Problems with the Research on Psychological Treatments

The need to separate the experience of distress from healthy functioning

Posted Nov 20, 2015

The most widely regarded guidebook of psychological disorders is the beloved and hated Diagnostic and Statistical Manual of Mental Disorders (a financial cesspool of government and industry costs). The reason I bring this up is that the definition of a mental disorder is tied to the DSM. If you ever wondered what your psychologist, psychiatrist, social worker, or neighbor was contemplating when deciding on your mental health, here is the DSM definition:

behavioral, emotional, or cognitive dysfunctions that are unexpected in their cultural context and associated with personal distress or substantial impairment in functioning

Pretty damn good - but loaded. In this one definition, statistically rare behaviors are viewed as problematic, behavior that is unexpected for a particular culture is viewed as problematic, and then there is the presence of either disability or pain. I could write a book on the problems with this definition, especially the focus on violating social norms (when and why is it problematic to deviate from the dominant culture? how do we account for social disruption and the harbingers of cultural change?). But my main issue is that a person only has to show personal distress OR substantial impairment. Certainly, the first criterion in determining whether someone has a disorder is the presence of disability or harm. By harm, I am talking about the production of impairment in major life activities - mortality, morbidity (check out the data on accidental poisonings and car accidents in those diagnosed with ADHD), pedagogy, and the ability to form and maintain social relationships, among others.

Is the experience of distress, without impairment, enough to warrant a claim that you have a genuine, mental health disorder? I don't have a clear answer. I know that much of what we know about the effectiveness of psychological interventions is based on clinical trials where there was no attempt to test whether people functioned better - making better progress toward major life activities. What I know is that far too many clinicians believe that treating distress is sufficient to help someone. And I think this is a problem.

To support the claim that clinicians lean more heavily on distress as an outcome instead of functioning, my colleagues and I conducted a systematic review of the past year of articles published in the leading outlet for clinical research trials – the Journal of Consulting and Clinical Psychology. These clinical research trials are used to determine what ends up on the list of research supported psychological treatments. Of the clinical trials published in 2014, 38/67 (57%) of them reported whether people showed a reduction in distressing symptoms without any information on whether people functioned better in everyday life. None of the trials measured whether people showed an improvement in healthy functioning as an outcome without distressing symptom measures. Thus, upon reviewing the leading peer-reviewed journal of clinical trials, we are confident of our assertion that distressing symptoms dominate the outcome literature.

Why does this matter? Because the amount of distress that you experience provides little information on whether you are functioning well. In fact, evidence continues to accumulate that distress can be healthy or irrelevant to your effort and progress toward meaningful life goals and your ability to navigate the shoals of the social world. It depends on the context or situation (see the amazing work of Maya Tamir, Iris Mauss, Amelia Aldao, and others).

We recently published two meta-analyses to provide evidence that it is no longer acceptable to target distress with the assumption that it is a proxy for healthy functioning.

McKnight, P.E., Monfort, S.S., Kashdan, T.B., Blalock, D.V., & Calton, J. (in press). Anxiety symptoms and functional impairment: A systematic review of the correlation between the two measures. Clinical Psychology Review

McKnight, P.E., & Kashdan, T.B. (2009).  The importance of functional impairment to mental health outcomes: A case for reassessing our goals in depression treatment research.  Clinical Psychology Review, 29, 243-259.

In our latest work, we chose to focus on the most prevalent and widely-studied anxiety disorders and their disorder-specific functional impairments. Understanding the impairment profile for those suffering from anxiety symptoms will help us better understand the hurdles that treatment may need to overcome. Furthermore, this understanding may lead to a more complete system for evaluating treatment outcomes. We do not advocate for the elimination of symptoms as a primary outcome for treatment and research. Instead, we wish to emphasize a more complete understanding of anxiety disorders and their downstream consequences. Treatment assessments that focus only on symptom alleviation or only on functional restoration represent an incomplete approach to understanding the troubles experienced by the individual or costs absorbed by the individual and society.

What did we discover in our meta-analysis of 83 articles published between 1988 and early 2014? Regardless of the anxiety disorder, the correlations between symptoms and functioning never exceed 0.50. Thus, by monitoring only symptoms, we lose at least 75% of the variance (r = 0.5; r2 = 0.25 or 25% of common variance) in concurrent functioning.

What are the clinical implications? Although skills taught in typical cognitive behavioral therapy (CBT) and similar models might generalize beyond just symptom reduction, more emphasis ought to be placed on a client’s daily life (i.e., daily functioning). If functional change falls outside of the scope of certain therapeutic models, therapists ought to advocate for simultaneous participation in other activities/groups that focus primarily on improving functioning in these areas. Supplemental activities and skills groups aimed at improving client functioning are important because functional change is not intuitive or easy, particularly for clients who have skill deficits. In addition, it is possible that functional change may help reduce anxiety symptoms - as is the case with behavioral activation and exposure techniques. Other evidence shows that by asking people to accept rather than alter or control their distress, and by asking them to increase their engagement with meaningful life pursuits, anxiety symptoms often increase or fluctuate wildly. This makes sense - by taking part fully in life, you experience the anxiety of confronting the uncertain, unfamiliar, and unsettling. These moments are springboards to the development of strengths, meaningful relationships, and the highest peaks. But think about this. What this means is that a reduction in anxiety after a psychological treatment might be bad! It might mean you are less stressed but failing to live a life where risks are taken, vulnerabilities are shown, difficult goals are pursued, and meaning and purpose exist in abundance.

It is time to appreciate distress. Whether it is good or bad, depends on the context. For this reason, it is a mistake for clinicians to mindlessly assume that reducing distress is an acceptable approach for testing the effectiveness of an intervention. When people are suffering, they might dream of a life free of stress and anxiety, but it is often because they envision what they would be doing without these concerns. Let us begin to directly target these behaviors, goals, and aspirations and move people towards  comprehensive mental health.

**enjoy this Harvard Business Review article- Companies Value Curiosity but Stifle It**

Dr. Todd B. Kashdan is Professor of Psychology and Senior Scientist at the Center for the Advancement of Well-Being at George Mason University. His new book explores the science and practice of how to tolerate, accept, and harness anxiety and stress to be more curious, courageous, and creative, titled: The upside of your dark side: Why being your whole self - not just your “good” self - drives success and fulfillment. More information can be found on his website: