Psyc 371 Week 3 Slides (1)

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Psychology 371 Intervention: Process & Outcome Lynnaea Owens, M.A. Simon Fraser University Department of Psychology September 21, 2023
Midterm Exam } 50 multiple choice questions (worth 1 point each), 1 long answer question (your choice between 2 options, worth 10 points). Will have two hours to complete } SFU policy – I cannot allow students to enter the exam after 30 minutes has passed (will affect people running late). Students cannot leave the exam until after 30 minutes } All material from class and readings is fair game } Review course policies in syllabus for missed exams } Midterm exam Q&A next week. Send me questions ahead of time or come to class with questions.
Today’s Topics v Which therapies work for which patients? v History of treatment research v The dodo bird verdict v CBT for Anxiety v What is CBT? v How is CBT used for anxiety? v CBT applications for Panic Disorder
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Studying Tip! v Names from these slides that you need to know for the exam will be highlighted v The ideas from other people will be testable, but you will not need to know their names
Evaluating Therapy } Hans Eysenck (1952): First person to formally evaluate psychotherapy } Reviewed the charts of 7,000 psychiatric patients
Evaluating Therapy } Eysenck’s findings: Treatment % Who Achieved Remission No treatment 72% Psychoanalysis 44% Eclectic therapy 64% } What else could be going on here? Eclectic therapy = using techniques from more than one theoretical orientation
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Evaluating Therapy Critique of Eysenck’s review… v Uncontrolled research v Patients were probably not comparable before treatment started v Treatments provided were not necessarily equivalent
Does Therapy Really Have No Impact? } How BIG are the effects? (Smith, Glass & Miller, 1980) } Meta-Analysis } Combined results of 475 studies (1941 – 1976). } Average patient with psychotherapy is better off than 80% of people who remain untreated } Mean effect size ( M tx - M cont / SD cont ) = .85. } (.20 = small, .50 = med, .80 = large)
Does Therapy Really Have An Impact? } YES! } Most modern meta-analyses show that treatment is better than no-treatment control } Average psychotherapy patient better off than 79% of patients in control groups (Wampold & Imel, 2015) } Therapy has larger effect sizes than many educational and medical interventions (Lipsey & Wilson, 1993)
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Okay so therapy works, but… Does it matter WHICH KIND of therapy you do?
Implications of Treatment Research } Which therapies should be covered by insurance? } Which therapies are taught to students training in psychology or counselling? } Which therapies should be offered by practitioners? } à This gets pretty heated
Major Approaches to Therapy } Norcross & Karpiak, 2012 Behavioral Cognitive Psychodynamic Eclectic/Integrative Humanistic Other 1981
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Major Approaches to Therapy } Norcross & Karpiak, 2012 Behavioral Other Psychodynamic Humanistic Cognitive Eclectic/Integrative 2010
Are All Treatments Equal? } Wampold et al. (1997): Meta-analysis of “horse race” studies } Bona fide treatments differ hardly at all in efficacy (difference in ES = .20) } Concluded that the Dodo Bird conjecture was true
The Dodo Bird Verdict Dodo bird from Alice in Wonderland: } “ At last, ” the Dodo said, “ Everybody has won, and all must have prizes ” Suggests the equivalence of outcomes in psychotherapy (proposed by Saul Rosenzweig in 1936)
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The Dodo Bird Verdict } But… some people disagree } Rachman & Wilson (1980) } “If the indiscriminate distribution of prizes argument carried true conviction…we end up with the same advice for everyone – ‘ Regardless of the nature of your problem seek any form of psychotherapy . ’ This is absurd. We doubt whether even the strongest advocates of the Dodo bird argument dispense this advice”
Research Against the Dodo Bird Crits-Christoph (1997) critique } Virtually all of the bona fide treatments Wampold included in his study were CBT programs
Research Against the Dodo Bird } Smith, Glass, & Miller (1980) } Cognitive and CBT highest (1.31 & 1.24) } Behavioral and psychodynamic (0.91 and 0.78) } Humanistic (0.63) } Developmental (vocational-personal development counseling and "undifferentiated counseling “ ) (0.42). } …Compared to some “no-treatment” control
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Treatment Type x Diagnosis (Shapiro & Shapiro, 1982) Behavioral Cognitive Dynamic/ Humanistic Total Anxiety/ Depression .74 1.34 .40 .67 # studies 21 1 5 30 Phobia 1.46 .92 1.28 # studies 56 9 76 Physical/habit 1.19 .37 .37 1.10 # studies 80 5 5 104 Social or sexual 1.08 1.19 .36 .97 # studies 51 9 8 74 Total 1.06 .94 .40 .98 # studies 310 39 20 410 Effect sizes: Small = .20, medium = .50, large = .80
Lipsey & Wilson (1993) } Meta-analyzed the meta-analyses } Therapy average effect size = .80 to 1.00 } “Minimal therapy” control conditions effect size = .30 to .50 } One interpretation = about half of all treatment outcomes are due to nonspecific factors
Conclusions } Therapy is better than no therapy! } Effect size of therapy is around 1.0, overall } There are some cases where particular types of therapy are an especially good fit: } E.g., exposure for anxiety disorders, CBT for depression
