Chapter 17 Outcomes and Issues in Psychological Intervention

1. Chapter 17 Outcomes and Issues in Psychological Intervention Ch 17

2. Therapy Evaluation • Evaluation of therapy assumes that one can determine the specific procedures that are used in the therapy • How therapy is conducted in practice can be different than what is specified in a therapy manual • Randomized controlled trials (RCTs) vs. idiographic analysis of a single clinical case, or replicated cases • Efficacy refers to how well a therapy does in a controlled clinical trial (i.e., an RCT) • Effectiveness refers to how well a therapy does in the real world of practice Ch 17.1

3. Problems associated with clinical trials • The use of therapy manuals in psychotherapy research help to standardize treatment. • Increase internal validity • However, reliance on therapy manuals in clinical trials may reduce external validity of results. • Therapy as actually practiced outside of clinical trials is typically less standardized and often much more eclectic. • Adherence to therapy manuals also intended to control differences among therapists. • These differences in therapist variables (e.g., empathy, warmth, openness) play an important role in therapeutic change process. • The role of therapist variables in clinical trials deserves greater attention.

4. Limitations of Clinical Trials • Volunteer participants are likely different from general public. • Will results from clinical trials based on these participants generalize to other groups of patients? • Use of DSM diagnostic categories to create homogeneous groups may blur differences between participants in groups. • Is there room for idiographic analysis of individuals in clinical trials?

5. The Challenge of Managed Care • Managed care organizations (contracting with employers) demand accountability from providers (MD and non-MD clinicians) • Evaluations of psychotherapy outcomes are not merely of academic research interest, but have practical implications for people in their daily lives. • Providers are concerned about the potential for abuse of patients’ privacy and denial of needed treatments • Stepped Care: Beginning with the least intrusive, least expensive level of care, and moving up only when necessary. (Question: Does this increase drop out risk compared to the initial use of the most powerful intervention? B&N, 9th edition, pp. 568-569)

6. Changing Face of Mental Health Care • More Scientifically Driven Treatments • More Manualized Treatments • Fewer Psychologists Providing Treatment • Briefer Therapies & Cost Containment • Fewer Hospitalizations • Greater Use of Medications

7. Duration of Therapy • Seligman (1995): • Treatment Worked • 87% Improved • Long Term Treatment Better than Short-Term • Therapy vs. Therapy Plus Meds Were Similar • Limit Care = Poor Outcome Consumer Reports Magazine

8. Consumer Reports, 2004 Survey

9. Psychoanalytic Concepts • The core issue in psychoanalysis is the removal of repressions that prevent the ego from developing into a healthy person • Psychoanalysis lifts repression via • Dream analysis • Free association • Interpretation • Psychoanalysis can be of long-duration or can be a brief therapy • Evaluation issue: Insight or social conversion process? Ch 17.2

10. Evaluation of Psychodynamic Therapies • Classical Psychoanalytic treatment has been evaluated in only 4 studies • These studies are limited by lack of a control group • General findings: • Patients with anxiety disorders do better in psychoanalysis than do schizophrenic patients • Better educated clients do better in therapy • Interpretation by the therapist may not be helpful for the therapy process • Outcome research has demonstrated that brief interpersonal therapy (IPT) is as effective as CBT for depression and bulimia nervosa • Process research in brief therapy has emphasized the importance of the therapeuticworking alliance Ch 17.3

11. Evaluation of Client-Centered Therapy • Humanistic psychotherapy assumes that people must be understood from their own point of view • Psychological disorders arise when people fail to appreciate their own internal worlds • Therapist role is to be accepting of the client and to be non-judgmental • Positive outcomes are not always related to therapist empathy Ch 17.4

12. Evaluation of Gestalt Therapy • Gestalt psychology holds that the goal of therapy is to make people aware of their own basic needs and desires • People create their own existence • There is a general lack of research on the effectiveness of Gestalt therapy • Some of the technique associated with Gestalt therapy (e.g. the empty-chair) have been shown to reduce self-rated anger Ch 17.5

