Chapter 1 - What Does It Mean For Therapy To Work Flashcards
What outcomes are we looking for in therapy?
- symptom reduction
- disorder remission (no longer criteria)
- better relationships
- better quality of life
- better functioning at work or school
- mortality rates
- reduced medication use
- reduces visits to hospital
- reduction of violence or aggression
Two processes of therapy:
Nomothetic: group focused- does a particular treatment work for clients with certain kinds of problems/ disorders/ characteristics
(Empirical)
Idiographic: individually focused - is the treatment I’m providing to this particular client producing the changes I’m hoping to produce
(Anecdotal)
What general outcomes are possible?
Person gets better, no change or worse
Duration effects
Acute relief: get well
Long term relief: stay well (cured)
What is anecdotal evidence?
Evidence derived from experience of therapists or clients without systematic observation
- testimonials
- consumer reviews
- some case studies
What are the problems with anecdotal evidence?
- hindsight bias (must have been the therapy that worked)
- confirmation bias (from therapist)
- demand characteristics
- placebo effects
Things we don’t know from anecdotal evidence
- what would happen with no treatment
- what would have happened with a different treatment
What is Empirical evidence?
Systematic, a priori system of observation to quantify change in targets
Example: measure x before give treatment measure x after (a-b-a)
Problems with pre-post design?
- spontaneous remission
- regression to the mean
Same problems with anecdotal evidence
- demand characteristics
- what would happen with no treatment
- what would happen with a different treatment
What prevents us from finding out if a treatment worked
Passage of time, regression toward the mean
Think therapy works based on our experience with therapy
Led by confirmation bias
We generalize (probably always works)
Might also bias results based in affiliation with therapy
Gold standard for evaluating treatments
Randomized controlled trials - experimental design with control groups - randomly assigned to either treatment or one or more comparison conditions
Matching:
What are key constructs you would want to hold equal between groups
Assign pairs based on key constructs
Randomly assign members of each pair to treatment or control
Developing treatments - stage 1
Stage 1 - development
- need for treatment
- feasibility
- face-validity
Developing treatment - stage 2
Stage 2 - validation
- efficacy
- internal validity
Developing treatments - stage 3
Stage 3 - dissemination
- effectiveness
- external validity
Empirically supported therapies
Clearly specified psych treatment shown to be efficacious in controlled research with a delineated population
4 components of knowing if treatments works
Efficacy
Specificity
Effectiveness
Efficiency
Efficacy
Does the treatment produce change compared to nothing at all
Must be able to attribute change to the treatment - if it’s explained by anything else no efficacy
- must be found in at least 2 studies (control for spurious findings) and by independent research teams (control for allegiance effects)
Does it work compared to passage of time or spontaneous remission - use wait list control to control for these
Possibly efficacious
Only 1 study and all conducted by 1 team
Hawthorne effect
Participants increase output simply as a result of being in a study
Specificity
Does the treatment do better than non specific factors - is there something unique about the treatment
To see this:
Use placebo that includes attention, warmth, expectations and appointments
Horse race study- more rigorous
Horse race studies
Control condition is another bona fide treatment
Non specific factors
Factors common across all therapies
- therapist attention
- warmth
- alliance
- expectation of change
- time spend in tx
Effectiveness
Does the treatment actually work in the real world clinical settings
Experiment; naturalistic settings, quasiexperimental, uncontrolled designs are common
Best conducted after efficacy research
Efficiency
Important to consider cost-effectiveness
If the treatment has the same effect ones that cost less are preferred
Need to consider long-term and short-term gain
Other consideration in treatment
Feasibility: is the treatment doable
Dissemination: how do we get the treatment to become available
Clinical significance: needs to be statistically significant turkey
Clinical significance
Must move close to mean a functional population compared to dysfunctional population
Must be: two standard deviation of mean of functional and be more than two standard deviation’s away from mean of dysfunctional
Sample description
Must have clearly defined the population from which the treatment was designed and tested
Often use criteria from the DSM or from cut off scores on a valid and reliable questionnaire
Other important considerations EST by chambless and hollen
Treatment manual
Reliable and valid outcome measures
Therapist training
Blinding (single-blind and double-blind)
Investigator allegiance
Occurs when the investigator also is the developer of the treatment
if they are specially invested in seeing that the treatment works
Therapist adherence
Did the therapist in the study deliver the treatment in a way that was consistent with the intention or the manual
Did they actually do the therapy well
Treatment compliance
Did the client to do what he or she was supposed to do
Important considerations in randomized controlled trial
Attrition/drop out Long-term outcomes How many relapse How long does it take until relapse Is it going to be useful for a particular client
Evidence-based practice
A new standard for providing healthcare
The integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences
Based on model of evidence-based medicine
Use of current best evidence in making decisions about the care of individual patients
Three legged stool of evidence-based practice
– Best available research evidence
–Patient preferences and values
– Clinical expertise
Purpose of evidence-based practice
To promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationships, and intervention
Compared to empirically supported therapies, evidence-based practice is more:
– More comprehensive
– Less rigid and prescriptive
-start with the patient and ask what research evidence will assist the therapist in achieving the best outcome
-includes a broader range of clinical activities
-includes multiple streams a research evidence, including but not limited to randomized controlled trial
Balance between internal and external validity
Evidence drawn from variety of designs and methodologies
Process of evidence-based practice
The five A’s
Ask, acquire, appraise, apply and assess
Ask:
Clinical questions about: patient characteristics Diagnosis: test results Prognosis Interventions
Acquire:
Evidence: You search engines like psych info Cochrane reviews History of clinical trials Nice: national Institute for health and clinical excellence – tells you what to do
Appraise:
Evidence:
Look for best available evidence
Gold standard is a good place to start such as double-blind and randomized controlled trial
Lower grades of evidence = Quasiexperimental studies and case studies
Strength of the findings
Completion rates of treatment in the study
If there is any follow-up data
Apply:
To my patient:
How similar is my patient to the sample in the study
-ease patient characteristics to determine – treatment structure and delivery format
Also keep in mind the clinician must be competent to provide the treatment
Assess:
– At the beginning
– Any change/progress
- if it’s not working, need to switch strategies, switch therapists or even stop therapy
Arguments for evidence-based practice and est
– Necessary to advance our status in medical settings
– If the scientific method is good enough for other sciences, it’s good for us
– Protect public welfare
– Meet aspiration to help people
Arguments against evidence-based practice and est
– Biased in terms of what gets tested?
Based on diagnosis; most clients to walk in with several diagnoses going on
– Training in EST is not sufficient for expertise in therapy
– Maybe what’s needed is empirically supported relationships – validate clinician rather than treatments
