Abstract:
This article will explore two psychotherapies as applied to family therapy: Family-Centered Therapy (known as Person-Centered Therapy, or Rogerian Therapy), and Gestalt Family Therapy. It will describe the philosophy and goals of the therapies, typical interventions, role of the therapist, and beliefs about family outcomes and change. It will compare and contrast the two psychotherapeutic models, and suggest how I blend these two therapies so they are complimentary.
While a family is a system comprised of individuals, it is the survival of the family unit which may be threatened when a family presents in therapy. Psycho-therapeutics has, in the past, attempted to emphasize the sum (family unit) over its parts (family members). I propose that perceiving the family as a gestalt unto itself is a “collectivist perspective,” while emphasizing the individuals within the group is a decidedly westernized, individualistic perspective. It seems to me that Family-Centered Therapy (Rogerian Therapy, 1951) is more of a collectivist-oriented modality, wherein the family unit’s good will be weighed, along with the individual member’s needs. Conversely, Gestalt Family Therapy seems to be of the individualistic persuasion. The logic seems to be that if the individual is happy, as a result, the group will be happier. I happen to agree with Gestalt Therapy’s emphasis on drawing out the individual’s needs within the family context. Bott (2001) reminds us that, “Families are made up of people. To use the metaphor of saying a family is LIKE a system as a way of conveying the rich interconnectedness of family members is quite different from the dehumanizing process of treating it AS a system.” Before exploring Gestalt Family Therapy further, let’s assess Family-Centered Therapy in more depth.
Person-Centered Therapy can be compared in structure to “embodying the perspective view that the presenting symptom or complaint is a “motor for growth,” and argue that the immediate alleviation of symptoms may be antithetical because it can preclude the opportunity for long-term, holistic healing of the self” (Keeney and Sprenkle, 1992). Rogerian therapists traditionally would not be in a rush for change, as they see the therapy process as a journey of self-actualization rather than a “destination.” In assessing the fitness of Rogerian philosophy for family therapy, Minuchin (1974, p. 123) has stressed the importance of empathy, saying, “The therapist should feel the family members pain at being excluded or scapegoated, and his pleasure at being loved.” Although Rogers advised the use of empathetic response, he did not work with couples or families. “However, it can be argued that the core conditions of unconditional positive regard, empathy and congruence (Rogers, 1951) can be the means to model the manner in which family members might more constructively respond to one another.” Roger’s therapeutic philosophy was decidedly humanistic: “The organism has one basic tendency and striving-to actualize, maintain and enhance the organism” (Rogers, 1951). Treacher (Reimers and Treacher, 1995, p. 200) remind us that, “A family therapist who actively works at believing in the potential of her clients from a basically humanistic point of view, can go a long way to overcome the inevitable dislikes that she may have for certain users.” I also share the belief in the “forward-moving tendency of the human organism” (Rogers, 1951, p. 489), and have experienced that when I display unconditional positive regard, empathetic listening and congruence to clients-what Rogers called the “necessary and sufficient conditions” for client change-“the actualizing potential of the client will be released and the client will begin to change and grow” (Mendor and Rogers, 1984, p. 164). However, can a Rogerian approach solve the real-world problems of today’s families?
Knight (2007) suggests the dilemma in applying the Rogerian model to family therapy is how to respond directively to the family’s needs for answers without interfering with the client’s focus on his inner experience, which Rogers taught was counterproductive. She suggests there are two windows of opportunity when “active problem solving appears most applicable: during initial contact with the client when specific problems are presented, and later in therapy when the client presents specific problems within the context of the ongoing Person-Centered Therapy approach.” In both cases, it is at the client’s specific invitation that an active problem-solving phase is engaged. The therapist encourages the client to brainstorm as many solutions as the client can think of, and then collaboratively, the client and counselor assess the viability of the possible solutions. “In essence, this approach to problem-solving is one in which the client is invited to generate and attend to multiple doors to resolution, or even to have doors presented by the therapist” (Knight, 2000). When clients take an active role in finding solutions to their problems, they may realize they are more capable of managing them than they first imagined. They also build a stronger sense of self-efficacy and self-confidence in active problem-solving. Now we will take a closer look at Gestalt Family Therapy.
Gestalt Family Therapy (GFT) is a structural therapy in that, “The therapist works primarily with the nuclear family, and therapy is aimed toward altering the structure of the interactions between various family members” (Hazelrigg, Cooper and Borduin, 1987). The philosophy of Gestalt Family Therapy is to develop each family member’s awareness of: interactional patterns, and becoming responsible for their own feelings, behavior, and needs. The role of the therapist in GFT is to provide therapeutic techniques and experiments which can stimulate positive change. “The family is an intimate system in which the behaviors of family members are connected in a complimentary way. Connections among members may be functional or dysfunctional, depending on the awareness, needs, and behaviors generated through such family networks” (Lawe and Smith, 1986). Goals of GFT are to enable family members to “represent themselves genuinely, and to accept and respect that they are separate and different from each other” (Lawe and Smith, 1986). Other goals include re-establishing contact between family members, and expression of feelings which were suppressed or denied. In Gestalt Therapy, the therapist works to improve individual family member’s self-awareness, and the awareness of the impact the client is having on the family system. In each family member’s quest to meet his needs, the therapist uses techniques and experiments to assist the members in defining their needs, expressing their needs, and improving intimate contact with other family members (Lawe and Smith, 1986). “A general goal for the therapist is to assist members in removing barriers they use to avoid being intimate” (Zinker, 1981). As is typical of Gestalt Therapy, GFT explores the following themes: (a) What feelings, perceptions and awareness do members have towards the family, each other, and themselves? (b) How do members deny taking responsibility and manipulate one another to get what they want? (c) What do members expect from each other? (d) What unresolved conflicts do members have with each other? Techniques which the Gestalt Family Therapist will use include: having all members of the family interact, requesting the members speak directly to each other, to intervene only when the interaction is at an impasse, identifying the dysfunctional relational patterns, role playing and the Empty Chair technique. How does the family know when therapy has been successful? “The resolution of conflict, anxiety and guilt may be seen as a basic goal of Gestalt Therapy. The more family members can clearly articulate their wants, needs, and expectations, as well as to understand, accept and support each other, the more the family is in harmony and balance…positive outcomes of therapy witness the increase in the family member’s ability to be responsive to the needs of its members. Members profit from therapy when they can forgive each other and let go of the past in order to accept and love each other as they are, and not as they think they “should be” (Lawe and Smith, 1986). Therapy is also seen as successful when members take responsibility for their role in family dysfunction, when conflict is resolved and resentments dissolved, and when each member of the family feels safe to “be themselves” rather than trying to live up to expectations of one another.
Certainly, both of these family therapy approaches have merit.
It is easier to see how the two models contrast rather than compare; differences in the two modalities are stark. The Rogerian humanist model is client-paced and relatively unstructured in format. It allows a wide berth for exploration of member’s feelings and concerns. Conversely, Gestalt is more structured and therapist-driven. Gestalt employs techniques and experiments which are introduced throughout crucial points in therapy, especially in moments when the member has reached an impasse. An apt metaphor might be to describe Family-Centered Therapy as more democratic, in that it takes into account the family as a whole, seeking to teach more equality and tolerance among family members. In contrast, Gestalt Family Therapy allows each member freedom of expression, need fulfillment and individualism. Although both therapies are ultimately focused on the well-being of the family unit, Family-Centered Therapy encourages family members to conceptualize themselves as a collectivist unit, while Gestalt Family Therapy conceptualizes the individuals as being a part of a family, while maintaining separateness.
In comparing these two therapies, “It may be the case that there are effective components and change mechanisms that are common to various types of family therapy” (Gurman et al, 1986). It seems to me the qualities that the Rogerian model lacks (being therapist-driven and introduction of techniques and experiments) Gestalt Therapy offers. And, the qualities that traditional Gestalt Therapy lacks (such as empathy and conformation of the client) Rogerian Therapy offers. I see these two very different therapies as being complimentary. If a Gestalt Family Therapist is willing to incorporate the relational-building principles of Rogerian Therapy, perhaps she will be more efficacious in her task of uniting a divided family. If the Family-Centered Therapist is willing to introduce techniques or an experiment at those moments of impasse when the family is looking to the therapist for direction, then perhaps these two therapies can be modified just enough to meet the demands of modern family therapy. Finally, what does research show about family therapy?
In a meta-analysis of 20 studies by Hazelrigg, Cooper and Borduin (1987), the results showed that family therapy had a positive effect on clients compared with no therapy and alternative treatments. “The family therapy approaches used in the studies included structural, strategic, and behavioral family therapies, and parent training in client-centered Rogerian methods. Because of the lack of complete information about the type of family therapy used, no conclusions can be drawn about differential effects for different types of therapies.” Certainly, more research is needed in order to establish the overall comparative effectiveness of family therapies. I will next briefly apply both models of therapy to the sub-system of Helen’s family in the movie, Parenthood (1989).