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So… } Maybe it’s time to move away from horse-race trials } Focus more on treatment matching! } As Chambless argues… } The Dodo Bird verdict can have dangerous implications for practice
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Cognitive Behavioral Therapy
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What is CBT? } Cognitive = having to do with thoughts } Content ( what you’re thinking) } Style ( how you’re thinking) } Behavioural = what you do, how you act } Especially patterns of behaviour (responses to a situation you repeat over and over)
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CBT Defined (ABCT Website) “ The behavioral therapies help people achieve specific changes or goals by using proven treatments that are firmly based on scientific research . They are effective, often in a brief period of time and usually focus on current situations rather than past ones. Behavior therapy and cognitive behavior therapy are the two most well-known forms of these therapies… ”
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CBT Defined (ABCT Website) “ Behavior therapists focus on how people learn and how what they have learned [influences] their actions in various situations. Behavior therapy is used to help people change destructive and/or unhealthy behaviors to more positive ones. It is also used to treat many kinds of problems and/or to improve important skills. ”
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History of CBT } Emerged in the 1960s } Recall what you’ve learned about behaviorism } E.g., Watson, Skinner. Bandura } Early developers include Aaron Beck, Albert Ellis } Assumes that mental health problems arise due to problems with cognitions and behaviour } Causal or maintaining factors
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CBT Compared to Other Tx Therapy Approach Causal Factor (where we intervene) Psychoanalytic Unconscious conflict Rogerian/Person-Centered Nurturing the core self Narrative Meaning making Interpersonal Faulty relationship styles Cognitive Behavioral Learning and responses
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How is CBT different from other therapies? } Present-Focused } Time-Limited / Brief } Pragmatic / Practical } Active } Evidence-based, scientist-practitioner } Homework } Change -Oriented…
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Some advantages of CBT } Often makes sense to clients } Based on patient’s experiences } Time limited } Therapist acts as collaborator or coach } Patients have sense of control } CBT works for many problems
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CBT Model Thoughts Emotional Behaviours Physical
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Cognitive Specificity Hypothesis } Distorted thoughts relate to specific mental illnesses } Core beliefs = deep-seated assumptions about ourselves, the world, and others } Anxiety : Core beliefs = dangerousness, uncontrollability, can’t cope } Depression : Core beliefs = failure, incompetence, unloveability
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Cognitive Specificity Hypothesis Often we see cognitive triads (for both anxiety + depression) Negative view of self Negative view of future Negative view of world Examples of specific thoughts for depression? Anxiety?
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Negative Automatic Thoughts } Spontaneous and fast in response to events } Automatic – meaning we can’t just not have them } Often develop from core beliefs } Hard to articulate Stressful situation Automatic thoughts Negative emotions
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CBT in Action } Standard session structure (review homework, set agenda, discuss topics, assign homework) } Target high-priority problems } Query client to clarify nature of problem } Select cognitive/behavioural techniques to use and provide rationale
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Core Interventions in CBT Cognitive Interventions Behavioral Interventions Psychoeducation SkillsTraining Cognitive Restructuring Contingency Management Socratic Questioning Exposure Behavioral exercises
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KELTY’S KEY (www.keltyskey.com) Anxiety Canada (https://anxietycanada.com) Online Resources for CBT
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CBT For Anxiety Disorders
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Anxiety Disorders DSM-IV • Generalized Anxiety Disorder • Panic Disorder • Agoraphobia • Specific Phobias • Social Phobias • OCD • PTSD • Acute Stress Disorder DSM-5 • Generalized Anxiety Disorder • Panic Disorder • Agoraphobia • Specific Phobias • Social Anxiety Disorder • Separation Anxiety Disorder • Selective Mutism
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Anxiety Disorders Mood and anxiety disorders most prevalent mental illnesses. } 1 in 4 Canadians will have an anxiety disorder in their life } 4.7% of Canadians over age of 15 meet criteria for an anxiety disorder over past year
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What is Anxiety? } Anxiety = physical symptoms, emotion, worry thoughts } 1) Intense and prolonged feelings of fear and distress that occur out of proportion to the actual threat or danger } 2) Feelings of fear and distress that interfere with normal daily functioning
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What Treatments Work for Anxiety Disorders? } Evidence Based Treatments are: } Cognitive Behavioral Therapy } Medication Anxiety Review Panel . Evans, M., Bradwejn, J. & Dunn L. (Eds.). Guidelines for the treatment of anxiety disorders in primary care. Toronto: Queen’s Printer of Ontario.
