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QUESTION-292: What evidence would show that a maintaining link, and not a regime's content, keeps a disorder in place: does the efficacy of a treatment that targets the link count, or only change in the link that is specific and comes before the outcome?

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StatusAnswered
Version2
Tagspsychopathology-and-treatment, complex-systems, emotion-and-affect
Linewill-organization
RefinesQUESTION-045 — Is a mental disorder that outlasts its trigger a protective lock-in at the individual scale, a regime kept stable by behaviour that blocks its own disconfirmation while the capacity to leave it degrades, and does cutting the maintaining link, with the regime's content held fixed, produce lasting change?
Cited as “answers” byTHEORY-053 — A treatment's efficacy is not evidence for its theory of change: only change in the theorised process that is specific and comes before the outcome bears on it, and moving the process without moving the outcome counts against the theory

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The question

QUESTION-045 asks whether a disorder that outlasts its trigger is a protective lock-in, and what would show that the maintaining link, such as safety behaviour, and not the content of a fearful belief, keeps it in place. A maintaining link is a theory of change. This question asks what evidence bears on such a theory.

The answer

THEORY-053, Active, states the standard, from both wings of CBT (Salkovskis et al. and Hofmann and Hayes):

  • Efficacy does not count. Every theory of change predicts that the treatment it informs works, so a treatment’s working cannot tell a link account from a content account.
  • What counts is change in the theorised process that is specific to it, comes before the outcome, and moves the outcome more than the rival’s process does.
  • The disconfirming case is a treatment that moves the process and leaves the outcome alone. A treatment that fails to move the process has not tested it.

Mediation evidence of this kind is necessary, not sufficient. Whether any disorder meets the standard, and so is a protective lock-in, remains QUESTION-045’s.

The RefraMED monograph, LIT-1838 (NOTE-1421), is a worked case of the answer’s two legs. Its causal mechanism analyses were meant as the evidence THEORY-053 asks for, and they meet neither leg. On specificity, the mediators are sessions attended, alliance and DBT skills, of which alliance and exposure are common factors and not RO DBT’s theorised process; the processes it names are reported only as differences between arms. On precedence, mediator and outcome are both at 7 months, and the planned analyses of temporal order are not reported. It does not count against the theory either: the processes moved, and whether the outcome moved through them was not estimated. THEORY-053 is noted the same day. The answer is unchanged.

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