A Person-Centered approach would work well for this family who have suppressed and internalized a great deal of anger and resentment towards their absent father, and in the case of the daughter Julie, seems to be projecting that onto their single mother. For the therapist to model empathy, unconditional positive regard and congruency would allow them each the opportunity to express their feelings, while looking to the therapist for a role model in inter-family communication skills. The gentler approach which Rogerian Therapy offers would soothe and sympathize with Helen’s plight, and also draw out her reclusive son. Todd has dropped out of school, and a Person-Centered approach might work well to prompt him to problem-solve both his dilemma of being a new husband and what to do with his future. However, in the case of Julie, Gestalt techniques might provide a powerful intervention for her, since she is at least expressing her true feelings of anger. She lacks self-awareness, as she does not understand the impact her rebellion and decisions have had on the family system. Her feelings of rejection and abandonment could be redirected from her mother to the appropriate place: her absent father. Perhaps she could use the Empty Chair to dialogue with her father, to express how his decision to leave their family to have an affair has impacted her life and their family. Family therapy would “take the heat off” of mother Helen in a number of ways: it would allow her to express the suppressed grief over the affair and divorce, and ask for her children’s support in beginning to date again. It also would allow her to make meaningful contact with her withdrawn son, and to establish healthier communications with Julie. With this volatile family sub-system, I would utilize Family-Centered Therapy initially, and gradually introduce Gestalt Therapy techniques to resolve inter-personal resentments, and draw out from each of the family members what they expect from one another and what their individual needs are. I feel using a combination of these two approaches would be a successful way to direct this fractured family sub-system.
In conclusion, while Family-Centered Therapy and Gestalt Family Therapy have not been considered the mainstay of family therapy models, when utilized together, perhaps they will produce a workable solution for family therapists who are willing to combine the best features of each modality. Therapists who are seeking a humanist, existential philosophical framework from which to build a relationally stable, yet flexible model of family therapy would do well to reconsider how these two “opposing” approaches can work together.
References:
Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications and theory: London, Constable.
Bott, D. (2001). Towards a family-centered therapy. Postmodern developments in family
therapy and the person-centered contribution. Counselling Psychology Quarterly, Vol
14(2), pp. 111-118.
Keeney, B. P., Sprenkle, D. H. (1992). In: The restoration of dialogue: Readings in the
philosophy of clinical psychology. Miller, Ronald B. (Ed.); Washington, DC, US:
American Psychological Association, 1992. pp. 477-495.
Minuchin, S., (1976). Families and Family Therapy. Cambridge, MA: Harvard University Press.
Reimers, S., Treacher, A. (1995). Introducing User-Friendly Family Therapy. London:
Routledge.
Mendor, B.D., Rogers, C.R. (1984). Person-centered therapy. In R.J. Corsin, Current
psychotherapies (3rd ed.). Itasca, IL: F.E. Peacock.
Knight, T.A. (2007). Showing clients the doors. Active problem-solving in person-centered
psychotherapy. Journal of Psychotherapy Integration, Vol 17(1). Special issue: The
Integration of Concrete Operating Procedures. pp. 111-124.
Hazelrigg, M.D., Cooper, H.M., Borduin, C.M. (1987). Evaluating the effectiveness of family
therapies. An integrated review and analysis. Psychological bulletin, 101 (3), pp. 428-
442.
Law, C.F., Smith, E.W. (1986). Gestalt processes and family therapy. Individual
Psychology. Journal of Adlerian Theory, Research & Practice, 42(4), pp. 537-544.
Zinker, J. (1981). Lies in intimate systems. Newsletter, Gestalt Institute of Cleveland, 1,2,1-4.
Gurmin, A.S., Kniskarn, D.P., Pinsof, W.M. (1986). Research on the process and outcome of
marital and family therapy. Insl.
Garfield & A.E. Bergin, Handbook of Psychotherapy
and Behavior Change (pp. 565-624). New York: Wiley.
Sunday, May 27, 2012
Tuesday, May 22, 2012
A View From Behind The Veil by Nina Bingham
Her article offered nothing in the way of trying to explain the gender cast system from a cultural perspective, which is again, typically ethnocentrically American. Psychologically, she sounded “shell shocked” and traumatized by trying to “fit in” when she clearly couldn’t adjust to their way of life. The crucial question Stack is indirectly raising in this article seems to be: if a woman says she is happy, or at least satisfied being dominated and controlled by men, is it still wrong for her?
In America, the rules for gender roles were changed forever in the 1960’s with the sexual revolution, and into the 1970’s with the feminist movement. These two decades revolutionized American women’s lives, giving them the freedom to express themselves sexually, and compete with men academically, and in the workplace. In the short span of two decades American women transitioned from domestic servants in the home to supervising men in the workplace. What women have traded in exchange for increased equality with men is losing the “protector-provider” role which a paternalistic society offers, much as Stack lost the feelings of anonymity which wearing the “abaya” loaned her. In theory, the “abaya” serves to preserve women’s modesty and propriety, and to protect them from prying eyes. It is the Saudi’s way of keeping women “safe.” In a collectivist society such as Saudi Arabia, the sexes have clearly defined and set gender roles to fulfill, so there is little confusion as to what is expected of you. However, anyone who deviates from this mold is shunned or punished, which is what I believe Stack was opposed to. Because she was an “outsider,” she could do little to change the status of women in Saudi Arabia. However, maybe she did. Just maybe a Saudi man read her article, and thought twice about the gender cast system. At the very least, she helped American readers to appreciate American democracy and freedom just a little bit more.
What I learned from her article is that it is nearly impossible to understand and appreciate another culture’s motives. It is easy to pass judgment on other societies without having a thorough understanding of another country’s history and perspectives. Sociology calls this propensity, “fundamental attribution error” (Aronson, Wilson & Akert, 2010); the attributing of motives to the person instead of to the environment. I learned again through her article that we all have cultural biases, and try as we might to assimilate into another culture, the social norms we are taught governs our belief systems and behaviors. Stack could have included more insight into how native Saudi women feel about the “gender cast system” they are born into. One Saudi woman didn't understand why Stack was incensed that women do not have the right to vote by responding, “We have husbands and a father, why would we need to vote?” (Stack, 2007). Stack did a decent job of communicating the role-related injustices that are simply an unquestioned way of life for Saudi women, such as: no driving or voting privileges, and no running for public office. Stack describes Saudi Arabia as having the reputation of a “modern, misunderstood kingdom” (Stack, 2007). However, when she describes the everyday injustices of what amounts to a gender cast system, there seems to be no misunderstanding; she seems to be saying that the oppression is deliberate. And yet, inconceivably, native Saudi females do not find it objectionable. Or if they do, they do not have the freedom to say so because of the cool to hostile reception they would receive.
Stack’s account could have been a cross-cultural lesson for her readers in tolerance and understanding of another culture’s motives, but it was not. Or it could have told us the “inside” story from an Arab woman’s point of view. Instead, Stack seems to be saying that behind her veil were feelings of shame and outrage about being treated like a second class citizen. According to who you ask, the Saudi social morays concerning women can either be considered a method of protection and respect, or a curse. It depends on who is behind the veil.
References:
Stack, Megan K. (2007). In Saudi Arabia, a view from behind the veil. New York Times, June 6, 2007 edition.
Woodward, Gary C., Denton, Robert E., Jr. (2010). Persuasion and influence in American life. Sixth edition, Waveland Press, Inc., Long Grove, Illinois.
Aronson, E., Wilson, T.D., Akert, R.M. (2010). Social Psychology. Seventh edition, Prentice Hall.
Cialdini, R. B. (2009). Influence: Science and practice. Fifth edition, Pearson.
Ecological Systems Theory: Bronfenbrenner’s Theory of Human Development Applied by Nina Bingham
Abstract:
The purpose of this article is to explain Bronfenbrenner’s Ecological Systems Theory.
I will describe in detail the Ecological Systems, Bronfenbrenner’s associated naturalistic
observation, his “person-process-context model,” and parental monitoring. I will apply this
theory by describing and evaluating how the systems have influenced my development, and
analyze how they have influenced my decision to obtain a master’s degree.
In 1977 Developmental Psychologist Urie Bronfenbrenner published, "Toward an experimental ecology of human development", which introduced his Ecological Systems Theory, today regarded as a landmark theory in psychological human development studies. Bronfenbrenner’s theory was a large step away from the phenomenological developmental theories of Erik Erickson and Jean Paiget; Bronfenbrenner dared propose a “broader approach to human development” (Bronfenbrenner, p. 513) wherein not only individual development is considered, but how the individual and the environment interact and influence on another. In 1979 Bronfenbrenner’s "The Ecology of Human Development: Experiments by Nature and Design" was published, where his “ecological theory” of development was presented, readily identified by a diagram of concentric circles of labeled systems, with a toddler pictured in the center. Rather than illustrate development in a linear, sequential form (as did Erickson and Piaget), Bronfenbrenner showed the interdependent systems which surround the child as occurring simultaneously, while having varying levels of influence on the child.
