Effectiveness of Therapy and Nonspecific Factors

1. Effectiveness of Therapy and Nonspecific Factors

2. Is Therapy Effective?

3. Is Therapy Effective? • Does it work? Who does it work for? • If it does work, why does it work? • What is it doing? • What parts work and what parts don’t work? • What is responsible for the most variance in change?

4. The Consumer Reports Study • In 1994, Consumer Reports decides to evaluate psychotherapy by surveying users in the same way that it does for other goods & services • The CR conclusions are controversial and generate much discussion regarding the nature of scientific therapies and methodology for clinical psychology

5. What are the CR findings? • 90% of people find therapy useful • Long-term therapy was more useful than short-term therapy • There is no difference between therapy alone and therapy + meds • Psychologists, psychiatrists, and social workers all perform equally well • Family doctors do well in short-term

6. What Are the CR Findings? • All service providers perform better than marriage counselors • AA did very well • Active shoppers of therapy do better than passive recipients • No specific therapy did better than the others • Limitations due to insurance are associated with worse outcomes

7. What’s the Problem with the CR study? • Most therapies being practiced do not have scientific support • Many consumers may not even be aware of what type of therapy they received or who provided it • It raises issues regarding the proper way to evaluate therapy outcomes

8. How Do we Know if Therapy works? • We can do two different types of studies to assess the outcomes of therapy: • Efficacy Studies • Effectiveness Studies

9. Efficacy Studies • Therapy is demonstrated to work in a: • Randomized control trial • With manualized treatment and a fixed # of sessions • A well-defined outcome • Double-blind raters • Clean samples • Efficacy studies have maximum internal validity

10. Efficacy Studies • Psychologists who are part of the clinical science model (and also the scientist-practitioner model) consider therapies that “survive” 2 RTC trials to be • “empirically supported” • Or “gold standard” • Ethically, many would argue, the gold-standard should always be used if there is one • Others argue this criteria is arbitrary

11. Effectiveness Studies • Therapy is demonstrated to work in the ‘real life’ conditions common to most patients • Not clean diagnosis or multiple problems • Changing number of sessions • Loosely or no manualized treatment • Clients choose their own therapies and self-correct • Focus on improvement, not symptom reduction • Effectiveness studies maximize on external validity

12. The CR Controversy • The CR study is purely an effectiveness study, and many scientists question its results

13. Seligman- Support of CR Study • Seligman (who is APA president) argues that efficacy studies leave out too many components to draw good conclusions • He thinks the CR is a good study: • Sample represents those who use therapy • Naturalistic treatment course • Self-correcting • Unbiased

14. Jacobsen & Christensen - Questioning the Conclusions • Others question the methodology • Study is retrospective (conclusions are uncorroborated, possibly distorted or inaccurate) • CR measures were unreliable and not that informative • Did not assess which therapies improve which problems

15. Which is Better? • Both types of studies are useful • for a treatment to have solid support, it should be shown to work in both

16. Does Therapy Work? • Yes, in general • Sometimes our effect sizes are not large • Certain disorders are treated mainly with therapy, we may have no other way to help: • Borderline Personality Disorder

17. Does Therapy Work? • For some therapies, relapse rates can be high • Depression (some estimate up to 50%) • For some disorders, we have little to no treatment • Personality disorders • Pervasive developmental disorders

18. Is it the Specifics? Or the NonSpecifics? • Specifics: • A specific component of a therapy that theoretically is necessary (e.g. Exposure) • Nonspecifics: • Factors common to all therapies that could explain outcomes

19. Factors Influencing Outcome • Can be divided into 4 components: • Extratherapeutic factors • Expectancy Effects • Specific therapy techniques • Common Factors (Lambert & Barley, 2002)

20. Extratherapeutic Factors: Spontaneous recovery or remission Fortunate events Social support Expectancy Effects: Placebo effects The Dodo bird hypothesis Factors Influencing Outcome

21. Specific Therapy Techniques: Exposure Changing cognitions (CBT) biofeedback Common Factors Relationship with therapist Support Hopefulness Factors Influencing Outcome

22. Factors Influencing Outcome

23. What Nonspecifics Help? • Orlinsky, Grave & Parks (1994): • Therapist credibility • Therapist skills • Empathetic understanding

24. What Nonspecifics Help? • Affirmation • Ability to engage patient • Focus on patient’s problems, direct patient

25. Humanistic Therapies • If you recall, humanistic therapies consist of many nonspecifics: • Unconditional positive regard • Caring, respect • Being genuine

26. What Are the Implications? • Much of the variance in outcome is accounted for by nonspecifics • Stay up to date and use ESTs • Remember the importance of therapeutic relationship & alliance, the interpersonal nature of therapy • The relationship provides the context for specific techniques to work

27. How Do We know Which One it Is (Specifics or Nonspecifics)? • Treatment studies always have a control group. May include a group who receives all the nonspecifics of the treatment group

28. How Do We know Which One it Is (Specifics or Nonspecifics)? • If the treatment group improves, above and beyond the control group, we know more than nonspecifics are at work

29. How Do We Know Which Part of Therapy works? • Component studies • Attempt to isolate effective “ingredients” • Dismantling designs & additive designs • Dismantling: compare entire Tx and Tx with the hypothesized critical variable removed • Additive: compare entire Tx and Tx + another component

30. How do We Know Which it is? • Dismantling: • If removing a component = worse patients, then that component is responsible • Additive: • If adding a component = better patients, then that component is responsible