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CBT Model of Anxiety Fear Stimulus Misinterpretation of Threat Anxiety Avoidant Coping Absence of Corrective Experience
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CBT Model of Anxiety Fear Stimulus Misinterpretation of Threat Cognitive restructuring Anxiety Relaxation training Avoidant Coping Exposure Absence of Corrective Experience Exposure
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Setting and Context } Usually outpatient (could be inpatient or self-directed) } Individual or group do not differ in outcomes } 10 – 20 weekly sessions
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Panic Disorder } DSM-5 criteria: } Recurrent, unexpected panic attacks that peak within 10 minutes } One month+ of fear of recurring panic attacks and/or avoidance of activities that fear may prompt an attack } Panic attacks (some symptoms) } Racing or pounding heart } Shortness of breath } Chest pain } Nausea } Dizziness/feeling faint } Fear of dying, fear of losing control } Chills or hot flushes } Depersonalization or derealization
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Panic Disorder } Two factors that are particularly important for panic disorder: } 1) Anxiety sensitivity or “fear of fear” } 2) Interoceptive awareness } S ensitivity to bodily sensations
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From Initial Attack to Panic Disorder } Often first (and later) attacks are unexpected } Leads to a generalized fear of having another attack } 1) Monitoring physical sensations à interoceptive conditioning } The physical sensations elicit bursts of anxiety } 2) Catastrophic misappraisal of bodily sensations ) of bodily serious and potentially fatal disease
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Specific Interventions } Psychoeducation regarding panic } Self-monitoring } Breathing retraining* } Applied relaxation* } Cognitive restructuring } Exposure } Especially interoceptive exposure } *mixed evidence – can become a safety behavior Safety Behavior = behavior that temporarily provides some relief from anxiety but can interfere with effective exposure therapy
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} Principles: } Fear learning generalizes } Safety learning is context dependent } As humans, we learn new associations } Goals: } Disconfirm misappraisals } Extinguish conditioned responses Principles and Goals of Exposure
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Important Steps of Exposure } 1) Provide a rationale } 2) Develop a hierarchy based on projected SUDs } 3) Exposure to all different parts of feared situations } Keep track of SUDs à check every 5 minutes } No safety behaviours } 4) Practice repeatedly in session } 5) Debrief } 6) Assign homework: regular practice is KEY!
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Fear Hierarchy
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Types of Exposure } Interoceptive: Expose client to feared bodily sensations } In vivo: Expose clients to feared situations in real life } Imaginal exposure if outcome not probable (e.g., tapes)
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Exposure in action } https://www.youtube.com/watch?v=wE5F-FjbTRk
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How does exposure work? ORIGINAL THEORY: } Emotional processing theory } Clients must HABITUATE to the fear } First habituate WITHIN the session } Then habituate ACROSS sessions } Then eventually the fear is diminished long-term } So, we want to see the SUDs subsiding each time we do an exposure exercise
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How does exposure work? } BUT… } Evidence suggests that within-session habituation is not a good predictor of treatment outcome } Some clients will not experience habituation in a 60-90 minute session } Evidence on between session habituation relative to outcome is mixed } Some clients experience great symptom reduction (e.g., less distress and avoidance) but experience similarly intense anxiety each time they are exposed to fear-inducing stimuli
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How does exposure work? CURRENT THEORY } Optimizing Inhibitory Learning } Focusing on reducing fear might be counterproductive } Lesson = fear is not dangerous IF it is controlled } Instead of extinguishing the fear, exposure is teaching a new, secondary association } Lesson = fear is not dangerous } Goal = increase client’s ability to tolerate fear
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What About Relaxation Training? } Exposure alone just as effective as exposure plus breathing retraining (BR not an essential component) } Meta-analyses of relaxation therapy and CBT for generalized anxiety disorder and panic disorder (Siev & Chambless, 2007) } RT and CBT equally effective for GAD } CBT superior to RT for all domains of panic disorder (treatment success 41% for RT, 59% for CBT)
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The Role of Medication in Anxiety Disorders } Medication only, CBT only, or combo are effective } Medication may be contraindicated during exposure } BUT D-cycloserine may improve effects } Sequential approach for anxiety: } 1) Try CBT } 2) Switch to meds after 3 months if no response
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0.68 0.88 0.47 0.55 0.55 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 CBT Benzo diazepines Effect Size (Cohen’s d) CBT (IE+CR) Non-SSRI ADMs SSRIs ADMs Meta-Analyses of Panic Disorder Treatment Studies (Gould et al., 1995; Otto et al., 2001)
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Treatment Gains in CBT for Panic
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Treatment Acceptability (i.e., Dropout Rates) 0 5 10 15 20 25 30 35 40 Panic SAD GAD OCD PTSD Diagnostic Group CBT BZ ADMs SSRI Percent Dropout Panic SAD GAD OCD PTSD
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So, what does the evidence tell us? CBT for Panic (and other Anxiety Disorders) } CBT is efficacious } CBT is specific } CBT is often superior to medications } CBT has good acceptability and low drop-out } CBT is effective } …. But we can still get better at treating panic
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Class Exercise } Suppose you have a client with whom you are about to start exposure for OCD. The client fears that she will be contaminated by dirt and germs and avoids touching anything in public places. She brings kleenex with her to wrap over her hand if she has to touch something. Her ritual to reduce her anxiety involves making sure objects are always organized symmetrically, and she spends hours each day organizing and reorganizing her possessions. } 1) Briefly explain how you would describe what “ exposure therapy ” is. Include a description of what you will do and how it’s supposed to work. } 2) Once you tell her about exposure, she is terrified to start. What might you say to calm her fears?
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