Bronfenbrenner theorized that the microsystem is in frequent contact with the child (family, classroom), while the Macrosystem has the least amount of direct influence (society). This conceptualization of multiple influences upon a child’s development was more complex than previous theories which theorized according to age. “…ecological systems theory is presented as a theory of human development in which everything is seen as interrelated…” (Darling, 2007). Bronfenbrenner called this phenomenon “reciprocal interaction,” the way the individual influences the environment, and reciprocally, the environment influences the individual. Bronfenbrenner’s contextually interrelated theory is interesting because it departs from the one-dimensional view of lifespan development. A student of Bronfenbrenner’s, after reviewing six decades of his work, concluded that it is his emphasis of the interplay between phenomenology and, “...the impossibility of understanding individual developmental processes in isolation” (Darling, 2007) which holds promise for future advancements in developmental psychology. Because Bronfenbrenner analyzed the contributors to development in such a way as to include all systems, rather than explain development one system at a time, his is a “multi-system” system, which doesn’t exclude social influences, but includes them. Bronfenbrenner outlined the systems thus: Microsystems, Mesosystems, Exosystems and Macrosystems. Bronfenbrenner didn’t stop at revising developmental psychology’s approach; he also critiqued the artificial laboratory environment which he called, “…the science of the strange behavior of children in strange situations with strange adults for the briefest possible periods of time” (p. 513). Bronfenbrenner attempted to normalize development research by devising experiments which were naturalistic observation of children, and without biasing, preconceived hypothesis.
Another facet of Ecological Systems Theory is what B. and Cronter (1983) described as a “person-process-context model,” where development was studied as a product of context (environment) and person (gender). In later work, B. and Ceci (1993, 1994) presented bioecological systems theory: explaining what part genetics played in the Ecological Systems model. In 1998, B. and Morris developed the “developmentally instigative characteristics,” a concept which accounted for how personal characteristics can evoke or instigate environmental reactions. However, Bronfenbrenner’s passion was the study of parenting. “Parental monitoring refers to the parent’s efforts to gain knowledge of children’s and adolescents’ behavior” (Darling, 2007). Monitoring was Bronfenbrenner’s discovery; one of the most consistent predictors of both positive child development, and the avoidance of problem behavior. The conclusion of these monitoring studies showed that low SES environments were correlated with negative behavior; as was low parental responsiveness. In the late 1990’s researchers influenced by Bronfenbrenner began to apply his model to understand parenting (Darling, 2007).
In 2000, Stattin and Kerr's critiques of the parental monitoring claims amended Bronfenbrenner’s theory by adding that, “…adolescents control of information, and not parental efforts, drove differences in knowledge.” Bronfenbrenner summed up his vision for the future of developmental psychology in, "Towards a critical social history of developmental psychology: A propaedentic discussion". He said, “I am suggesting a biological-functional criterion for direction in development. I am suggesting further that when this criterion is not met, living systems can fall apart. I have in mind two kinds of systems-the biopsychological system that a human being is, and the socio-economic-political system that an environment is…so I see our field of (developmental psychology) as having reached an important turning point. The issue is whether we will have the resolve and the wisdom to confront the newly discovered complexities of the phenomenon we are committed to study” (1986).
In reply, developmental researcher and colleague Kessen (1983a) replied, “(John) Dewey would be outraged, as Urie (Bronfenbrenner) is outraged, about the present condition of children in the United States, as I am.” Though developmental psychology is a specialty of psychology which is updating its theories as other disciplines evolve, in some ways I feel as if it is a branch of psychology in its infancy. It has progressed rather slowly as compared to other technologically-oriented sciences such as neuroscience and sociology, which means there is much promise for the future, and “room” for breakthroughs in our understanding of the developing human in relation to his environment. Now I’d like to turn the discussion homeward.
I can apply Bronfenbrenner’s Ecological System to my personal development. Using Bronfenbrenner’s Chronogram (a pictorial of his systems), I will work my way inside-out, beginning with describing my Microsystem first. I am the product of a single-parent home, where my mother was an entrepreneur, and my father was an unemployed alcoholic. By observational learning my mother taught me how to care for the household duties and be bold in business. From my father I was conditioned to be afraid and distrustful of men, and to protect my siblings from abuse. My mother insisted we attend church several times a week at least, and from the Christian teachings I learned to have a “personal relationship with Jesus Christ.” I remained a Christian until the age of 33, when I decided to be an enthusiastic agnostic. School was always a happy respite from home for me as a child. We were a low-income family, so my maternal grandparents took a big part in raising us while my mother was at work after my parents divorced at the age of 11. From my Microsystem I learned a strong work ethic, Christian values and family values such as: honesty and respect, thanks to the influence of my grandparents. After the age of 11, my father abandoned my siblings and I, moved to another state and remarried, and had more children. It wasn’t until I was 28, and had his first grandchild that I contacted him with the news.
My Exosystem was confined to the mass media, and cousins who visited every summer. Other than that, our family, due to the trauma we had endured with our father, was a “closed system.” We didn’t try to get to know our neighbors, involve ourselves in community affairs, and had no involvement with social service agencies or friends of the family. Our grandparents took up the “slack” financially so we lived modestly, and the church was our social point of contact. Because my mother owned a local beauty salon, many women in our small resort town knew her, and us, as a result.
My Macrosystem included the culture of Northern California which was blessed with tepid weather and sunshine. I grew up swimming in the river during summers with my cousins, bike riding and playing in the great outdoors. The culture in my neighborhood was strange; a blend of home owners that only visited their small resort homes during the summer, families with children like ours, and Russian homeowners who were old women, whose husbands had passed. Our “hill” was a modest resort neighborhood, so the scenery was naturalistically poetic; the Sonoma Valley boasted rolling hills of grape vineyards and the Russian River where we spent most of our summers frolicking in the then-clean water. In retrospect, it was an amazingly clean and wholesome place to grow up. There was no crime to speak of; I don’t remember ever seeing a patrol car during my entire childhood. Though my natural environment was enviable, my childhood was fraught with physical and emotional abuse by my Bipolar father. Without the mitigating influences of my grandparents and the ideal small town I grew up in, I wouldn’t have fared well psychologically. Even so, I required psychotherapy as an adult to resolve the abuse issues. My psychotherapeutic experience is what kindled my interest in counseling.
My decision to earn a master’s degree in mental health counseling is both the result of my childhood Microsystem experience with my mentally ill father, and my adult Exosystem experience of obtaining mental health counseling. These two systems have influenced my life more than the other systems. An abusive father (Microsystem), and mental health support in the form of therapy (Exosystem) has caused me to devote the remainder of my life to assisting the mentally ill. In conclusion, applying Bronfenbrenner’s Ecological Systems has enabled me to understand how important considering all influences are on personality development and behavior. To ignore important environmental influences is not only short-sighted. Bronfenbrenner’s theory is holistic; it accounts for the individual’s temperament and personality, and his environment, from a multi-systems perspective. His is a complex theory, which why I appreciate it. He was a theorist who didn’t assume to know; he saw development as an ever-changing, ever-evolving puzzle, just as the human mind is, and found the answers to development in a multitude of places.
References:
(1977) Brofenbrenner, Urie. Toward an experimental ecology of human development, American Psychologist, Vol 32 (7), Jul, 1977. pp. 513-531, American Psychological Association.
(1979) Bronfenbrenner, Urie. The Ecology of Human Development: Experiments by Nature and Design, American Psychologist, Vol 32(7), Jul, 1977. pp. 513-531, American Psychological Association.
(2007) Darling, Nancy. Ecological Systems Theory: the Person in the Center of the Circles. Research in Human Development, 4 (3-4), 203-217, Lawrence Erlbaum Associates, Inc.
(1986) Bronfenbrenner, Urie. Towards a critical social history of developmental psychology: A propaedeutic discussion. American Psychologist, Vol 41 (11), Nov 1986. pp. 1218-1230, American Psychological Association. (1983a)
Kessel, F.S. & Siegel, A.W., (Eds.), The child and other cultural interventions (pp. 26-39). New York: Praeger.
In 1977 Developmental Psychologist Urie Bronfenbrenner published, "Toward an experimental ecology of human development", which introduced his Ecological Systems Theory, today regarded as a landmark theory in psychological human development studies. Bronfenbrenner’s theory was a large step away from the phenomenological developmental theories of Erik Erickson and Jean Paiget; Bronfenbrenner dared propose a “broader approach to human development” (Bronfenbrenner, p. 513) wherein not only individual development is considered, but how the individual and the environment interact and influence on another. In 1979 Bronfenbrenner’s "The Ecology of Human Development: Experiments by Nature and Design" was published, where his “ecological theory” of development was presented, readily identified by a diagram of concentric circles of labeled systems, with a toddler pictured in the center. Rather than illustrate development in a linear, sequential form (as did Erickson and Piaget), Bronfenbrenner showed the interdependent systems which surround the child as occurring simultaneously, while having varying levels of influence on the child.
Bronfenbrenner theorized that the microsystem is in frequent contact with the child (family, classroom), while the Macrosystem has the least amount of direct influence (society). This conceptualization of multiple influences upon a child’s development was more complex than previous theories which theorized according to age. “…ecological systems theory is presented as a theory of human development in which everything is seen as interrelated…” (Darling, 2007). Bronfenbrenner called this phenomenon “reciprocal interaction,” the way the individual influences the environment, and reciprocally, the environment influences the individual. Bronfenbrenner’s contextually interrelated theory is interesting because it departs from the one-dimensional view of lifespan development. A student of Bronfenbrenner’s, after reviewing six decades of his work, concluded that it is his emphasis of the interplay between phenomenology and, “...the impossibility of understanding individual developmental processes in isolation” (Darling, 2007) which holds promise for future advancements in developmental psychology. Because Bronfenbrenner analyzed the contributors to development in such a way as to include all systems, rather than explain development one system at a time, his is a “multi-system” system, which doesn’t exclude social influences, but includes them. Bronfenbrenner outlined the systems thus: Microsystems, Mesosystems, Exosystems and Macrosystems. Bronfenbrenner didn’t stop at revising developmental psychology’s approach; he also critiqued the artificial laboratory environment which he called, “…the science of the strange behavior of children in strange situations with strange adults for the briefest possible periods of time” (p. 513). Bronfenbrenner attempted to normalize development research by devising experiments which were naturalistic observation of children, and without biasing, preconceived hypothesis.
