interested in their welfare.  

This study supports Miller, Duncan and Sparks client directed work and the role played by therapy support tools like their Outcome and Session Rating Scales (ORS/SRS) and the How Am I Doing (HAID) and How are We Doing (HAWD) tools being used at New Hope Foundation.  Both sets of instruments solicit client feedback to see if the therapies being applied are having the desired effect and if the therapeutic alliance is sustaining a quality adequate for the effective delivery of an appropriate therapy.  The use of the instruments is also intended to foster client input into correcting for shortfalls in the here and now and improving the process. 

While the alchemy in these processes appears to lay with the fact that we simply ask the questions sincerely and respond or act as called for, the related written communications and instrumentation insure for a consistency that contributes to the overall quality of care.  The instruments or therapy support tools contribute to the structure and thus the context of care and, with respect to this blog, perhaps provide the main sheet and down haul shaping the therapy sails to insure forward progress through what are inevitably shifting winds and waters. 

Some thoughts on outcome in response to a question posed

The question that has not been asked is: who gets to define the outcome?  If we are talking about managing a chronic illness any improvement represents a positive outcome and from a public health perspective, we're really looking at the three tiers of prevention: a. preventing it from happening in the first place, b. catching it early before it becomes a problem, and c. managing a chronic condition so that it doesn't get any worse.  I find Lambert's work most compelling in its potential application to practice and the parallel works of Scott Miller and Barry Duncan that actually operationalize Lambert's findings.  Basically Lambert found that only about 1% of clinical outcome has to do with the specific therapy that is applied, evidence based or not, and that the largest controllable contributor to outcome is the therapeutic alliance; the suggestion is, for example MET and MI work because of their facilitation of a therapeutic alliance.  While this is the case, there is nothing wrong with evidence based practices; the alchemy lay with what Miller termed "the client's theory of change" and the alignment of evidence based practices in a way that potentiates the change trajectory.  Outcome in the art and science of therapy is measured by engagement, for example the HEDIS measure, tracking improvement and decline, and applying timely interventions that are consistent with "the client's theory of change."

The gap between research and practice

Barry Wolfe published a thought provoking piece in the July issue of Psychotherapy that attempted to find pathways to bridge the gap between research and practice (Healing the research practice split: Let’s start with me. 49. No.2, 101-108). Basically he attempted to break down the perception of all or nothing approaches on both sides of the equation with the suggestion that researchers believe that empirical evidence is the key and clinicians should just do it, and clinicians believing that randomized clinical trials are too simplistic and the resulting protocols just are not practical or applicable to the complications of practice in the real world. The gap is bridged in a faux dialogue that softens both sides of the argument and results in: a broadening of what’s considered clinically useful; increased and improved collaboration between researchers and practitioners; and, giving clinicians ready role-model access to video examples of how research results are applied in practice.

While all of this is good and I agree with Dr. Wolfe’s direction, again, in application, the devil is in the details and the ever shifting therapy outcome target remains unchanged. The alchemy in Dr. Wolfe’s thoughts lay with what I read as his suggestion that there be an ongoing sharing and reflection on the potential uses for research protocols, the blossoming of a thousand flowers in real therapy work, the sharing of case studies and examples of applications and again, reflection and application in an ongoing feedback loop. Short of a grand scheme, it strikes me that this process is and always has been our responsibility as clinicians; my guess is that some do it better than others. I also know researchers that are very interested in working with and getting feedback from clinicians; my guess again is that some do it better than others.

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Welcome

Welcome! This blog is named after the control mechanisms that guide and help power a sailboat through the natural world of winds and ocean currents toward the skippers goals. As sailors know, winds and currents are unpredictable as are the processes and context that drive clinical outcomes in mental health care.  I post thoughts on current literature that may translate into how research results might be used in clinical practice.  This includes snippets that remind me that science is also a motivated and very human art form that reaches towards a paradox.  We are always working in the space between.