Psyc 371 Week 2 Slides

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Psychology 371 Intervention: Process & Outcome Lynnaea Owens, Ph.D. Simon Fraser University Department of Psychology September 14, 2023
Course Updates v In-Class Reflection 1 Grades on Canvas v Please review Canvas announcement on missed reflections v Readings are now updated on Canvas v Please email me if you’re unable to see the course in Canvas
Today’s Topics v How do we know if therapy works? v Empirically Supported Treatments v Evidence-Based Practice
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Is Therapy Art or Science? v A quick pretest: v A) Therapists should follow their clinical intuition when deciding how to respond to clients v B) Therapists should stick to a manual of established practices when deciding how to respond to clients
Is Therapy Art or Science? v A quick pretest: v A) The most important part of therapy is maintaining a good relationship with the client v B) The most important part of therapy is achieving measurable improvements in the client’s symptoms or functioning
Is Therapy Art or Science? v A quick pretest: v A) It is impossible to quantify the mechanisms and outcomes of therapy because there are too many individual differences in clients and therapists v B) It is necessary to quantify the mechanisms and outcomes of therapy to understand what works, for whom, and how
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What does it mean for therapy to WORK? } Two processes: } IDIOGRAPHIC: Is the treatment I’m providing to this particular client producing the changes I’m hoping to produce? } NOMOTHETIC : Does a particular kind of treatment work for clients with certain kinds of problems/disorders/characteristics ?
What does it mean for therapy to WORK? } What outcomes are possible? } The patient gets better } There is no change } The patient gets worse } Mixed outcomes (better in some ways, worse in others) } Problem = who decides? } Duration of effects? } Acute relief: Get well } Long-term relief: Stay well (being “cured”)
What does it mean for therapy to WORK? } What outcomes are we looking for in therapy? As a clinician… As a policy maker… As a client…
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Types of evidence v 1) Anecdotal (idiographic) v 2) Empirical (nomothetic) v Pre-post designs v Experimental
Types of Evidence Anecdotal : What are the problems? v Hindsight bias
Types of Evidence Anecdotal : What are the problems? v Confirmation bias
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Types of Evidence Anecdotal : What are the problems? v Demand characteristics
Types of Evidence Anecdotal : What are the problems? v Placebo effects
Types of Evidence v Empirical : Systematic, a priori system of observation to quantify change in targets. v Pre-post designs : Measure X before, give treatment, measure X after. Depression Before (Clinical interview? Self- report measure?) Depression After (same assessment as before) 10 sessions of CBT
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Types of Evidence Pre-post designs : What are the problems? v We know it worked but don’t know why v Spontaneous remission/passage of time v Regression to the mean v Many of the problems with anecdotal still apply v Researchers have cognitive biases v Overgeneralization (if it worked in this study, it will always work) v Affiliation with the type of therapy
Types of Evidence How do we get around this? v Experimental designs with a CONTROL group v The gold standard for evaluating treatments is a Randomized Controlled Trial (RCT) v RCT = An experiment in which patients are randomly assigned to the treatment of interest OR to one or more comparison conditions
Random Assignment v Random assignment is a procedure used in experiments to create multiple study groups, that include participants with similar characteristics so that the groups are equivalent at the beginning of the study. v Planned – groups allocated before treatment
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Randomized Controlled Trial Treatment of Interest (n = 50) No Treatment Control (n = 50) Sample (n = 100)
Random Assignment v Often, we don’t have very large samples in psychotherapy research Solution = Matching! v 1) What are key constructs you would want to hold equal between groups? v 2) Assign pairs based on key construct v 3) Randomly assign members of each pair to treatment or control
Other Considerations in RCTs v Attrition/Drop-Out rates v Long-term outcomes (what happens after treatment?) v Increased benefits? No change? Relapse?
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Battling Bad Science
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Empirically Supported Treatments
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Treatment Development How Do People Develop Treatments? } Stage 1: Development } Need for Treatment } Feasibility } Face-validity } Stage 2: Validation } Efficacy } Internal Validity } Stage 3: Dissemination } Effectiveness } External Validity
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Empirically Supported Therapies (ESTs) } Late 1990s, we decided to make formal criteria! } EST : Clearly specified psychological treatment shown to be efficacious in controlled research with a delineated population
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In general, when I talk about ESTs } Assume they’re being delivered by someone who is competent at basic clinical skills } Any therapy, if delivered poorly, isn’t going to do well } Manual ≠ robot
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ESTs Efficacious Specific Effective Efficient
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ESTs: Efficacy } Efficacy (Chambless & Hollon, 1998) } Does the treatment produce change? } We must be able to attribute any change that happens to the treatment we gave. } If change could be explained by anything else, we don’t have efficacy!