Another facet of Ecological Systems Theory is what B. and Cronter (1983) described as a “person-process-context model,” where development was studied as a product of context (environment) and person (gender). In later work, B. and Ceci (1993, 1994) presented bioecological systems theory: explaining what part genetics played in the Ecological Systems model. In 1998, B. and Morris developed the “developmentally instigative characteristics,” a concept which accounted for how personal characteristics can evoke or instigate environmental reactions. However, Bronfenbrenner’s passion was the study of parenting. “Parental monitoring refers to the parent’s efforts to gain knowledge of children’s and adolescents’ behavior” (Darling, 2007). Monitoring was Bronfenbrenner’s discovery; one of the most consistent predictors of both positive child development, and the avoidance of problem behavior. The conclusion of these monitoring studies showed that low SES environments were correlated with negative behavior; as was low parental responsiveness. In the late 1990’s researchers influenced by Bronfenbrenner began to apply his model to understand parenting (Darling, 2007).
In 2000, Stattin and Kerr's critiques of the parental monitoring claims amended Bronfenbrenner’s theory by adding that, “…adolescents control of information, and not parental efforts, drove differences in knowledge.” Bronfenbrenner summed up his vision for the future of developmental psychology in, "Towards a critical social history of developmental psychology: A propaedentic discussion". He said, “I am suggesting a biological-functional criterion for direction in development. I am suggesting further that when this criterion is not met, living systems can fall apart. I have in mind two kinds of systems-the biopsychological system that a human being is, and the socio-economic-political system that an environment is…so I see our field of (developmental psychology) as having reached an important turning point. The issue is whether we will have the resolve and the wisdom to confront the newly discovered complexities of the phenomenon we are committed to study” (1986).
In reply, developmental researcher and colleague Kessen (1983a) replied, “(John) Dewey would be outraged, as Urie (Bronfenbrenner) is outraged, about the present condition of children in the United States, as I am.” Though developmental psychology is a specialty of psychology which is updating its theories as other disciplines evolve, in some ways I feel as if it is a branch of psychology in its infancy. It has progressed rather slowly as compared to other technologically-oriented sciences such as neuroscience and sociology, which means there is much promise for the future, and “room” for breakthroughs in our understanding of the developing human in relation to his environment. Now I’d like to turn the discussion homeward.
I can apply Bronfenbrenner’s Ecological System to my personal development. Using Bronfenbrenner’s Chronogram (a pictorial of his systems), I will work my way inside-out, beginning with describing my Microsystem first. I am the product of a single-parent home, where my mother was an entrepreneur, and my father was an unemployed alcoholic. By observational learning my mother taught me how to care for the household duties and be bold in business. From my father I was conditioned to be afraid and distrustful of men, and to protect my siblings from abuse. My mother insisted we attend church several times a week at least, and from the Christian teachings I learned to have a “personal relationship with Jesus Christ.” I remained a Christian until the age of 33, when I decided to be an enthusiastic agnostic. School was always a happy respite from home for me as a child. We were a low-income family, so my maternal grandparents took a big part in raising us while my mother was at work after my parents divorced at the age of 11. From my Microsystem I learned a strong work ethic, Christian values and family values such as: honesty and respect, thanks to the influence of my grandparents. After the age of 11, my father abandoned my siblings and I, moved to another state and remarried, and had more children. It wasn’t until I was 28, and had his first grandchild that I contacted him with the news.
My Exosystem was confined to the mass media, and cousins who visited every summer. Other than that, our family, due to the trauma we had endured with our father, was a “closed system.” We didn’t try to get to know our neighbors, involve ourselves in community affairs, and had no involvement with social service agencies or friends of the family. Our grandparents took up the “slack” financially so we lived modestly, and the church was our social point of contact. Because my mother owned a local beauty salon, many women in our small resort town knew her, and us, as a result.
My Macrosystem included the culture of Northern California which was blessed with tepid weather and sunshine. I grew up swimming in the river during summers with my cousins, bike riding and playing in the great outdoors. The culture in my neighborhood was strange; a blend of home owners that only visited their small resort homes during the summer, families with children like ours, and Russian homeowners who were old women, whose husbands had passed. Our “hill” was a modest resort neighborhood, so the scenery was naturalistically poetic; the Sonoma Valley boasted rolling hills of grape vineyards and the Russian River where we spent most of our summers frolicking in the then-clean water. In retrospect, it was an amazingly clean and wholesome place to grow up. There was no crime to speak of; I don’t remember ever seeing a patrol car during my entire childhood. Though my natural environment was enviable, my childhood was fraught with physical and emotional abuse by my Bipolar father. Without the mitigating influences of my grandparents and the ideal small town I grew up in, I wouldn’t have fared well psychologically. Even so, I required psychotherapy as an adult to resolve the abuse issues. My psychotherapeutic experience is what kindled my interest in counseling.
My decision to earn a master’s degree in mental health counseling is both the result of my childhood Microsystem experience with my mentally ill father, and my adult Exosystem experience of obtaining mental health counseling. These two systems have influenced my life more than the other systems. An abusive father (Microsystem), and mental health support in the form of therapy (Exosystem) has caused me to devote the remainder of my life to assisting the mentally ill. In conclusion, applying Bronfenbrenner’s Ecological Systems has enabled me to understand how important considering all influences are on personality development and behavior. To ignore important environmental influences is not only short-sighted. Bronfenbrenner’s theory is holistic; it accounts for the individual’s temperament and personality, and his environment, from a multi-systems perspective. His is a complex theory, which why I appreciate it. He was a theorist who didn’t assume to know; he saw development as an ever-changing, ever-evolving puzzle, just as the human mind is, and found the answers to development in a multitude of places.
References:
(1977) Brofenbrenner, Urie. Toward an experimental ecology of human development, American Psychologist, Vol 32 (7), Jul, 1977. pp. 513-531, American Psychological Association.
(1979) Bronfenbrenner, Urie. The Ecology of Human Development: Experiments by Nature and Design, American Psychologist, Vol 32(7), Jul, 1977. pp. 513-531, American Psychological Association.
(2007) Darling, Nancy. Ecological Systems Theory: the Person in the Center of the Circles. Research in Human Development, 4 (3-4), 203-217, Lawrence Erlbaum Associates, Inc.
(1986) Bronfenbrenner, Urie. Towards a critical social history of developmental psychology: A propaedeutic discussion. American Psychologist, Vol 41 (11), Nov 1986. pp. 1218-1230, American Psychological Association. (1983a)
Kessel, F.S. & Siegel, A.W., (Eds.), The child and other cultural interventions (pp. 26-39). New York: Praeger.
Comparison of Assessment Instruments for Eating Disorders by Nina Bingham
Abstract:
This article will compare two assessment instruments designed to measure eating disorders. It will compare: validity and reliability. It will also describe: the purpose of the instruments, cross-cultural validity, scales of measurement, test-retest stability, inter-scorer agreement, and future suggested utility of the instrument. I will evaluate which tool seems to be the stronger of the two.
In comparing the constructs of two instruments designed to measure Eating Disorders, much is to be considered.
Assessing an eating disorder is a complex issue, as the Diagnostic and Statistical Manual (DSM-IV-TR) defines three separate categories of eating disorders: Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified (NOS). The tests I chose to compare are diametrically different. The widely-used and older test, “Eating Disorder Inventory-3” (EDI-3) (Garner, Garfinkle, 1979) is based upon 20 years of research in eating disorders, and is in its third revision. It assesses the eating disorder categories listed in the DSM, except Binge Eating Disorder. However, “The EDI-3 is not designed to arrive at a diagnosis of eating disorder. Instead the emphasis is placed on the measurement of psychological traits relevant to the development and maintenance of such disorders” (Kagee, 1984-2004).
