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Letters to the Editor Dear Editor: The article in the Spring '97 issue of the IP concerning the Pennsylvania Psychological Association Practice Research Network's Psychotherapy Outcomes project appears to be a rather noble and ambitious undertaking, but I have some comments. First, I do not understand how our "scientific foundation...allowed psychology to leap ahead of psychiatry over the past 50 years"? Psychiatry has utilized a medical-scientific basis to specialize in psychopharmalogical treatment and has certainly produced experimentally valid results in helping the seriously mentally disturbed. I assume this is partially the reason that clinical psychologist's are seeking Prescription Privileges! The most important point, however, is that the PRN's psychotherapy Outcome study has some serious experimental design flaws. The most glaring is that NO CONTROL GROUP is mentioned. What ever happened to the PLACEBO EFFECT? Since neither the Experimenter (Therapist) or the Subject (Client) are BLIND to the intention of this research, it seems clear to me that they both have a mutual investment in seeing a Positive Outcome. This is emphasized by the VOLUNTEER basis of this research: By using volunteers, there is a bias in selecting the most motivated therapist and clients (usually these are the successful ones!). I realize this is an inherent limitation to some extent, but it will tend to rule out less competent therapists and treatment failures. The article mentions that "60 clinicians have already enrolled 101 clients...with completed pretherapy measures". This averages 1.68 clients per therapist. If the therapists "typically see 21.9 clients per week", what happened to the other 20? The sample SELECTED represents only 10% of their caseload! Wouldn't you wonder about the Success/Failure of the other 90%? Certainly, there could be a serious bias in the Therapist's selection of the 10% who volunteered. These clients are most likely those who want to improve and cooperate with the Therapist's wishes (conscious or subconscious), and are unlikely to report negative results (especially if "feedback is provided to clinicians following each evaluation"?). By increasing this "sample" size to "1,000 psychologists...throughout North America with 5,000 of their patients" eventually leading to "data from 50,000 patients for 10 years", the expansive nature of this design flaw is only MAGNIFIED! I hope this criticism will end up being of some use to Dr. Ragusea and his colleagues. Stephen Safran, Ph.D. Dear Editor: In his article in the August 1997 edition of Commentary, Bruce A. Barron tells us that: " In many managed-care programs, the amount of time for patient-physician contact has been significantly curtailed and the level of clinical training required for a given task has been redefined downward. Patient care is provided by....psychologists" To call getting care from a psychologist instead of a psychiatrist redefining clinical training downward is plain nonsense. A small point, perhaps, but not to a child psychologist with 21 years of clinical experience. To treat patients with mental illness we need all the qualified, experienced professionals we can get, psychologists and social workers as well s psychiatrists. It is in fact very difficult to find psychiatrists who are trained to do psychotherapy and psychological assessment, which is not the case with psychologists. Some managed-care mental-health plans prefer cheap labor, which often means inexperienced professionals, whatever their title, who are hungry for patients. As Dr. Barron acknowledges, the horror of managed care is that "it is not a mechanism for managing care at all; it is a mechanism for managing costs.". Just good old-fashioned ruthless rationing--keeping costs low and quality down--mixed with plenty of political doublespeak. Wasting time, not to mention risking life and limb, and saving money. What a bargain! We are resurrecting Soviet-style health care in America. Steven J. Ceresne |
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