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ESTs: Efficacy Requires controlled research (remember RCTs) } Efficacious: (Chambless & Hollon, 1998) } When a treatment has been found efficacious in at least 2 studies } And …When a treatment has been found efficacious by independent research teams } Possibly efficacious: } Only one study } Or …all research conducted by one team
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ESTs: Efficacy (Chambless & Hollon) } Why do we need differences in > one study? } Need to control for spurious findings, experimental differences } Why different research teams? } Need to control for allegiance/investigator effects: } Is the investigator the developer of the treatment? Are they especially invested in seeing if the treatment works?
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ESTs: Efficacy } Efficacy is basically, does the treatment work better than if we do nothing at all ? } Passage of time } Spontaneous remission
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ESTs: Efficacy } Ethically, we can’t just do nothing } Tx is compared to a WAIT LIST CONTROL
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ESTs: Efficacy } WAIT LIST CONTROL holds constant: } Passage of time } Regression to the mean } To some extent, hope / expectation of change
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ESTs Efficacious Specific Effective Efficient
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ESTs: Specificity } If you have specificity, must have efficacy…. } Efficacious and Specific } If the treatment is found to be superior to conditions that control for nonspecific processes
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ESTs: Specificity } Hawthorne Effect (Roethilsberger & Dickson 1939). } Participants increased output simply as a result of being in a study } So, attention alone can make a difference!
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Non-Specific Factors } Factors that are common across all therapies } Therapist attention } Warmth } Alliance } Expectation of change } Time spent in tx
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Specific Factors } Does the treatment X do better than these non- specific factors ? } … better than just warmth and attention? } … better than a therapy placebo? } Is there something unique about treatment X that makes it effective?
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Specificity What is a reasonable therapy placebo ? } Horse-race studies: Control condition is another bona fide treatment à most rigorous comparison } Should include attention, warmth, expectations, appointments } Control conditions can include attention only control, non-specific or supportive therapy, treatment as usual, etc.
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ESTs Efficacious Specific Effective Efficient
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ESTs: Effectiveness } Effectiveness: } Does the treatment actually work in real-world clinical settings? } Studies in naturalistic settings } Quasi-experimental, uncontrolled designs are common, but not the only way!
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ESTs: Effectiveness “Treatment efficacy studies involve methodological efforts to maximize the internal validity of a study, . . . such as random assignment to treatment and control conditions, training of therapists to a specified level of competence in providing the treatment, and ensuring that all participants have the condition that the treatment was designed to address. Treatment effectiveness studies , on the other hand, strive to maximize external validity while maintaining an adequate level of internal validity . . . Most commonly, efforts to enhance external validity involve locating the treatment study within clinical service sites that provide ongoing health services, thus using clinicians who are routinely providing psychological services and patients who have been referred to the clinical settings” (Hunsley, 2007, p. 117)
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ESTs Efficacious Specific Effective Efficient
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ESTs: Efficiency } Efficiency: } Cost effectiveness } Treatments that cost the least are likely to be preferred if there is no great difference in outcome } Need to consider short-term and long-term gain
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ESTs – Self Quiz 1. Is therapy X cost- effective? 2. Does therapy X work? 3. Does therapy X work in real-world settings? 4. Does therapy X work better than therapy Y? B. Specific C. Effective D. Efficient A. Efficacious
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ESTs - Answers 1. Is therapy X cost- effective? 2. Does therapy X work? 3. Does therapy X work in real-world settings? 4. Does therapy X work better than therapy Y? B. Specific C. Effective D. Efficient A. Efficacious
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ESTs: Other Considerations } Feasibility: Is the treatment “doable”? Do clients show up? Can therapists do it? } Dissemination: How do we make the treatment available?
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ESTs: Other Considerations } Clinical Significance (Jacobson et al., 1999) } How meaningful or important are the effects of the treatment? } Return to “ normal functioning ” } Effects must be statistically significant. } % who no longer have diagnosis? } % improved?
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ESTs: Other Important Considerations (Chambless & Hollon) } Clearly defined population } Treatment manual } Reliable and valid outcome measures } Patient compliance } Therapist training/therapist adherence } Blinding } Single-blind is assessors OR client don’t know what condition client is in } Double-blind is client AND assessors don’t know what condition client is in
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Class Exercise } Research Issues in Treatments } Break up into groups of three } Work on vignettes together } Critique the study } What ’ s wrong (if anything) with the researcher ’ s approach, and what do you think could improve it?