The newer test, “Questionnaire For Eating Disorder Diagnosis” (Q-EDD) (Mintz, O’Halloran, Mulholland, and Schneider, 1997) also operationalizes eating disorder criteria of the DSM, but goes further than the EDI-3, in that it differentiates: (a) between those with and without an eating disorder diagnosis, (b) between symptomatic and asymptomatic individuals, and (c) between anorexia and bulimia diagnosis. The Q-EDD also tested three different groups, and included a supplementary clinical oral interview to arrive at their research conclusions. The EDI-3 can be administered in 20 minutes, has 25 questions, and utilizes a Likert Scale. It can be used with individuals or groups. The symptom checklist is written at a sixth grade level, thus it can easily be scored by the administrator, and even a lay-person, such as a teacher or athletic coach. This makes it an apt screening tool for academic and athletic purposes, wherein the administrator could use the tests results for referral. Again, “The rationale behind the development of the EDI-3 was to test the continuum model of anorexia nervosa, which states that this disorder is the final stage of a continual process beginning with voluntary dieting and progressing to more stringent forms of dieting accompanied by progressive loss of insight” (Kagee, 1984-2004). Although it has high cross-cultural validity (both U.S. and international samples), group normative sample numbers were not divulged, other than describing them as, “moderate-size samples of U.S. and international male and female adults, as well as international male and female adolescents” (Garner, 1984-2004). Overall, its factor analysis validity is poor, other than proving inverse convergent validity for low self-esteem scores of .82 when compared to Rosenberg Self-Esteem Scale (Rosenburg, 1965) on a nonclinical sample of 543 females. Exploratory factor analysis three-factor model accounted for 63% of variance, and 60.8% and 65.6% of variance among different sample groups (Atlas, 1984-2004). Reliability was more impressive, ranging from .90 to .97 across four diagnostic groups and three normative groups (Kagee, 1984-2004). Test-retest stability of scores of 34 females after 1-7 days: “Correlation coefficients ranging from .86 (for Asceticism) to .98 (for Interpersonal Alienation) suggested excellent stability of subscale and composite scores, albeit on a very restricted study sample” (Atlas, 1984-2004). Overall, critics Kagee and Atlas (1984-2004) found the EDD-3 to be disappointing in construct. Future utility of the instrument seems to be for screening purposes only in detection of eating disorders, and their progress on a spectrum.
The second test, “The Questionnaire for Eating Disorder Diagnosis” (Q-EDD) (Garner, 1984-2004) “…represents the first attempt in the field of eating disorders to provide a comprehensive assessment of the widely used methodology of operationalizing the DSM into a questionnaire format” (Mintz, O’Halloran, Mulholland, Schneider, 1997). It is a self-report, 50 questions, and takes 5 to 10 minutes to complete. The group sample was a non-clinical group of 1,400 college women who completed three eating disorder tests: the Q-EDD, revised Bulimia Test (BULIT-R; Thelen, Farmer, Wonderlich, & Smith, 1991), and the Eating Attitudes Test (EAT; Garner & Garfinkel, 1979). In addition, participants completed a structured interview by clinicians. I consider this to be a large sample group, and rigorous construct methodology. On Test 1, “Criterion validity was assessed by an examination of the diagnosis yielded by the Q-EDD and those yielded by clinical interviews, and accuracy rate was 98% and 90%. Incremental validity was examined by comparing the level of agreement between Q-EDD diagnosis and clinical interview diagnosis with the level of agreement between preexisting inventory diagnosis and clinical interview diagnosis” (Mintz, O’Halloran, Mulholland, Schneider, 1997). Incremental accuracy rates were 97% and 94%.
Hence, the Q-EDD and the BULIT-R were roughly equivalent in all aspects except for positive predictive power: the Q-EDD was correct at predicting Bulimia 78% of the time, whereas the BULIT-R was correct 54% of the time. The incremental validity of the Q-EDD in comparison with the EAT was not examined, because there was only one interview-defined anorexic. Test 1 test-retest was delayed for 1-3 months, and scored 64% and 54%. This wider reliability score could be due to waiting a longer period of time before retesting subjects. Inter-scorer agreement was 100%, and fifty randomly selected Q-EDDs were scored by two scorers. On Test 2, 167 college women were tested, and the test instruments were the same (Q-EDD, BULIT-R, and EAT). Convergent validity could not be calculated, as there was only one bulimic. The test-retest was calculated as follows: 94% and 85%; the higher scores would be a result of retesting just 2 weeks later. Inter scorer agreement was 100%, and 50 randomly selected Q-EDDs were scored by two scorers. On Test 3, “The purpose of Study 3 was to assess criterion validity. Study 1 indicated that…the Q-EDD demonstrated good criterion validity; we were thus interested in determining whether this good criterion validity would hold for the clinical sample” (Mintz, O’Halloran, Mulholland, Schneider, 1997). 37 participants were recruited by therapists, and all had been diagnosed with eating disorders. In comparing the diagnosis of clinicians to the Q-EDD, accuracy rates were 78%. The sensitivity and accuracy rates for the differentiation of anorexia from bulimia were 100%, and the false-negative rate was 0%. Based on these three studies, “Strong support was obtained for the psychometric properties of the Q-EDD…convergent validity was demonstrated by significant correspondence between Q-EDD diagnosis and scores on the BULIT-R and the EAT. Test-retest reliabilities found that Q-EDD diagnosis were quite stable over a 2-week period and less stable over a 1 to 3 month period. The 100% inter-scorer agreement indicates that scoring of the Q-EDD can be easily mastered” (Mintz, O’Halloran, Mulholland, Schneider, 1997). In terms of validity, due to the low number of anorexics in Study 1, the Q-EDD and the EAT could not be compared. However, the high level of anorexia diagnosis in Study 3 leads to the conclusion that Q-EDD is a better measure of DSM anorexia than the EAT. The Q-EDD and the BULIT-R performed equally well on measuring bulimia; therefore, clinicians wanting to distinguish bulimics from nonbulimics could use either instrument. Although these conclusions build a strong case for using the Q-EDD, perhaps the most significant psychometric support was the criterion validity of the Q-EDD across both the clinical interview and judgment scores. Accuracy rates were: 98% and 90% in Study 1, 78% and 78% in Study 3. In differentiating anorexia from bulimia, accuracy rate was 100% in Study 3” (Mintz, O’Halloran, Mulholland, Schneider, 1997).
Apparently, the Q-EDD is very effective at differentiating a diagnosis of anorexia from bulimia. Fairburn et al., 1990 and Williamson et al., 1995 wrote, “There is a great need in the eating disorder field for an instrument that can operationalize a full spectrum of eating disorders and make differential diagnosis.” The Q-EDD may be the first questionnaire to achieve that goal. In terms of future clinical utility, “Because the Q-EDD yields both a diagnosis and frequency data for individual behaviors, it can be used to track progress in therapy” (Mintz, O’Halloran, Mulholland, Schneider, 1997). To use a crude analogy, one could compare these two tests instruments as one would compare cars. They are both used for driving. However, the EDI-3 would drive like the trusty family station wagon; a time-tested and dependable ride, less concerned with safety, but roomy and easy to drive. The Q-EDD would drive like a 10-year-younger protégé; designed with safety, speed and utility in mind. If I had to pick from these two cars, I wouldn’t hesitate to choose the Q-EDD, even though it’s a relative “newcomer” to the market of testing instruments. It has greater validity, reliability, test-retest reliability, and inter-rater agreement than the EDI-3. Although the EDI-3 has served its purpose as an assessment tool, it’s time for a newer construct which can accurately distinguish and diagnose eating disorders. Sometimes, new is better.
References:
Garner, D. M., & Garfinkel, P. E. (1979). The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273– 279.
Kagee, A. (1984-2004). Review of the Eating Disorder Inventory-3. Mental Measurements Yearbook and Tests in Print. Accession Number: 17123228.
Mintz, L. B., O'Halloran, M., Mulholland, A. M., & Schneider, P. A. (1997). Questionnaire for Eating Disorder Diagnoses: Reliability and validity of operationalizing DSM—IV criteria into a self-report format. Journal of Counseling Psychology, 44(1), 63-79. doi:10.1037/0022-0167.44.1.63
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press.
Atlas, J. A. (1984-2004). Review of the Eating Disorder Inventory-3. Mental Measurements Yearbook and Tests in Print. Accession Number: 17123228.
Thelen, M. H., Farmer, J., Wonderlich, S., Smith, M. (1991). A revision of the Bulimia Test: The BULIT—R. Psychological Assessment: A Journal of Consulting and Clinical Psychology, Vol 3(1), pp. 119-124. US: American Psychological Association.
Fairburn, C. G., Phil, M., & Beglin, S. J. (1990). Studies of the epidemiology of bulimia nervosa. American Journal of Psychiatry, 147, 401– 408.
Williamson, D. A., Anderson, D., Jackman, L. P., & Jackson, S. R. (1995). Assessment of eating disordered thoughts, feelings, and behaviors. In Allison (Ed.), Handbook of assessment methods for eating behaviors and weight-related problems (pp. 303– 346). Thousand Oaks, CA: Sage.
Assessing an eating disorder is a complex issue, as the Diagnostic and Statistical Manual (DSM-IV-TR) defines three separate categories of eating disorders: Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified (NOS). The tests I chose to compare are diametrically different. The widely-used and older test, “Eating Disorder Inventory-3” (EDI-3) (Garner, Garfinkle, 1979) is based upon 20 years of research in eating disorders, and is in its third revision. It assesses the eating disorder categories listed in the DSM, except Binge Eating Disorder. However, “The EDI-3 is not designed to arrive at a diagnosis of eating disorder. Instead the emphasis is placed on the measurement of psychological traits relevant to the development and maintenance of such disorders” (Kagee, 1984-2004).
