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6/11/14 A Generic Model of Psychotherapy Before discussing Process Variables, will skip to bottom of Generic Model and focus on Outcome “Process Variables” A Generic Model of Psychotherapy Outcome Variables • What are you interested in with regard to the outcome of psychotherapy? • What is the purpose of psychotherapy? • What is it that you are trying to change in your patients? • How will you measure it? • Do you rate it? • Can you trust the patient to rate it? • Should you get an observer to rate it? 1 6/11/14 Psychotherapy Outcomes • What is the outcome desired in psychotherapy? • May vary by input variables • Societal context: Family, Employer • Patients vary in terms of desired outcome • Psychotherapists vary in terms of desired outcome • May vary by interest in process variables • May want a measure that reflects the effect of the alliance • May want a measure that reflects particular treatment • E.g., cognitive change • E.g., ability to relate to others Psychotherapy Outcomes • Examples of outcome research questions • Does psychotherapy lead to improvement? • Does it ever harm? • How quickly does change occur? • Does change endure? 2 6/11/14 Psychotherapy Outcomes (cont.) • Measuring outcome is fundamental issue • Need reliable and valid measurements • Reliability is a necessary condition for validity • (Reliability does not guarantee validity, but you cannot measure something with validity unless your measurement is reliable.) Psychotherapy Outcomes (cont.) Reliability (cont.) • The most common concern about reliability is inter-item reliability or internal consistency • Is a requirement for test-retest and inter-rater reliability • Means the items are measuring the same concept 1. Are you depressed lately? 2. Are you feeling sad a lot? 3. Has your sleep been bad? 4. Is your self-esteem bad? 5. Are you drinking too much? 3 6/11/14 Psychotherapy Outcomes (cont.) Reliability (cont.) • Internal consistency usually measured using “Cronbach’s alpha” • Developed by Lee Cronbach • Want an adequate value of alpha to be sure that the items are measuring the same underlying construct Psychotherapy Outcomes (cont.) Reliability • A reliable measure will yield the same results (assuming the conditions have not changed) regardless of: • When administered • Called test-retest reliability • For example, a depressed patient gets same score on measure from one week to the next 4 6/11/14 Psychotherapy Outcomes (cont.) Reliability (cont.) • Test-retest reliability: • Imagine an IQ score changing from year to year • Intelligence is supposedly a fixed (permanent) characteristic of a person • We would question the measure’s reliability Psychotherapy Outcomes (cont.) Reliability (cont.) • Test-retest reliability: • Imagine if a measure of depression changed a lot even though the patient (or group) was not getting better (or worse) 5 6/11/14 Psychotherapy Outcomes (cont.) Reliability (cont.) • A reliable measure will yield the same results (assuming the conditions have not changed) regardless of: • Who administered it • Called inter-rater reliability • For example, a depressed patient gets same score on measure regardless of person who gives and takes back (e.g., the assistant) • Rater may need to be trained in administration (see “standardization”) • Measures differ a great deal with regard to how much training the administrator requires • For example, psychologists are trained in the IQ tests Psychotherapy Outcomes (cont.) Reliability (cont.) • Getting reliable results also depends on standardization of administration of measures (including training) • Given/Taken the same way each time • For example: • always administered by the assistant • always taken before session • Need to ensure standardization • Can measure success of standardization 6 6/11/14 Psychotherapy Outcomes (cont.) • Summary: Issues in choosing a measure (what, who, when, where, how) • Does it have internal consistency? • Does the measure have test-retest reliability? • Is there good inter-rater reliability? (Often means, “Is administration standardized? Was there training? [If no training] Is it relatively simple to administer?”) • Who administers the measure? • When is it completed? • Where is it completed? • How is it completed? Psychotherapy Outcomes (cont.) • Most studies use paper-pencil, self-report measures • What: Tend to be specific to study (e.g., depression, PTSD, drinking behavior) • Who: Often completed by patients • When: Completed at multiple time points; usually just prior to or just after session • Where: Completed at clinic or research office • How: Given by research assistant; done anonymously • Why not given by clinician? 7 6/11/14 Psychotherapy Outcomes (cont.) Psychotherapy Outcomes (cont.) 8 6/11/14 Psychotherapy Outcomes Questions? Outcome Measurement in Psychotherapy Studies • Researchers have distinguished “statistical significance” and “clinical significance” • Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12-19. 