SOWK6190/SOWK6127 Cognitive Behavioural Therapy and Cognitive Behavioural Intervention

1. SOWK6190/SOWK6127Cognitive Behavioural Therapy and Cognitive Behavioural Intervention Week 1 - Psychological treatments that work – and what convinces us they do? The empirical status of cognitive-behavioral therapy Dr. Paul Wong, D.Psyc.(Clinical)

2. Lecture 1 How I teach? Overview of course Evidence-based practice The empirical status of cognitive-behavioral therapy Homework

3. How I teach? • Two major principles: • Based on a "Tell me, I'll forget. Show me, I'll remember. Involve me, I'll understand"principle. Thus, I will do some lecturing, you will have many opportunities to discuss, practice, interact during the lectures.

4. How I teach? • 2. Principle of adult learning (Field, 1990): • Become ready to learn when they recognize a deficiency in their own skills and accept that they need to take action to remedy it; • Want learning to be problem-based, leading to the solution of particular problems facing the individual; • Want to be treated as adults, enjoying the respect of the instructor and of other learners, and to have the experience they bring with them accepted as valid; • Bring to the learning situation their unique mix of characteristics such as self-confidence and self-image, learning style, and personality.

5. Overview of the course Please read the course outline carefully

6. Evidence-based Practice

7. Why Evidence-based practice? • increase understanding of health pathologies that produce the foundation in developing precisely targeted interventions. • advancement in clinical research methodologies that produce new evidence for effectiveness of interventions • global concerns over expenses of health care (Huppert, Fabbro, & Barlow, 2006). • implications over legal concern (Havighurst, Hutt, McNeil & Miller, 2001).

8. EBM as “the integration of best research evidence with clinical expertise and patient values”

9. Components of Clinical Expertise • assessment, diagnostic judgment, systematic case formulation, and treatment planning • clinical decision making, treatment implementation, and monitoring of patient progress • interpersonal expertise • continual self-reflection and acquisition of skills • appropriate evaluation and use of research evidence in both basic and applied psychological science • understanding the influence of individual and cultural differences on treatment • seeking available resources • having a cogent rationale for clinical strategies

10. Patient characteristics, culture, and preferences • exploring “what works for whom” • Patient characteristics: functional status, readiness to change, and level of social support, • Social factors and cultural background • Familial factors • Current environment context, stressors • Developmental considerations • Problem variations: Comorbidity and polysymptomatic presenations • Personal preferences, values, and preferences related to treatment (goals, beliefs, worldviews, and treatment expectations)

11. Evidence-based Practice • de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and • stresses the examination of evidence from clinical research. (Evidence-Based Medicine Working Group, 1992)

12. Evidence-Based Practice in Psychology (EBPP) (Levant, 2005) • APA Presidential Task Force on Evidence-Based Practice in 2005 • ‘ the purpose …to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention (p. 5)

13. Evidence-based practice in Social Work • The NASW Code of Ethics states that "Social workers should critically examine and keep current with emerging knowledge relevant to social work and fully use evaluation and research evidence in their professional practice" (5.02(c)). • This guideline also pertains to the ethical mandate of informed consent, because professionals need to know the evidentiary basis for alternative practices and policies in order to fully honor theinformed consent principle (Gambrill, 2003)."

14. Steps in evidence-based practice • Formulate a question to answer practice needs; • Search for the evidence; • Critically appraise the relevant studies you find; • Determine which evidence-based intervention is most appropriate for your particular client; • Apply the evidence-based intervention; and • Evaluate and feedback

15. Level and Quality of Evidences UK: 5 Levels of Evidence (Centre for Evidence-based Medicine, University of Oxford, 2009) http://www.cebm.net/index.aspx?o=1025

17. Challenges in applying EBP in counseling settings • Based on studies of clients unlike those typically encountered in everyday life practice; • Lack of evidences over choices of multiple evidences; • Manualized brief intervention vs process-oriented intervention • Technicalization vs professionalism • Use of RCT in clinical settings • Knowledge, skills and attitudes (of you and your supervisors/organizations)

18. The work of Hans Eysenck (1952, 1960, 1969) – “The Effects of Psychotherapy” • Reviewed 24 treatment studies of 7000 treated patients and concluded: • “Roughly two-thirds of a group of neurotic patients will recover or improve to a marked extent within about two years of the onset of their illness (compared with the psychotherapy group)” • “patients treated by means of psychoanalysis improved to the extent of 44%......, patients treated only custodially or by general practitioners improved to the extent of 72%. There thus appears to be an inverse correlation between recovery and psychotherapy” • In 1960, he wrote “the therapeutic effects of psychotherapy are small or non-existent, and do not in any demonstrable way add to the non-specific effects of routine medical treatment, or to such events as occurs in patients’ everyday experience”.

