Chapter 1 - What Does It Mean For Therapy To Work

Question 0

What outcomes are we looking for in therapy?

Answer 0

• 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

Question 1

Two processes of therapy:

Answer 1

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)

Question 2

What general outcomes are possible?

Answer 2

Person gets better, no change or worse

Question 3

Duration effects

Answer 3

Acute relief: get well

Long term relief: stay well (cured)

Question 4

What is anecdotal evidence?

Answer 4

Evidence derived from experience of therapists or clients without systematic observation

• testimonials
• consumer reviews
• some case studies

Question 5

What are the problems with anecdotal evidence?

Answer 5

• 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

Question 6

What is Empirical evidence?

Answer 6

Systematic, a priori system of observation to quantify change in targets

Example: measure x before give treatment measure x after (a-b-a)

Question 7

Problems with pre-post design?

Answer 7

• 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

Question 8

What prevents us from finding out if a treatment worked

Answer 8

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

Question 9

Gold standard for evaluating treatments

Answer 9

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

Question 10

Developing treatments - stage 1

Answer 10

Stage 1 - development

• need for treatment
• feasibility
• face-validity

Question 11

Developing treatment - stage 2

Answer 11

Stage 2 - validation

• efficacy
• internal validity

Question 12

Developing treatments - stage 3

Answer 12

Stage 3 - dissemination

• effectiveness
• external validity

Question 13

Empirically supported therapies

Answer 13

Clearly specified psych treatment shown to be efficacious in controlled research with a delineated population

Question 14

4 components of knowing if treatments works

Answer 14

Efficacy
Specificity
Effectiveness
Efficiency

Question 15

Efficacy

Answer 15

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

Question 16

Possibly efficacious

Answer 16

Only 1 study and all conducted by 1 team

Question 17

Hawthorne effect

Answer 17

Participants increase output simply as a result of being in a study

Question 18

Specificity

Answer 18

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

Question 19

Horse race studies

Answer 19

Control condition is another bona fide treatment

Question 20

Non specific factors

Answer 20

Factors common across all therapies

• therapist attention
• warmth
• alliance
• expectation of change
• time spend in tx

Question 21

Effectiveness

Answer 21

Does the treatment actually work in the real world clinical settings
Experiment; naturalistic settings, quasiexperimental, uncontrolled designs are common
Best conducted after efficacy research

Question 22

Efficiency

Answer 22

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

Question 23

Other consideration in treatment

Answer 23

Feasibility: is the treatment doable
Dissemination: how do we get the treatment to become available
Clinical significance: needs to be statistically significant turkey

Question 24

Clinical significance

Answer 24

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

Question 25

Sample description

Answer 25

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

Question 26

Other important considerations EST by chambless and hollen

Answer 26

Treatment manual
Reliable and valid outcome measures
Therapist training
Blinding (single-blind and double-blind)

Question 27

Investigator allegiance

Answer 27

Occurs when the investigator also is the developer of the treatment
if they are specially invested in seeing that the treatment works

Question 28

Therapist adherence

Answer 28

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

Question 29

Treatment compliance

Answer 29

Did the client to do what he or she was supposed to do

Question 30

Important considerations in randomized controlled trial

Answer 30

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

Question 31

Evidence-based practice

Answer 31

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

Question 32

Three legged stool of evidence-based practice

Answer 32

– Best available research evidence
–Patient preferences and values
– Clinical expertise

Question 33

Purpose of evidence-based practice

Answer 33

To promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationships, and intervention

Question 34

Compared to empirically supported therapies, evidence-based practice is more:

Answer 34

– 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

Question 35

Process of evidence-based practice

Answer 35

The five A’s

Ask, acquire, appraise, apply and assess

Question 36

Ask:

Answer 36

Clinical questions about:
patient characteristics
Diagnosis: test results
Prognosis
Interventions

Question 37

Acquire:

Answer 37

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

Question 38

Appraise:

Answer 38

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

Question 39

Apply:

Answer 39

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

Question 40

Assess:

Answer 40

– At the beginning
– Any change/progress
- if it’s not working, need to switch strategies, switch therapists or even stop therapy

Question 41

Arguments for evidence-based practice and est

Answer 41

– 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

Question 42

Arguments against evidence-based practice and est

Answer 42

– 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