9 6/11/14 Outcome Measurement in Psychotherapy Studies (cont.) • Statistical significance has long been the “norm” • The difference between the mean score of the treatment group and the mean score of the control group is larger than would be expected to occur by chance • Compares groups • Clinical Significance • The practical value of the effect of an intervention to the individual clients • Does it make a “real” difference? Outcome Measurement in Psychotherapy Studies (cont.) • Statistical significance question: Is change score on a certain measure different between the two groups? • For example, we do a study of treatment of depression • Family-focused therapy: • 32 patients • Pre-treatment scores M = 32; Post-treatment scores M = 18 (difference = 14) • Pharmacotherapy: • 34 patients • Pre-treatment scores M = 35; Post-treatment scores M = 26 (difference = 9) 10 6/11/14 Outcome Measurement in Psychotherapy Studies (cont.) • Clinical Significance evaluates each patient individually • Tries to answer question: How many patients experienced “meaningful change” due to the treatment? • Defines “meaningful change” as moving from the dysfunctional population to the functional population Outcome Measurement in Psychotherapy Studies (cont.) • Clinical significance (study of treatment of depression) • Family-focused therapy: • 32 patients: 18 (56%) “Improved” but did not cross into “normal”, 12 (38%) improved and moved to “normal” (“Recovered”) • Pharmacotherapy: • 34 patients: 10 (29%) moved to “normal”, 15 improved (44%) 11 6/11/14 Clinical vs Statistical Significance Questions? Seminal Studies in Psychotherapy Outcome • Meta analytic studies • Dose-effect model • Phases of change model 12 6/11/14 Meta Analyses • Meta-analysis involves the use of statistical techniques to combine results from multiple studies to establish general trends and consistencies in results across studies • Meta-analyses are extremely important in the provision of EBPP Patient Clinician • Are a summary of the “best available evidence” Evidence Meta Analyses: Does Psychotherapy Work? • Eysenck (1952) • Concluded psychotherapy does not work • “Spontaneous improvement” of untreated persons not significantly different than improvement due to therapy • Launched a great deal of psychotherapy research • Smith & Glass (1977) • Meta-analysis of 475 studies • Average effect size of 0.85 • Average treated person better than 80% of untreated 13 6/11/14 Meta Analyses: Does Psychotherapy Work? • Lambert (2004) Bergin & Garfield’s Handbook of Psychotherapy & Behavior Change. Conducted a meta analysis of meta analyses. Does Psychotherapy Work? • Psychotherapy is, without question, the most frequently, intensively and widely studied health care in the history of mankind. • There is a plethora of evidence that it does work. • Quickly • Better than medications for most problems (except psychosis, bipolar disorder, and severe depression) • Change endures 14 6/11/14 Meta Analyses Overall Questions? Dose-Effect Model of Psychotherapy Outcome • Howard, Kopta, Krause & Orlinsky. (1986). American Psychologist. • Conducted meta analysis of multiple effectiveness studies • Dependent variable = percentage of patients “improved” • Independent variable = # sessions 15 6/11/14 Dose-Effect Curve By session 8, half of patients had improved Phase Model of Psychotherapy Outcome • Howard et al. (1993). Journal of Consulting and Clinical Psychology. • Tracked three measures over time • Subjective Distress • Symptoms • (e.g., anxiety, depression, drinking, delusions) • Life Functioning • (e.g., self-care, relationships, occupation) 16 6/11/14 Phase Model of Psychotherapy Outcome (cont.) Phase Model of Psychotherapy Outcome (cont.) • In first phase, “Subjective Distress” decreases • Patients grow more hopeful • Experience immediate relief • In next phase, Symptoms improve • Patients become less depressed, anxious, etc. • Experience immediate relief • In last phase, Life Functioning improves • Patients able to do better in life roles, as romantic partner, as employee/student, as parent, etc. Patients expect better, feel better, do better 17 6/11/14 Dose-Effect and Phase Models Questions? Outline of Presentation • Define psychotherapy • Inputs, Processes, Outcomes • Contextualize psychotherapy research within Evidence-Based Medicine (EBM) • Review basics of scientific inquiry • Reliability, Validity, Measurement, Control • Review primary methods of studying psychotherapy • Naturalistic studies • RCTs (experiments) • (Single case studies) • How to apply in practice (“How to practice EBPP”) 18 6/11/14 A Generic Model of Psychotherapy Process variables are among the most commonly researched • The contract and the interventions can be controlled (efficacy) • The alliance tends to need to be measured (effectiveness) “Process Variables” } A Generic Model of Psychotherapy • Starting with the therapeutic alliance 19 6/11/14 The Therapeutic Alliance In all treatment models, a good therapeutic alliance is considered a necessary condition for patients to engage in the difficult work of therapy • The “alliance” concept in research = the participants are “confident in and committed to the process” • The Therapeutic Alliance in Psychotherapy Research • Therapeutic Alliance has three parts (Bordin) • Emotional bond • Empathic understanding • Sense of genuineness and commitment • Unconditional warmth and acceptance • Agreement on goals • What do they want to achieve? • Agreement on tasks • How will it be achieved? 