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Empirically Supported Psychological Treatment

Empirically Supported Psychological Treatment. C. Ervin Davis III, Ph.D. Assistant Professor Department of Psychology East Carolina University daviscl@ecu.edu http://core.ecu.edu/psyc/daviscl/. Outline of Session. Part I. The Research METHODS

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Empirically Supported Psychological Treatment

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  1. Empirically Supported Psychological Treatment C. Ervin Davis III, Ph.D. Assistant Professor Department of Psychology East Carolina University daviscl@ecu.edu http://core.ecu.edu/psyc/daviscl/

  2. Outline of Session • Part I. The Research METHODS • Definitions & Concepts (What is psychotherapy research?) • empirical, theory, hypotheses, psychotherapy, efficacy vs. effectiveness • The Methods (How to do research?) • Part II. The Research RESULTS • A History Lesson • In answer to your question… • Going Beyond

  3. Part I. The Research METHODS

  4. What is Empirically Supported Treatment? (EST) • For psychotherapy, does EST mean anything? • Or, have we been played for a Fool? • Medical Model • Science & Art

  5. What is Psychotherapy Research? • First – some definitions • Empirical • Psychotherapy • Theory • Hypothesis • Empirical Support • Efficacy & Effectiveness • Second – Methods of research

  6. Empirical • 1: originating in or based on observation or experience <empirical data>2: relying on experience or observation alone often without due regard for system and theory3: capable of being verified or disproved by observation or experiment <empirical laws>4: of or relating to empiricism Source: Merriam-Webster Online Dictionary

  7. Psychotherapy – What is it? • “..a formal process of interaction between two parties … may be two or more … for the purpose of amelioration of distress … in the following areas of disability or malfunction: cognitive functions …affective functions …or behavioral functions …with the therapist having some theory of personality’s origins, development, maintenance and change along with some method of treatment related to the theory …” Source: Corsini in Corsini & Wedding (2005)

  8. Psychotherapy – The Important Points • It’s -- “interaction” “talk” • Involves cognition, affect, behavior • Has a personality theory (philosophy) • Has a theory of change • Has a set of techniques

  9. Theory & Hypotheses Theory Theory: set of ideas, principles to explain & predict Hypotheses: tentative, statements based on theory that can be tested empirically Hypothesis Hypothesis Hypothesis

  10. Empirical Support • Data in accord with hypothesis • Gives support to hypotheses & theory • Does not contradict, falsify theory • Gradual building • Natural laws govern behavior, mind • objectivism, materialism The word empiricism comes from the Greek word εμπειρισμός, a noun meaning a "test" or "trial"

  11. Efficacy or Effectiveness • Efficacy – In the Lab – Analog Therapy – Not real therapists, Not real patients, Not real world • Effectiveness – In the real world Vs. Reality Lab Most of the research on psychotherapy has been of efficacy.

  12. Methods of Research • Experiments or Non-experiments • Randomized Controlled Trials • Quasi-experiments • Naturalistic Study • Case Study • Effects of therapy and not expectancy, time, attention, repeated assessment, regression • Sample Selection • analog • select • genuine clinical

  13. Randomized Control Trial--try to remove pre-existing differences Random assignment to Treatment Group Control group Get’s the “therapy.” Get’s an alternative. Waitlist, contact/attention placebo, no-treatment Standard treatment (TAU)) Blinding?

  14. Research Methods • Samples • Analog • Highly select • Genuine clinical • Assessment (to measure condition or outcome) • Meta analysis-- cumulative outcome-- effect sizes • Alternatives (to compare with treatment) • Wait list • Contact or attention placebo (non-Therapy) • No treatment (Assess Only) • Standard treatment (TAU/Another Treatment) “OK, sorry…just forget I asked for a double blind, placebo control”

  15. Effect Size How much did these groups (means) differ? • Cohen (1988) Cohen’s d, effect sizes as "small, d = 0-.2," "medium, d = .3-.5," and "large, d = .8-1,0 • Corresponds to correlation coefficient r=.1, r=.24, r=.37 • g = M1- M2/ s where (between 2 conditions) s = Ö[å(X - M)² / N] (standard deviation) • where X is the raw score, M is the mean, and N is the number of cases.

  16. The Research problem How big is this question about psychotherapy research? Client Problems (diagnosis) X Client Personal Characteristics X Therapy Approaches X Therapist Characteristics X Situation/ Circumstances Big cube “She’s BIG problem quicksdraw” 10 x 10 x 10 x 10 x 10 = 100,000 combinations!

  17. Part II. The Research RESULTS

  18. Outline • Part II. The Research RESULTS • A History Lesson • In answer to your question: Questions about what the research says: e.g. Does therapy work? Which is better? How long? (Highlights of the most significant research findings) • Going Beyond (Some important topics for future research)

  19. History 101-- Psychotherapy Research Where’d that therapist go? • See your Timeline

  20. History 101 • 1920s-1930s Early research on psychodynamic and behavioral therapy • 1936 Rozensweig’s Common Factors • 1952 Eysenck No evidence for psychotherapy effectiveness • 1958 Wolpe – Reciprocal Inhibition • 1960 Psychotherapies proliferate

  21. History 101 • 1971 Bergin & Garfield 1st Edition • 1976 Beck Cognitive Therapy • 1977, 1980 Glass meta analysis • 1994 Consumer Reports Survey • 1995, 1998 APA Task force • 1990s – current -- Many Meta analyses • 1990s – managed care

  22. Results A large body of research has addressed the following questions: • Does Psychotherapy Work? • Are some therapies better than another? • Does therapist experience matter? • Is psychotherapy better than drugs? • Is longer or shorter therapy better? • Are specific ingredients/factors therapeutic? • Are improvements maintained? Remember the “fool” and the 100,000 combinations.