The newer test, “Questionnaire For Eating Disorder Diagnosis” (Q-EDD) (Mintz, O’Halloran, Mulholland, and Schneider, 1997) also operationalizes eating disorder criteria of the DSM, but goes further than the EDI-3, in that it differentiates: (a) between those with and without an eating disorder diagnosis, (b) between symptomatic and asymptomatic individuals, and (c) between anorexia and bulimia diagnosis. The Q-EDD also tested three different groups, and included a supplementary clinical oral interview to arrive at their research conclusions. The EDI-3 can be administered in 20 minutes, has 25 questions, and utilizes a Likert Scale. It can be used with individuals or groups. The symptom checklist is written at a sixth grade level, thus it can easily be scored by the administrator, and even a lay-person, such as a teacher or athletic coach. This makes it an apt screening tool for academic and athletic purposes, wherein the administrator could use the tests results for referral. Again, “The rationale behind the development of the EDI-3 was to test the continuum model of anorexia nervosa, which states that this disorder is the final stage of a continual process beginning with voluntary dieting and progressing to more stringent forms of dieting accompanied by progressive loss of insight” (Kagee, 1984-2004). Although it has high cross-cultural validity (both U.S. and international samples), group normative sample numbers were not divulged, other than describing them as, “moderate-size samples of U.S. and international male and female adults, as well as international male and female adolescents” (Garner, 1984-2004). Overall, its factor analysis validity is poor, other than proving inverse convergent validity for low self-esteem scores of .82 when compared to Rosenberg Self-Esteem Scale (Rosenburg, 1965) on a nonclinical sample of 543 females. Exploratory factor analysis three-factor model accounted for 63% of variance, and 60.8% and 65.6% of variance among different sample groups (Atlas, 1984-2004). Reliability was more impressive, ranging from .90 to .97 across four diagnostic groups and three normative groups (Kagee, 1984-2004). Test-retest stability of scores of 34 females after 1-7 days: “Correlation coefficients ranging from .86 (for Asceticism) to .98 (for Interpersonal Alienation) suggested excellent stability of subscale and composite scores, albeit on a very restricted study sample” (Atlas, 1984-2004). Overall, critics Kagee and Atlas (1984-2004) found the EDD-3 to be disappointing in construct. Future utility of the instrument seems to be for screening purposes only in detection of eating disorders, and their progress on a spectrum.
The second test, “The Questionnaire for Eating Disorder Diagnosis” (Q-EDD) (Garner, 1984-2004) “…represents the first attempt in the field of eating disorders to provide a comprehensive assessment of the widely used methodology of operationalizing the DSM into a questionnaire format” (Mintz, O’Halloran, Mulholland, Schneider, 1997). It is a self-report, 50 questions, and takes 5 to 10 minutes to complete. The group sample was a non-clinical group of 1,400 college women who completed three eating disorder tests: the Q-EDD, revised Bulimia Test (BULIT-R; Thelen, Farmer, Wonderlich, & Smith, 1991), and the Eating Attitudes Test (EAT; Garner & Garfinkel, 1979). In addition, participants completed a structured interview by clinicians. I consider this to be a large sample group, and rigorous construct methodology. On Test 1, “Criterion validity was assessed by an examination of the diagnosis yielded by the Q-EDD and those yielded by clinical interviews, and accuracy rate was 98% and 90%. Incremental validity was examined by comparing the level of agreement between Q-EDD diagnosis and clinical interview diagnosis with the level of agreement between preexisting inventory diagnosis and clinical interview diagnosis” (Mintz, O’Halloran, Mulholland, Schneider, 1997). Incremental accuracy rates were 97% and 94%.
Hence, the Q-EDD and the BULIT-R were roughly equivalent in all aspects except for positive predictive power: the Q-EDD was correct at predicting Bulimia 78% of the time, whereas the BULIT-R was correct 54% of the time. The incremental validity of the Q-EDD in comparison with the EAT was not examined, because there was only one interview-defined anorexic. Test 1 test-retest was delayed for 1-3 months, and scored 64% and 54%. This wider reliability score could be due to waiting a longer period of time before retesting subjects. Inter-scorer agreement was 100%, and fifty randomly selected Q-EDDs were scored by two scorers. On Test 2, 167 college women were tested, and the test instruments were the same (Q-EDD, BULIT-R, and EAT). Convergent validity could not be calculated, as there was only one bulimic. The test-retest was calculated as follows: 94% and 85%; the higher scores would be a result of retesting just 2 weeks later. Inter scorer agreement was 100%, and 50 randomly selected Q-EDDs were scored by two scorers. On Test 3, “The purpose of Study 3 was to assess criterion validity. Study 1 indicated that…the Q-EDD demonstrated good criterion validity; we were thus interested in determining whether this good criterion validity would hold for the clinical sample” (Mintz, O’Halloran, Mulholland, Schneider, 1997). 37 participants were recruited by therapists, and all had been diagnosed with eating disorders. In comparing the diagnosis of clinicians to the Q-EDD, accuracy rates were 78%. The sensitivity and accuracy rates for the differentiation of anorexia from bulimia were 100%, and the false-negative rate was 0%. Based on these three studies, “Strong support was obtained for the psychometric properties of the Q-EDD…convergent validity was demonstrated by significant correspondence between Q-EDD diagnosis and scores on the BULIT-R and the EAT. Test-retest reliabilities found that Q-EDD diagnosis were quite stable over a 2-week period and less stable over a 1 to 3 month period. The 100% inter-scorer agreement indicates that scoring of the Q-EDD can be easily mastered” (Mintz, O’Halloran, Mulholland, Schneider, 1997). In terms of validity, due to the low number of anorexics in Study 1, the Q-EDD and the EAT could not be compared. However, the high level of anorexia diagnosis in Study 3 leads to the conclusion that Q-EDD is a better measure of DSM anorexia than the EAT. The Q-EDD and the BULIT-R performed equally well on measuring bulimia; therefore, clinicians wanting to distinguish bulimics from nonbulimics could use either instrument. Although these conclusions build a strong case for using the Q-EDD, perhaps the most significant psychometric support was the criterion validity of the Q-EDD across both the clinical interview and judgment scores. Accuracy rates were: 98% and 90% in Study 1, 78% and 78% in Study 3. In differentiating anorexia from bulimia, accuracy rate was 100% in Study 3” (Mintz, O’Halloran, Mulholland, Schneider, 1997).
Apparently, the Q-EDD is very effective at differentiating a diagnosis of anorexia from bulimia. Fairburn et al., 1990 and Williamson et al., 1995 wrote, “There is a great need in the eating disorder field for an instrument that can operationalize a full spectrum of eating disorders and make differential diagnosis.” The Q-EDD may be the first questionnaire to achieve that goal. In terms of future clinical utility, “Because the Q-EDD yields both a diagnosis and frequency data for individual behaviors, it can be used to track progress in therapy” (Mintz, O’Halloran, Mulholland, Schneider, 1997). To use a crude analogy, one could compare these two tests instruments as one would compare cars. They are both used for driving. However, the EDI-3 would drive like the trusty family station wagon; a time-tested and dependable ride, less concerned with safety, but roomy and easy to drive. The Q-EDD would drive like a 10-year-younger protégé; designed with safety, speed and utility in mind. If I had to pick from these two cars, I wouldn’t hesitate to choose the Q-EDD, even though it’s a relative “newcomer” to the market of testing instruments. It has greater validity, reliability, test-retest reliability, and inter-rater agreement than the EDI-3. Although the EDI-3 has served its purpose as an assessment tool, it’s time for a newer construct which can accurately distinguish and diagnose eating disorders. Sometimes, new is better.
References:
Garner, D. M., & Garfinkel, P. E. (1979). The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273– 279.
Kagee, A. (1984-2004). Review of the Eating Disorder Inventory-3. Mental Measurements Yearbook and Tests in Print. Accession Number: 17123228.
Mintz, L. B., O'Halloran, M., Mulholland, A. M., & Schneider, P. A. (1997). Questionnaire for Eating Disorder Diagnoses: Reliability and validity of operationalizing DSM—IV criteria into a self-report format. Journal of Counseling Psychology, 44(1), 63-79. doi:10.1037/0022-0167.44.1.63
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press.
Atlas, J. A. (1984-2004). Review of the Eating Disorder Inventory-3. Mental Measurements Yearbook and Tests in Print. Accession Number: 17123228.
Thelen, M. H., Farmer, J., Wonderlich, S., Smith, M. (1991). A revision of the Bulimia Test: The BULIT—R. Psychological Assessment: A Journal of Consulting and Clinical Psychology, Vol 3(1), pp. 119-124. US: American Psychological Association.
Fairburn, C. G., Phil, M., & Beglin, S. J. (1990). Studies of the epidemiology of bulimia nervosa. American Journal of Psychiatry, 147, 401– 408.
Williamson, D. A., Anderson, D., Jackman, L. P., & Jackson, S. R. (1995). Assessment of eating disordered thoughts, feelings, and behaviors. In Allison (Ed.), Handbook of assessment methods for eating behaviors and weight-related problems (pp. 303– 346). Thousand Oaks, CA: Sage.
Wednesday, May 16, 2012
12 Steps and 12 Promises by Alchoholics Anonymous
1. We admitted we were powerless over _____________ ---that our lives had become unmanageable.
Promise: We are going to know a new freedom and a new happiness.
2. Came to believe that a Power greater than ourselves could restore us to sanity. Promise: We will not regret the past nor wish to shut the door on it.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him. Promise: We will comprehend the word serenity and we will know peace.
4. Made a fearless and moral inventory of ourselves. Promise: No matter how far down the scale we have gone, we will see how our experience can benefit others.