20 6/11/14 The Therapeutic Alliance in Psychotherapy Research (cont.) • Most common measure developed by Horvath and colleagues • The “Working Alliance Inventory” 21 6/11/14 Process Variables - - Alliance • Zuroff & Blatt (2006). Journal of Consulting and Clinical Psychology • Research Question (Societal Context): Does therapeutic • • • • alliance predict outcome? Patients: 250 persons with severe depression; 11 never started treatment; 191 finished treatment Therapists: Multiple sites; multiple therapists Contract: 16 sessions planned Treatments: Four treatments compared (IPT, CBT, drug, placebo) Process Variables - - Alliance (cont.) • Design: Randomized clinical trial (RCT) • Process measure (Therapeutic Alliance) • The Barrett-Lennard Relationship Inventory (1962) • Patient’s perception of therapist accurate empathy, unconditional positive regard, and genuineness • Not manipulated; only measured • Outcome • Measured (a) depression (Beck Depression Inventory) and Social Adjustment Scale • Results showed that a more positive therapeutic relationship early in treatment predicted more rapid improvement 22 6/11/14 Therapeutic Alliance • Often studied within studies of an intervention • Alliance difficult to manipulate • Would potentially be unethical • Many, many, many studies of the alliance • More associated with outcome than diagnosis • More associated with outcome than technique • Poor alliance predicts client dropout • Lambert meta-analysis (2001) Therapeutic Alliance • Process factor • Often studied within studies of an intervention • That is, studied “naturalistically” within an RCT • Alliance difficult to manipulate • Would potentially be unethical 23 6/11/14 Therapeutic Alliance – Research Summary • Many, many, many studies of the alliance • More associated with outcome than diagnosis • More associated with outcome than technique • Poor alliance predicts client dropout • Lambert meta-analysis (2001) Therapeutic Alliance – Research Summary • Lambert meta-analysis (2001) 24 6/11/14 Therapeutic Alliance – A Common Factor • Effectiveness of all treatments due in part to factors common to all treatments • Hope • Expectancy • Therapeutic alliance A Generic Model of Psychotherapy 25 6/11/14 Psychotherapy Contract • The agreement between the patient and therapist regarding the practical and legal aspects of the provision of psychotherapy services • Who, what, when, how often, why, how, how paid • Is there a professional relationship at all? When is it established? • What does the contract obligate the provider to “do”? • Who is involved? Individual/Couple/Family • Who gets to know? (Parents, Legal system, Employer) • When does therapy happen? How often? • How to cancel? • Who pays? The Psychotherapy “Contract” in Treatment Research • In psychotherapy research, the “contract” comprises the specifics of the therapy offered • Model of treatment (CBT, IPT, psychodynamic) • How therapy is monitored • How long therapy will endure 26 6/11/14 The Psychotherapy “Contract” in Treatment Research (cont.) • In efficacy studies (R.C.T.’s), experimental control is paramount concern • Therefore, the contract is highly specified • Type of treatment, duration, frequency • In effectiveness studies, contract is allowed to occur naturally • In either type of study, important to measure what actually happened • For example, McRae et al. (insomnia study) was planned for 6 sessions, but it reported on number of patients that finished at least 3 A Generic Model of Psychotherapy 27 6/11/14 Interventions • Psychoanalysis • Psychodynamic therapy • Cognitive therapy • Behavioral therapy • Cognitive-behavior therapy • Acceptance and Commitment Therapy • Interpersonal therapy (IPT) • Emotion-focused therapy • Behavioral marital therapy • And so forth …. Intervention Research Questions • Does treatment X work better than nothing? • Does treatment X work better than treatment Y? • What components of the treatment lead to positive therapeutic change? • What are the “active components” of treatment? • Insight? Cognitive change? Acceptance? • Can the effects of treatment be enhanced? • Can the effects of treatment be made to last? 28 6/11/14 Methods for Studying Interventions • Naturalistic studies • Study interventions as conducted in real world • High external validity • Effectiveness studies • Experimental studies (i.e., RCTs) • Study interventions in controlled settings (i.e., labs) • High internal validity • Efficacy studies Psychotherapy Research Strategies • Naturalistic studies • Non-random assignment; patients and therapists (especially) choose what treatment to conduct • May be several conditions, but no random assignment • “Naturally-occurring” psychotherapy However, cannot be certain what was actually done 29 6/11/14 Experimental Studies (RCTs) • Investigator completely controls treatment • Type, amount, duration • Who receives what (randomization) • Regarded as the most scientifically vigorous study design • Can confidently attribute effect to the treatment RCTs – Overview 1. Inclusion and Exclusion Criteria 2. Baseline, termination and follow-up measurements 3. Random assignment 4. Treatment condition (“standardized”) 5. Control or comparison condition (also “standardized”) 6. Statistical comparison 30 6/11/14 RCT Basics Inclusion Criteria Many persons Sample apply to be in study Exclusion Criteria Baseline Assessment (Week 1) Post-treatment Assessment (Week 16) Follow-up Assessment (Week 40) 1. Inclusion and Exclusion Criteria • Inclusion criteria = Requirements of persons to be study participants • e.g., depressed, literate (able to complete questionnaires) • Want persons that enter study to be somewhat similar • Exclusion criteria = Qualities of persons that would disqualify them from study • e.g., suicidal, psychotic, low IQ, unstable living situation • Try to exclude persons at high risk of not completing study 31 6/11/14 2. Measurements • Measure characteristics that might be related to treatment outcome • Demographic information (gender, age, etc.) • Measurements of problems related to disorder • e.g., severity of depression • other measures (e.g., life functioning) • Done at numerous time points to compare change • Baseline, mid-treatment, post-treatment • Follow-up measurements have proven very important 3. Random Assignment • Randomize to conditions • Treatment vs. No Treatment (or Wait List) • Treatment A vs. Treatment B vs. Treatment C • Usually “Treatment of Interest” vs. “Control Condition” 100 depressed persons that meet study criteria Random Assignment Treatment of Interest 50 receive CBT (16 weeks) Control Condition 50 placed on “wait list” (will get treatment after 6 week wait) 32 6/11/14 3. Random Assignment (cont.) • What if we allowed persons to choose? • What if we assigned all males to Treatment A and all females to Treatment B? • What about “severely depressed to Meds Condition and less depressed to Psychotherapy Condition”? 3. Random Assignment (cont.) • Randomization maximizes likelihood that the two groups will be comparable • Random assignment controls for nuisance variables (e.g., choice, severity of illness) that might otherwise affect outcome • Groups should be equally depressed, equal number of males and females, etc. • Randomization ensures that any observed differences at end of study can be attributed to differences in conditions (i.e., to the treatment) 33 6/11/14 4. Treatment Condition and 5. Control Condition • In an experiment, the Independent Variable (IV) needs to be highly controlled • Need to be sure that CBT Condition received CBT • Need to be sure that Control Condition did not receive CBT but rather the alternative How can we do that? 4. Treatment Condition and 5. Control Condition • Train therapists • Use “treatment manuals” • Evaluate “fidelity” or “adherence” to treatment 34 6/11/14 RCT of Depression Treatments • TDCRP (Treatment of Depression Collaborative Research Project) (Elkin et al.) • Research Question (Societal Context): Is psychotherapy as effective as medications in the treatment of depression? • Patients: 250 persons with severe depression; 11 never started treatment; 191 finished treatment • Four conditions compared • Interpersonal Psychotherapy (IPT) • Cognitive Therapy (CT) • Imipramine (drug of choice in 1980s) • Placebo (sugar pill) } Treatment Conditions Control Condition “Manualized” Treatment • Manuals specify treatment • How disorder is conceptualized • What to do session by session (or phase by phase) • What topics to cover • What homework to give • Cognitive Therapy (CT) condition • One of original treatment manuals • Developed for this study (as was IPT manual) • Therapists were trained to do manual 35 6/11/14 Drug and Control Condition • The drug and placebo conditions were also manualized • Physicians were trained to follow manual • “Don’t talk about cognitions” • Ask how patient is feeling • Monitor worsening of symptoms • Monitor for suicide risk 6. Statistical Analyses • Classical analytic strategy = compare groups 36 6/11/14 6. Statistical Analyses (cont.) • Current strategy is to examine individual responses Experiments vs. Naturalistic Studies of Psychotherapy • Experiments have high internal validity • Naturalistic studies have high external validity 37 