19. Meta-analysis of Psychotherapy Outcome Studies (Smith and Glass, 1972) • Effect size = mean (case-control)/SD control • Analyzed 833 treatment studies • 16 independent variables, e.g., type of therapy, its duration, group vs individual, professional identity, age and IQ of patients etc. • Average study showed .68 of a SD over control types of therapy studied, average effect size for best therapies were:

20. Meta-analysis of Psychotherapy Outcome Studies (Smith and Glass, 1972), cont. • .9 systematic desensitization • .77 for rational emotive therapy • .76 for behaviour modification • .63 for client-centred therapy • .59 for psychodynamic therapy • “outcomes of psychotherapy remains controversial”

21. “Mental Health: Does Therapy Help?” – Martin Seligman (1995) • Psychotherapy does work as people report fewer symptoms and a better life after therapy than before • Methodological problems also raises questions of efficacy vs. effectiveness • Efficacy – how well does a treatment work under optimum conditions • Effectiveness – how well does it work in the general community after disseminations for others to follow

22. “Mental Health: Does Therapy Help?” – Martin Seligman (1995) • 180,000 readers of Consumer Reports, 7000 replies to the survey, 2900 saw a mental health professional, and concluded: • Level of satisfaction with therapy was equivalent whether respondents saw a social worker, psychologist, or psychiatrist; those who saw a marriage counselor, however, were somewhat less likely to report having benefited from therapy; • Respondents who sought therapy from a family doctor reported doing well, but those who saw a mental health professional for more than 6 months reported doing much better; • Psychotherapy alone worked as well as combined psychotherapy and pharmacotherapy; while most persons who took prescribed medication found it helpful, many reported side effects; and • Respondents who had tried self-help groups, especially Alcoholic Anonymous, felt especially good about the experience.

23. All of these works lead to the development and the pursue of “empirically-validated treatments”

24. The empirical status of cognitive-behavioural therapy: a review of meta-analyses

25. How to read the findings of meta-analyses • In meta-analysis, treatment efficacy is quantified in terms of an effect size (ES). An ES indicates the magnitude of an observed effect in a standard unit of measurement (e.g., a standard deviation or correlation coefficient). • Effect sizes have been categorized along a continuum of no effect (ES<0.2), low (0.2-0.5), medium (0.5-0.8) and high (>0.8) (Cohen, 1988). • Hence, the strength of meta-analysis comes from the use of a standardized unit to compare outcomes from studies that may use different measures. Also, by averaging effect sizes across different studies and comparisons, meta-analysis increases the effective sample size and minimizes the influence of extraneous factors.

26. U3 represents the percentage of the scores in the lower-meaned group that was exceeded by the average score in the higher-meaned group (Cohen, 1988). • The relationship between ES and U3 is important to understand when interpreting the findings from meta-analyses. • For example, an ES of 0.0 would indicate no treatment effect. It converts into a U3 of 50%, which in this review would indicate that the average CT patient did as well as the average control group member. • A controlled ES of 1.0 would represent a large treatment effect and would translate into a U3 of 84%, indicating that the average CT patient had an outcome superior to that of 84% of the control group.

31. Discussions • CT is highly effective for adult unipolar depression, adolescent unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, PTSD, and childhood depressive and anxiety disorders. • Significant evidence for long-term effectiveness was found for depression, generalized anxiety, panic, social phobia, OCD, sexual offending, schizophrenia, and childhood internalizing disorders. In the cases of depression and panic, there appears to be robust and convergent meta-analytic evidence that CT produces vastly superior long-term persistence of effects, with relapse rates half those of pharmacotherapy. • In addition, CT appears to show greater long-term effects in the treatment of generalized anxiety disorder as compared to applied relaxation.

32. Homework Please read Bulter’s article and this one - Beck, A. (2005). The Current State of Cognitive Therapy - A 40-Year Retrospective.Arch Gen Psychiatry. 2005;62:953-959

33. References Butler, A., Chapman, J., Forman, E.M. & Beck, A. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31. Evidence-Based Medicine Working Group (1992). Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA, 268(17):2420-2425. Gambrill, E. (2003). Evidence-based practice: Sea change or the emperor's new clothes? Journal of Social Work Education, 39(1), 3-23. Havighurst, C. C., Hutt, P. B., McNeil, B. J., & Miller, W. (2001). Evidence: Its meanings in health care and in law. Journal in Health Politics, Policy and Law. 21(2), 195-215. Huppert, J. D., Fabbro, A., & Barlow, D. H. (2006). Evidence-based practice and psychological treatment. In G. M. Reed & E. Eisman (eds.) Evidence-based psychotherapy: Where practice and research meets (p. 131 – 152). Washington, DC: American Psychological Association. Levant, R. F. (2005, July 1). Report of the 2005 presidential task force on evidence-based practice. Retrieved June 20, 2008 from http://www.apa.org/practice/ebpreport.pdf McNeece, C. A. & Thyer, B. A. (2004). Evidence based practice and social work. Journal of Evidence-Based Social Work. 1(1), 7 - 25. Nathan P. & Gorman J. (1998). Treatments that work – and what convinces us they do (pp.3-25). In P. Nathan & J. Gorman. A guide to treatment that work. Oxford: Oxford University Press. Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Editorial: Evidence based Medicine: what it is and what it isn't. BMJ, 312, p. 71-72.