  23. Does Psychotherapy Work? • Smith & Glass, 1977 – Meta-analysis of 475 studies, overall effect size of 0.85 – mean treated better than 80% of untreated • Table 5.1 Summarized Meta-Analytic reviews, from Lambert, 2004 • Seligman, 1995 – Consumer Reports Survey (Generalizability, Effectiveness Issue)

  24. Lambert, 2004 in Bergin & Garfield’s Handbook of Psychotherapy & Behavior Change.

  25. Seligman, 1995 – Consumer Reports Survey

  26. Seligman, 1995 – Consumer Reports Survey

  27. Are Some Therapies Better than Others? • Luborsky, Singer, & Luborsky, 1975 “Do-Do Bird: All must have prizes” • APA Task Force on Promotion & Dissemination of Psychological Procedures, 1995 – The List • Wampold, 1997 Meta analysis – Test of Do-Do hypothesis

  28. 27 effect sizes .05 – 4.34 Lambert, 2004

  29. 59 effects, -.19 to 3.45 Lambert, 2004

  30. APA Task Force Report 2 group studies >Placebo or other Tx. Adequate power Or large series single case manualized Samples defined 2 group studies >Waiting-list Or 2 by same lab or 1 good Sample heterogeneous Or small series single case

  31. Does therapist experience matter? M.S.W. • Strupp & Hadley, 1979 Therapists vs. College Professors • Stein & Lambert, 1995 Meta Analysis, 33 studies--more training correlated with lower dropout, more satisfaction & better outcome Ph.D. M.A. PsyD R.N M.D.

  32. Is psychotherapy better than drugs? • NIMH Depression Collaborative Research program -- (Elkin, Gibbons, Shea, Sotsky, & et al., 1995) equally efficacious for less severe depression • Thase, 1997 Depression Single & Combined Txt, Depends on Severity • Gloaguen et al., 1998 CBT>Rx, d=.38 • CBT 1-yr relapse 29%, Rx 60% • Reynolds et al., 1999 Recurrence after successful treatment

  33. PLA-CM PLA-CM, CBT CBT IMI-CM IPT IPT IMI-CM More severely depressed patients Figure 2. Estimated Hamilton Rating Scale for Depression (HRSD) scores in cognitive behavior therapy (CBT), interpersonal psychotherapy (IPT), imipramine plus clinical management (IMI-CM), and placebo plus clinical management (PLA-CM) conditions for high initial severity patients based on the Global Assessment Scale. Figure 1. Estimated Hamilton Rating Scale for Depression (HRSD) scores in cognitivebehavior therapy (CBT), interpersonal psychotherapy (IPT), imipramine plus clinical management (IMI-CM), and placebo plus clinical management (PLA-CM) for high initial severity based on HRSD. “Lower is better” • NIMH Depression Collaborative Research Program -- (Elkin, Gibbons, Shea, Sotsky, & et al., 1995)

  34. Therapy alone or combined with medication No sig Diff. Sig. Diff. Meta analysis In 6 studies Thase, 1997

  35. (Reynolds et al., 1999) Figure 2. Recurrence Rates of Major Depressive Episodes. Survival function of 4 treatment groups (log-rank statistic=34.31; df=3; P=.001). On pairwise analysis, each of the 3 active treatment groups was significantly better than placebo. IPT indicates interpersonal psychotherapy. 107 pts fully recovered from depression at BL, Age > 59

  36. Is longer or shorter therapy better? • Lambert, Hansen, & Finch, 2001 “dose-response curve” • data from 6,072 patients • therapy as usual, with a wide variety of treatment methods

  37. Meta Analysis Lambert, Hansen, & Finch, 2001 6,072 patients

  38. Are specific ingredients therapeutic? • (Ahn & Wampold, 2001) • Meta Analysis of 27 studies comparing a treatment and a treatment without a therapeutically important component

  39. Ahn & Wampold, 2001

  40. Aggregate effect size not significantly different from zero. Ahn & Wampold, 2001

  41. Common Factors From Lambert (2004)

  42. Are improvements maintained? • (Nicholson & Berman, 1983) – 67 studies “information obtained at follow-up often added little to that obtained at the end of treatment. Findings highlight the general durability of gains achieved during psychotherapy, suggesting that costly follow-up procedures may be used more selectively” • Bakker et al., 1998 Anxiety & Panic Follow-up Meta analysis, 68 studies, Gains maintained for variety of treatments • (Jarrett et al., 2001) Maintenance Cognitive Therapy for Depression vs. control (evaluation only)

  43. Jarrett et al., 2001

  44. Different Strokes for Different Folks? • Or “What works for whom?” • (Chambless & Ollendick, 2001) Reviews the results of Task Forces in the US and UK – List of Treatments by Disorder and category of support

  45. Going beyond • Treatment Matching • Access to Treatment • 3rd Party payment • Integrated Treatment • Effectiveness Weiten 2001, Adapted from Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services, 1999

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