6/11/14 Internal Validity Treatment via Improvement of manual (IV) Internal validity patient (DV) External Validity Treatment in community (IV) External validity Improvement of patient (DV) Experiments vs. Naturalistic Studies of Psychotherapy (cont.) • Therapy manuals standardize IV and increase internal validity, but probably reduce external validity • Therapy as actually practiced less standardized • Manuals to control differences between therapists (make them all “standardized”) • But differences between therapists major determinant of outcome • Capacity for empathy • Expertise 38 6/11/14 Experiments vs. Naturalistic Studies of Psychotherapy (cont.) • RCTs considered by some to be “best” or “gold standard” • However, naturalistic studies are vital Experiments vs. Naturalistic Studies of Psychotherapy (cont.) • Properties of psychotherapy as done in the community differ than RCTs • Patients may actively seek out certain techniques or practitioners (vs. random assignment) • Psychotherapy not of fixed duration • Continues until patient is improved or until patient terminates (sometimes against advice) • Psychotherapy is self-correcting • Therapist might add another technique, switch entirely to another technique, suggest some time off • Patient might be referred to another therapist 39 6/11/14 Experiments vs. Naturalistic Studies of Psychotherapy (cont.) • Patients usually have multiple problems (high “comorbidity”) • Psychotherapy will focus on numerous difficulties/ problems/diagnoses • Psychotherapy attempts to provide general improvement (efficacy studies usually focused on a single disorder, meaning symptoms of a single disorder) Summary of Treatment-Based Research 40 6/11/14 Meta Analyses of Different Treatments • Rosenzweig S. (1936) American Journal of Orthopsychiatry • Quoted “Alice in Wonderland” • As in the results of the race, comparing treatments reveals that, “At last the Dodo said, ‘Everybody has won and all must have prizes.’” • Has been found repeatedly • e.g., Wampold et al. (1997). Psychological Bulletin. A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “All must have prizes.” Meta Analyses of Different Treatments (cont.) • Different treatments account for a small amount of the variance in psychotherapy outcomes • Virtually all psychotherapy models and techniques are effective with some people, some of the time • Outcome differences between therapists using the same model have been found to be 2-3 times greater than the differences between models 41 6/11/14 What Diagnoses Have Been Shown to Be Treatable? • So far, all of them • Depression, Bipolar Disorder • Panic disorder, OCD, Phobias • Bulimia Nervosa, Anorexia Nervosa • PTSD • Schizophrenia • Headache, Pain • Oppositional Children, ADHD • Marital distress, Sexual Dysfunction • Etc. ……… “Patient-Focused Research” • Different research questions about treatments (a) Does the treatment work under experimental conditions? (Treatment efficacy studies) (b) Does the treatment work in practice? (Treatment effectiveness studies) • Question of ultimate interest to this patient and this therapist: (c) Is the treatment working for a particular patient? • Referred to as “patient focused research” 42 6/11/14 Patient Profiling Howard, K. I., Moras, K., Brill, P., Martinovich, Z., & Lutz, W. (1996). The evaluation of psychotherapy. American Psychologist, 52, 1059-1064. Patient Profiling 43 6/11/14 Patient Profiling Outline of Presentation • Define psychotherapy • Inputs, Processes, Outcomes • Contextualize psychotherapy research within Evidence-Based Medicine (EBM) • Review basics of scientific inquiry • Reliability, Validity, Measurement, Control • Review primary methods of studying psychotherapy • Naturalistic studies • RCTs (experiments) • (Single case studies) • How to apply in practice (“How to practice EBPP”) 44 6/11/14 Single Case Psychotherapy Research • Single case designs can be either experimental or naturalistic Single Subject Experimental Design • Can be used to evaluate any type of psychotherapy • Frequently used to evaluate new therapy • Method • Repeated assessment of behavior of primary interest • Establishment of a baseline; Monitor progress • Treatment clearly specified; Treatment implemented then withdrawn, then implemented • Called “ABAB design” • A = No treatment (baseline/mid-treatment ) • B = Treatment of interest 45 6/11/14 Single Subject Experimental Design (cont.) • Changes in dependent variable (outcome) after introduction of Treatment • Return to baseline after removal of treatment Using Psychotherapy Research Methods in Your Own Practice (Single Subject Naturalistic Design) • Research supports outcome monitoring • Routine measurement (patient self report outcome questionnaires) to monitor response • Early identification of poor response • Given large body of evidence related to alliance • Can also routinely monitor • Identify and “repair” problems 46 6/11/14 Thank you! • Questions? 47