5. Admitted to God, ourselves, and another human being the exact nature of our wrongs. Promise: That feeling of uselessness and self-pity will disappear.
6. Were entirely ready to have God remove all these defects of character. Promise: We will lose interest in selfish things and gain interest in our fellows.
7. Humbly asked Him to remove our shortcomings. Promise: Self-seeking will slip away.
8. Made a list of all persons we have harmed, and became willing to make amends to them all. Promise: Our whole attitude and outlook upon life will change.
9. Made direct amends to to such people wherever possible, except when to do so would injure them or others. Promise: Fear of people and economic insecurity will leave us.
10. Continued to take personal inventory and when we were wrong promptly admitted it. Promise: We will intuitively know how to handle situations which used to baffle us.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Promise: We will suddenly realize that God is doing for us what we could not do for ourselves.
12. Having had a spiritual awakening as the result of these steps,we tried to carry the message to __________, and to practice these principles in all our affairs.
2. Came to believe that a Power greater than ourselves could restore us to sanity. Promise: We will not regret the past nor wish to shut the door on it.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him. Promise: We will comprehend the word serenity and we will know peace.
4. Made a fearless and moral inventory of ourselves. Promise: No matter how far down the scale we have gone, we will see how our experience can benefit others.
5. Admitted to God, ourselves, and another human being the exact nature of our wrongs. Promise: That feeling of uselessness and self-pity will disappear.
6. Were entirely ready to have God remove all these defects of character. Promise: We will lose interest in selfish things and gain interest in our fellows.
7. Humbly asked Him to remove our shortcomings. Promise: Self-seeking will slip away.
8. Made a list of all persons we have harmed, and became willing to make amends to them all. Promise: Our whole attitude and outlook upon life will change.
9. Made direct amends to to such people wherever possible, except when to do so would injure them or others. Promise: Fear of people and economic insecurity will leave us.
10. Continued to take personal inventory and when we were wrong promptly admitted it. Promise: We will intuitively know how to handle situations which used to baffle us.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Promise: We will suddenly realize that God is doing for us what we could not do for ourselves.
12. Having had a spiritual awakening as the result of these steps,we tried to carry the message to __________, and to practice these principles in all our affairs.
Sunday, May 13, 2012
The Perfection Manifesto-by Nina Bingham
The Perfection Manifesto
If we humans must be perfect, that is, if we continue to hold ourselves (and one another) to a standard of perfection which the fashion, fitness and entertainment industries have perpetuated, we will keep buying their products. It only makes sense. Or, in the case of the fashion industry alone, not "cents," but big dollars: "The United States is home to about 100,000 retail clothing stores, which reap annual revenues of $150 billion annually. This tally results in a per store revenue average of $1.5 million" (Chron.com, 2012).
In a quest for the perfect face, body, and style, we will keep butchering ourselves with plastic surgery, starving ourselves with eating disorders, and relentlessly comparing ourselves and never feeling "good enough." And here's the psychological secret that the corporations know will keep us coming back for more: odds are we will never feel "good enough," because the average consumer has the lingering, uneasy feeling that we don't measure up (thanks to being bombarded by media messages). And besides, there's always a new, improved product to try that holds out the distant hope for us that we may someday, in fact, feel "good enough." More accurately, that we might be seen as at least close to perfect?
I can think of no other perfectionist manifesto so evil except that of the Nazi's ideal of a superior Aryan race. Hitler's mania sprang from the hope that he could create the perfect people, superior to all others in looks and intelligence; they would have blond hair and blue eyes, and be tall in stature. What is so pitifully ironic is Hitler's eyes and hair were brown, so he himself refused to father any children, because not even HE was "good enough!" Yet his tyrannical thirst for perfection to create a master race was the cause for the euthanasia of at least 11 million people (one also encounters the statistics of 11-17 million). And who were these "less than perfect people" that didn't deserve to live? "6 million of these were Jewish. In addition, Hitler targeted homosexuals, political dissidents, most Slavs, Jehovah's Witnesses, Protestant pastors and Catholic priests, black people, the mentally and physically disabled, and others. The figures include the camps as well as the mass graves in the countryside, killings in the street, organized mass shootings (such as Babi Yar, etc.) and basically, any person singled out for their race, religion, political beliefs, or their sexual orientation" (wikianswers.com, 2012). I dare say many of us would have been included in the Nazi's extermination had we lived then, being in the wrong place at the wrong time. Those who didn't measure up to the Nazi's ideal of perfection were judged and condemned. Why do I make this dramatic comparison?
Less than a century later, the world is still caught in the sticky web of striving for perfection. The perfect look, perfect style, perfect mate, perfect job, the perfect life. Because perfection is not attainable, the result is dissatisfaction and unhappiness. Soon afterwards, depression and anxiety set in. Add to this substance abuse. Or worse, the ultimate act of self-hate and hopelessness: the act of suicide or homicide. Are we really so different in our thinking from Hitler's ideal of creating the perfect human, or are we just as susceptible to demanding perfection from ourselves now and the German nation was then?
If we somehow managed to get off this hamster wheel that the money mongers have us consumers on, and accepted reality as it is, maybe we could learn to accept instead of reject. Perhaps we could learn to love instead of hate. Perhaps we could learn to be perfectly imperfect?
References:
Wallace, Maxwell. (2012). Chron.com. Retrieved from: http://smallbusiness.chron.com/much-revenue-average-clothing-company-make-30775.html
wikianswers.com. (2012). How many people were killed in the holocaust? Retrieved from: http://wiki.answers.com/Q/How_many_people_were_killed_in_the_Holocaust
If we humans must be perfect, that is, if we continue to hold ourselves (and one another) to a standard of perfection which the fashion, fitness and entertainment industries have perpetuated, we will keep buying their products. It only makes sense. Or, in the case of the fashion industry alone, not "cents," but big dollars: "The United States is home to about 100,000 retail clothing stores, which reap annual revenues of $150 billion annually. This tally results in a per store revenue average of $1.5 million" (Chron.com, 2012).
In a quest for the perfect face, body, and style, we will keep butchering ourselves with plastic surgery, starving ourselves with eating disorders, and relentlessly comparing ourselves and never feeling "good enough." And here's the psychological secret that the corporations know will keep us coming back for more: odds are we will never feel "good enough," because the average consumer has the lingering, uneasy feeling that we don't measure up (thanks to being bombarded by media messages). And besides, there's always a new, improved product to try that holds out the distant hope for us that we may someday, in fact, feel "good enough." More accurately, that we might be seen as at least close to perfect?
I can think of no other perfectionist manifesto so evil except that of the Nazi's ideal of a superior Aryan race. Hitler's mania sprang from the hope that he could create the perfect people, superior to all others in looks and intelligence; they would have blond hair and blue eyes, and be tall in stature. What is so pitifully ironic is Hitler's eyes and hair were brown, so he himself refused to father any children, because not even HE was "good enough!" Yet his tyrannical thirst for perfection to create a master race was the cause for the euthanasia of at least 11 million people (one also encounters the statistics of 11-17 million). And who were these "less than perfect people" that didn't deserve to live? "6 million of these were Jewish. In addition, Hitler targeted homosexuals, political dissidents, most Slavs, Jehovah's Witnesses, Protestant pastors and Catholic priests, black people, the mentally and physically disabled, and others. The figures include the camps as well as the mass graves in the countryside, killings in the street, organized mass shootings (such as Babi Yar, etc.) and basically, any person singled out for their race, religion, political beliefs, or their sexual orientation" (wikianswers.com, 2012). I dare say many of us would have been included in the Nazi's extermination had we lived then, being in the wrong place at the wrong time. Those who didn't measure up to the Nazi's ideal of perfection were judged and condemned. Why do I make this dramatic comparison?
Less than a century later, the world is still caught in the sticky web of striving for perfection. The perfect look, perfect style, perfect mate, perfect job, the perfect life. Because perfection is not attainable, the result is dissatisfaction and unhappiness. Soon afterwards, depression and anxiety set in. Add to this substance abuse. Or worse, the ultimate act of self-hate and hopelessness: the act of suicide or homicide. Are we really so different in our thinking from Hitler's ideal of creating the perfect human, or are we just as susceptible to demanding perfection from ourselves now and the German nation was then?
If we somehow managed to get off this hamster wheel that the money mongers have us consumers on, and accepted reality as it is, maybe we could learn to accept instead of reject. Perhaps we could learn to love instead of hate. Perhaps we could learn to be perfectly imperfect?
References:
Wallace, Maxwell. (2012). Chron.com. Retrieved from: http://smallbusiness.chron.com/much-revenue-average-clothing-company-make-30775.html
wikianswers.com. (2012). How many people were killed in the holocaust? Retrieved from: http://wiki.answers.com/Q/How_many_people_were_killed_in_the_Holocaust
Sunday, May 6, 2012
Ethical Use of Assessments: Assessing Borderline Personality Disorder by Nina Bingham
Abstract
This article will assess
the interview instrument for diagnosis of Borderline Personality Disorder (BPD)
entitled, “Diagnostic Interview for Borderline Patients (DIB)” (Gunderson, Ludolph, Silk, Lohr & Denny, 1982-1983). I will show that it is both ethical, and a
proven diagnostic instrument to determine BPD traits. It will show that the DIB
has used the DSM-lll as its template to understand BPD, and that only
experienced clinicians can use the DIB effectively, further adding to its
reliability.
