Psychotherapy outcome research: Implications of a new clinical taxonomy

Since the publication of DSM-III in 1980, the scientist-practitioner gap in clinical psychology has expanded, as almost all outcome research in clinical psychology has been on diagnosed mental disorders within a medical model using drug trial methodologies, whereas most practising clinicians undertake functional analyses and case formulations of clinical psychological problems (CPPs) and then apply tailored interventions within an ongoing hypothesis-testing methodology. But comparatively reliable assessment and generalizable conclusions in psychotherapy outcome research require a comprehensive theory-derived conception or operational definition of 'CPPs', standardized functional analyses, and a taxonomy of CPPs comparable to DSM's listings of mental disorders. An alternative conception and taxonomy of CPPs have recently been proposed, offering improvements in the reliability and generalizability of case formulation-based psychotherapy outcome research. It conceives of CPPs as instances of the formation and operation of self-sustaining problem-maintaining circles (PMCs) of psychological-level causal elements-that is, at the level of cognitions, behaviours, emotions, and events or situations (stimuli). The paper describes this new conception of CPPs, a subsequent nascent taxonomy of evidence-based PMCs which standardizes the underlying mechanisms that maintain CPPs, and ensuing benefits to research (as well as to practice) in clinical psychology. These benefits include being able to encompass all treatment-worthy CPPs, not just diagnosable mental disorders; to assess theory-derived intervention strategies, not just arbitrary therapy bundles; and to directly feed back into psychological theories, not just expand an atheoretical list of patented "evidence supported therapies."

A new conception and subsequent taxonomy of clinical psychological problems

BACKGROUND

A taxonomy of the objects of study, theory, assessment, and intervention is critical to the development of all clinical sciences. Clinical psychology has been conceptually and administratively dominated by the taxonomy of an adjacent discipline - psychiatry's Diagnostic and statistical manual of mental disorders (DSM). Many have called for a 'paradigm shift' away from a medical nosology of diseases toward clinical psychology's own taxonomy of clinical psychological problems (CPPs), without being able to specify what is to be listed and classified.

MAIN TEXT

An examination of DSM's problems for clinical psychology, especially its lack of clinical utility, and a search for the essence of CPPs in what clinical psychologists actually do, leads to the proposal that: The critical psychological-level phenomenon underlying CPPs is the occurrence of 'problem-maintaining circles' (PMCs) of causally related cognitions, emotions, behaviours, and/or stimuli. This concept provides an empirically-derived, theory-based, treatment-relevant, categorical, essentialist, parsimonious, and nonstigmatizing definition of CPPs. It distinguishes psychological problems in which PMCs have not (yet?) formed, and which may respond to 'counseling', clinical psychological problems in which active PMCs require clinical intervention, and psychopathological problems which are unlikely to be 'cured' by PMC-breaking alone.

CONCLUSION

A subsequent classification and coding system of PMCs is proposed, and expected benefits to research, communication, and the quality of case formulation in clinical psychology are described, reliant upon a development effort of some meaningful fraction of that which has been devoted to the DSM.