13. Evaluation of Counterconditioning / Exposure Methods • Counterconditioning involves imaginal and/or real-life exposure to threat stimuli • Systematic desensitization involves having a deeply relaxed person imagine a series of fear-inducing situations • Systematic desensitization / exposure methods are effective for the treatment of anxiety-related problems • Simple phobias, agoraphobia • PTSD • Obsessive-compulsive disorder • Panic disorder Ch 17.6

14. Evaluation of Operant Methods • Operant methods involve the systematic rewarding of desirable behaviors and extinguishing undesirable behaviors • Operant methods are effective for a wide range of behavioral problems, particularly in children • Caveat: The problem behavior must be an operant (i.e. under the control of a contingent reinforcer) Ch 17.7

15. Evaluation of Rational-Emotive Behavior Therapy • Rational-emotive behavior therapy (REBT) acts to remove unreasonable cognitive beliefs • REBT has been shown to • Reduce self-reports of anxiety • Improve self-reports of social anxiety • Reduce anger, depression and antisocial behavior • Reduce the Type A behavior pattern Ch 17.8

16. Evaluation of Beck’s Cognitive Therapy • People in emotional distress operate under cognitive schemas that are disabling • The goal of Beck’s cognitive-behavioral therapy (CBT) is to challenge these schemas • CBT has been shown to • Improve depression and to prevent future depression episodes • Be comparable to drug therapy in overall effectiveness for the treatment of depression • See pp. 581-582, for comparison with Ellis’ REBT Ch 17.9

17. Generalization/Maintenance of Treatment Effects • Generalization seeks to identify the factors that allow clients to maintain treatment-related gains while in the real world • Using intermittent and natural reinforcers is helpful • Eliminating secondary gain (through use of paradox) • Reducing the likelihood of relapse by encouraging clients to attribute their slips to external, unstable, specific and controllable factors • Attribution of treatment gains to oneself may be usefulfor the person(e.g., self-control strategies) • Some basic issues in cognitive and behavioral therapy • Internal behavior and cognition • Importance of relationship factors (the therapeutic alliance) Ch 17.10

18. Evaluation of Couples and Marital Therapy • The focus of couples and family therapy is on improving communication • Family/couples therapy is • More successful in conjoint therapy than individual therapy • Successful in reducing relationship stress • Not always clinically significant • Depression, “emotional disengagement”, and low frequency of sexual behavior can be predictors of poor outcome Ch 17.11

19. Review of Community Psychology • The focus of community psychology is prevention of disorder • Community psychology has been useful in • Prevention of cigarette smoking • Prevention of HIV infection • Reducing the risk of cardiovascular disease • Community psychology efforts do not work when the disorder of interest is not subject to social/environmental change Ch 17.12

20. Psychotherapy Integration • Integration seeks to determine the common ground among the various therapy schools • Technical eclecticism refers to a situation in which a therapist uses techniques from other disciplines, without adopting the theories that spawned them • Common factorism seeks strategies that are common to all therapy schools • Theoretical integration attempts to synthesize both theory and technique across schools Ch 17.13

21. Cultural Issues in Therapy • Cultural diversity is the norm in the United States • There is an assumption, not proven, that clients do better in therapy with therapists who are similar to the client in cultural and ethnic background • Therapists need to • Understand unique problems experienced by clients from diverse groups. • Develop sensitivity to the cultural background of each patient. Ch 17.14

22. Cultural Issues in Therapy • African Americans tend to have better rapport with African American therapists than white therapists • More guarded and less open with white therapists • However, therapists who are highly empathic are rated as more helpful. • Latinos • Latino clients are themselves a diverse group based on their geographical roots. • Be careful not to generalize from one group to all Latinos. • Cultural barrier to “seeking help”, especially for Latino men. • Importance of religion, socioeconomic level, and any language differences need to be taken into consideration. • CBT with its emphasis on guidance and problem solving may be more acceptable to Latinos.