Due to the prevalence and controversy of
diagnosis of Borderline Personality Disorder (BPD), I chose to analyze the
“Diagnostic Interview for Borderline Patients (DIB)” (Gunderson,
Ludolph, Silk, Lohr & Cornell, 1982-1983). Of all personality disorders,
there is more controversy over diagnosing Borderline Personality Disorder (BPD)
than any other personality disorder, because, “When compared with research on
other psychiatric disorders, such as depression and anti-social personality
disorder, research on the development of BPD has been strikingly sparse. This
is troubling, given the high rates of mortality associated with the disorder. Currently, the developmental trajectories that
lead to BPD in adulthood remain unclear” (Crowell, Beauchaine, Linehan, 2009). While
still an etiological puzzle to researchers, “Data suggests that BPD affects
from 1.2% to almost 6% of the general population, and approximately 10% of
these seek outpatient services, and as many as 20% undergo inpatient treatment”
(Grant et al., 2008; Leib, Zanarini, Schmahl, Linehan & Bohus, 2004). Also,
clinicians may be misdiagnosing BPD: “CBT clinicians were more likely to
diagnose PTSD than BPD or other disorders, and psychodynamic clinicians were
more likely to diagnose BPD or other disorders than PTSD” (Woodward, Halley,
Taft, Gordon and Meis, 2009). “The importance of training in personality
disorders for clinicians is evidenced by epidemiological data, which indicate
that personality disorders have a high lifetime prevalence ranging between 10%
and 14% in the community” (Skodol et al., 2002). “These findings strongly
suggest at least two evidence-based principles. The first is given the
prevalence of personality disorders, all clinicians need to develop specific
expertise in at least identifying and diagnosing patients with these disorders.
Second, given that personality disorders are so frequently comorbid with a
range of Axis 1 disorders, it is incumbent upon the clinician to assess for
personality disorders because it would likely affect the course and treatment
of the disorder. Failing to do so could be considered derelict” (Levy, 2010). In
summary, “…clinicians everywhere have sought ways to psychometrically apprehend
this elusive patient” (Peterson, 1982-1983).
As a clinician in private practice,
utilizing an empirically sound assessment tool to diagnose BPD is important,
because once a client has been assigned the BPD “label” (diagnosis), it will
shape their treatment trajectory within the mental healthcare system, follow
them interminably in their medical records, and influence how other medical
professionals approach and relate to them. It behooves the private
practitioner, therefore, to be cautious, and as empirically sound as possible before
assigning the BPD diagnosis to a client. It is both part of her ethical nomenclature
as a medical professional to “do no harm” (Lasagna, 1964) and her ethical
obligation to assess her own boundaries of competence: “Counselors practice only within the boundaries of their
competence…Counselors gain knowledge, personal awareness, sensitivity,
and skills pertinent to working with a diverse client population” (American
Counseling Association, 2005, C.2.a.,
Boundaries of Competence).
In meeting these ethical
criteria, The Diagnostic Interview for Borderline Patients (DIB) calls for a
clinical degree of skill: “The items vary in depth of influence and degree of
clinical judgment, but, in the main, call for a high degree of clinical skill
and favor a psychodynamic orientation” (Peterson, 1982-1983). In my opinion,
inexperienced clinicians should not be diagnosing BPD, as it is a clinically
complicated diagnosis, and a controversial designation. The DIB prohibits a
“hasty” clinical assessment, and therefore, is ethically sounder than other
less structured, less clinical instruments would be.
In regards to test structure
and reliability, the DIB is a complex, yet
semi-structured interview as a rating scale, to confirm or deny the presence of
borderline symptoms. It is considered “semi-structured” because, “The
interviewers are given considerable leeway on how to conduct the interview and
are encouraged to probe as needed. No suggestion is made as to who should use
this test, and whether it is suited for research or clinical practice”
(Peterson, 1982-1983). It is considered
complex in structure because five sections of the instrument provide estimates
of, “Social Adaptation, Impulse Action Patterns, Affects, Psychosis, and
Interpersonal Relations” (Deysach, 1982-1983). Also, twenty-nine statements
indicative of BPD “…are rated on a three point scale reflecting presence or
absence of symptoms…” (Peterson, 1982-1983). The DIB has a high cut-off score (7 or higher
out of 10 points) that identifies BPD. Higher cut-off scores can distinguish
BPD symptoms from other clinical syndromes. The DIB can be administered in 50
to 90 minutes using an interview format. Descriptors help stabilize ratings of
the five diagnostic clusters, and scoring Guidelines offer explicit criteria. Yet,
“the complexity of the scale…renders it difficult for use by the inexperienced
examiner” (Deysach, 1982-1983). Other
measures of test reliability show that while reliability on DIB total scores
range from mid-80s to low 90%, Test-retest reliabilities have ranged from .47
to .64. “Overall, while reliabilities are generally of the order to warrant
continued use of the DIB, cautiousness regarding the reliability would seem to
be in order if the instrument were used to make individual treatment decisions”
(Deysach, 1982-1983). However, “It has been reported in the literature that the
DIB is useful in generating diagnostic judgments of BPD compatible to those
based upon the criteria presented in DSM-lll” (Deysach, 1982-1983). So
DSM-friendly is the DIB that Deysach (1982-1983) suggests using it as a
training tool to attempt to differentiate borderline behavioral patterns:
“…reliable and valid use of the DIB depends upon variables such as examiner
experience…it is for the clinician-in-training that the DIB may be of greatest
value.” Peterson (1982-1983) similarly comments, “ The several validity studies
does suggest the DIB does distinguish BPD from Schizophrenia and other
psychoses as well as from other personality disorders…the DIB does correlate
significantly with the DSM-lll.” However, before the reader concludes that the
DIB is free of criticism, Peterson (1982-1983) takes issue with the
instrument’s “absence of scaling algorithm that equally weighs items or
scales…the too simple advocacy of one cutting score…the absence of an adequate
test manual.”
Overall, I found
that The Diagnostic Interview for Borderline Patients (DIB)” (Gunderson, Ludolph, Silk, Lohr & Denny, 1982-1983) is a
valid and reliable interview for the assessment and diagnosis of BPD because it
utilizes the DSM-lll diagnostic criteria, which requires clinical experience to
interpret. It allows for a semi-structured interview with the patient, which
builds rapport between client and clinician, and can be administered in an hour
to 90 minutes. It is high in validity and reliability (although its test-retest
scores were mid-range). Most importantly, the DIB is an ethically sound test,
as it requires the clinician to be skilled in the language of diagnostics in
order to administer the test. Overall, The Diagnostic Interview for Borderline
Patients (DIB) is a clinical interview I would feel confident about using in my
private practice to assess and diagnosis Borderline Personality Disorder.
References:
Gunderson,
John G., Ludolph, Pamela S., Silk, Kenneth R., Lohr, Naomi E., Cornell, Dewey
G. (1982-1983). Diagnostic Interview for Borderline Patients. Mental
Measurements Yearbook and Tests in Print. Yearbook: 10. Accession Number:
10120015.
Crowell, Shiela E., Beauchaine,
Theodore P., Marsha M. Linehan. (2009). A biosocial developmental model of
borderline personality: Elaborating and extending linehan’s theory.
Psychological bulletin, Vol. 135 (3), p. 495-510.
Grant et al., (2008); Leib, Zanarini, Schmahl, Linehan
& Bohus, (2004). Grant, B. F., Chou, P.,
Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T.
D., et al. ( 2008). Prevalence, correlates,
disability, and comorbidity of DSM–IV borderline
personality disorder: Results from the Wave
2 National Epidemiologic Surveys on Alcohol and Related
Conditions. Journal of Clinical
Psychiatry, 69, 533– 545.
Woodward, Halley E.,
Taft, Casey T., Gordon, Richard A., and Meis, Laura A. (2009). Psychological
trauma. Theory, Research, Practice, and Policy, Vol. 1 (4), p. 282-290.
Skodol, A. E., Gunderson, J. G., McGlashan, T. H.,
Dyck, I. R., Stout, R. L., Bender, D. S.,
Grilo, C. M., et al. (2002). Functional impairment in
patients with schizotypal, borderline,
avoidant, or obsessive-compulsive personality disorder.
American Journal of Psychiatry, 159,
276–283.
Levy, Kenneth, N. (2010). Practice at the border: The
art of integrating the science on
personality disorders for clinical practice. Professional
Psychology: Research and Practice, Vol.
41 (1), p. 68-71.
Peterson, Charles, A. (1982-1983). Review of the
diagnostic interview for borderline patients.
Mental Measurements Yearbook 1982-1983. American
Psychological Association.
Lasagna,
Louis. (1964). "The
Hippocratic Oath: Modern Version".
Doctors' Diaries. WGBH Educational Foundation. Retrieved 04-29-12.
American Counseling
Association Governing Counsel. (2005). Code of ethics: C.2.a., boundaries of competence. American
Counseling Association.
Deysach, Robert E. (1982-1983). Diagnostic Interview
for borderline patients. Mental
Measurements Yearbook 1982-1983. American Psychological
Association.
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