Because of skyrocketing prescriptions to youth, we were pleased to see the APA Monitor reporting on the APA Working Group on Psychotropic Medications for Children and Adolescents (Medicate or not? Meyers, 2006 Nov., 24-25)). After reading the article, however, we were disheartened, and our baloney sniffers activated, to discover that there was no mention of the main conclusion and recommendation of the Working Group: "For most of the disorders reviewed herein, there are psychosocial treatments that are solidly grounded in empirical support as stand-alone treatments. Moreover, the preponderance of available evidence indicates that psychosocial treatments are safer than psychoactive medications. Thus, it is our recommendation that in most cases, psychosocial interventions be considered first"(p. 174, emphasis added).

Also, there are several inaccuracies in the article summary of the task force regarding ADHD.  The task force did not recommend combined treatments for ADHD.  It actually recommended a choice of each treatment alone or in combination in the short run but concluded that behavioral treatment had the best risk benefit ratio. The task force also concluded that the risk benefit ratio of combined treatments was better compared to medication alone because lower doses were needed. And finally, the task force concluded that the risk benefit ratio of medication was not favorable in the longer run because beneficial effects appear to dissipate while adverse effects (e.g., growth suppression) do not.

It is confusing that a story about an important APA task force would have such glaring omissions and inaccuracies in an APA publication. One is left to wonder why? Call us cynical, but we couldn’t help but wonder whether psychology’s pursuit of prescription privileges (and total assimilation into the medical Borg) was at least partially responsible. We wrote a letter to the editor highlighting the omissions and inaccuracies, but it was not published. Go figure!

Scott and Barry—you have been gallivanting around the globe asserting that therapists should monitor outcome with clients because early change is a robust predictor of ultimate change, but new research shows that early change does not necessarily predict later change. In fact, Lambert’s recent research suggests that the more and faster a client deteriorates in the first two weeks of therapy, the faster the client will improve in the further course of therapy. People are saying that the old adage that things have to get worse before they get better is really true after all.

Yes, Lambert's article "What is the predictive value of responses to psychotherapy for its future course?" published in May, 2006 in Psychotherapy Research does report data which suggest that early progress in therapy is not necessarily a good predictor of overall progress in therapy—for that relatively small portion of clients who stay in therapy and do not drop out despite poor results.This is a big qualifier that is often left out of descriptions of this study.  The study only speaks to a minority of clients and is not characteristic of most clients.

Furthermore, like most research articles, you gotta read 'em to see if what is being touted as findings are actually in the study or are no more than wishful thinking supporting someone’s ideological beliefs (and we don’t mean Lambert, but rather those who seem to have a religious zeal to undermine the predictive value of early change). First, the most glaring aspect that undermines any generalization from this study to typical outpatient settings is that, of three separate data sets and analyses, the first two were inpatient samples! Therefore, the first two samples were a totally captive audience, a luxury that outpatient settings do not have—so the dropout issue, the biggest critique of this type of prediction, was sidestepped altogether (recall that drop out rates in the US exceed 47%). The prediction of a positive outcome from earlier deterioration or a lack of change is based on the notion that if you get people to stay in treatment, even if they are not doing well, they may eventually do well (this is often called the Random Walk phenomenon). This is likely true but we know that that almost half will drop out, which of course, an inpatient sample cannot reflect.    

Another confound is the whole hospitalization experience. Was the initial deterioration due to the addition of medication and/or adjustment to being hospitalized, and therefore an artifact of such settings? Who knows? 

The third analysis, the only outpatient sample, really tells the tale and accurately depicts the issues at hand.  Of 1012 clients, only 260 fit the criteria set for analysis. Even though the average number of sessions in this setting was 3, they set the criteria for the study as those clients who completed at least 5 sessions and remained over the clinical cutoff (over the cutoff means a clinical population on the measure used in the study). So these were people who were not changing but were willing to hang out more than 4 sessions—a skewed group to be sure and one not representative of the majority of those who sought outpatient treatment at this setting or those that seek treatment elsewhere. The overwhelming majority of clients will not hang on like this 25% group, and even those will drop out at nearly a 50% rate thereafter. This small group will ultimately fit the pattern of the random walk where some will improve despite early deterioration or no change. However, the majority of clients will fit the robust finding that early change predicts ultimate change, especially when drop outs are considered.