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Class Exercise Vignette #1: Dr. Logaria ’ s Treatment for Long-Talkers Dr. Logaria developed a new treatment to reduce excessive talking in “ long talkers ” . Her treatment (Talk Reduction Therapy; TRT) was based on the theory that people talk excessively because they have developed a style of life that involves seeking dominance, as evidenced by monopolizing conversations. As such, the treatment involved helping the client to recognize their style of life and develop a more pro-social style of life. She assigned the first 40 long- talkers to enter her clinic to TRT and the next 40 to a wait-list control condition. The therapists consisted of bachelor level psychology undergrads recruited from the local university. Dr. Logaria met with the therapists at the end of the study to ask them what types of interventions they used during treatment. The assessors evaluated clients’ talk-time percentages and other aspects of talking behaviour at several intervals over the 4-month treatment. TRT resulted in greater reductions in talking frequency and length, but this finding did not occur in a second study conducted at another lab by Dr. Abrupt. Nevertheless, Dr. Logaria criticized the second study and concluded that her treatment was efficacious.
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Class Exercise Vignette #2: Dr. Hope ’ s Treatment for Suicide Dr. Hope developed a new treatment to reduce suicidal behaviour. His treatment (Behavioural Control Therapy; BCT) was based on the theory that people attempt suicide because they have difficulty inhibiting impulsive, self-destructive behaviour. As such, the treatment involved reducing suicide attempts by learning how to control impulsive behaviour. He randomly assigned 50 suicidal individuals to his treatment and 50 suicidal individuals to an alternative, well-established treatment for suicidal behaviour. The assessors in his clinic (under his supervision) were given a list of the clients being treated and the therapists treating them, and conducted assessments of client functioning at several intervals throughout the 1-year treatment. The therapists were well-trained and their adherence to treatment was monitored. The findings indicated that BCT performed better than the alternative treatment in reducing suicide attempts. Dr. Hope concluded that his treatment was efficacious and specific .
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Critiquing the Research } Things to look out for… } Was there a control group ? } Was it an appropriate control group? } Would we be able to determine efficacy and specificity ? } Were the therapists trained adequately? } Who were the participants ? } Were there enough study participants for the results to be meaningful ? } Did the study evaluate adherence to treatment? } Was there random assignment to groups? } Did the investigators evaluate appropriate outcomes ? } How did they manage allegiance effects?
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Evidence-Based Practice
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Evidence-Based Practice } Based on model of Evidence-Based Medicine (Sackett et al., 1996) } A new standard for providing health care (APA, 2006) } “ …the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences . ” - APA, 2006, p. 273
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Continuum of Care Nomothetic (decisions based on disorders, guidelines, treatment manuals, ESTs) Evidence-based practice Idiographic (decisions based on individual patients and circumstances)
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Three Components of EBP (Bauer, 2007) Best available research Patient characteristics Clinical expertise EBP
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Clinical Expertise } The individual clinician’s competency for treating specific clients with specific problems } Develops through: } Graduate training } Ongoing training (e.g., workshops, seminars) } Clinical experience from working with clients Therapists use clinical expertise to plan therapy, or, if they do not have sufficient expertise, referring the client somewhere else or seeking supervision.
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Patient Characteristics Universal Group Individual Universal: • Biological similarities • Common life experiences • Self-awareness • Ability to use symbols to communicate
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Patient Characteristics - Group Race Gender Ability/Disability Sexual Orientation Socioeconomic Status Religion/ Spirituality Geographic Location Culture Age
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Patient Characteristics - Individual Preferences about therapy Personality Past experiences
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Patient Characteristics } “culture can be defined as a dynamic process involving worldviews and ways of living in a physical and social environment shared by groups, which are passed from generation to generation and may be modified by contacts between cultures in a particular social, historical, and political context” ~ Whaley & Davis, 2007
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Cultural Competency } Psychologists are expected to develop cultural competency in three categories (Sue, 2001): } Attitudes/beliefs – understand one’s own culture and experiences that affects personal beliefs, values, and attitudes } Knowledge – understand the worldviews of culturally different individuals and groups } Skills – develop culturally appropriate intervention/ communication skills
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Complexity! } Intersectionality – everyone belongs to multiple groups based on ethnicity, gender, culture, age, sexual orientation etc. } Culture can be visible and invisible } How people dress = visible; beliefs = invisible } Every group has internal diversity } Not every member of a group will share the same beliefs or engage in the same behaviors } Identities and cultures are dynamic, they change over time } One never “achieves” cultural competency Due to this complexity, it is important to not make assumptions about someone’s identity.
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Best Available Research… } Evidence drawn from variety of designs and methodologies } Balances internal and external validity
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Research Generalizability External Validity Internal Validity The Balance
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The Process of EBP } The Five As (Sackett et al, 2000) } Ask } Acquire } Appraise } Apply } Assess
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The Process of EBP: ASK } Ask clinical questions about… } Patient characteristics } Diagnosis: what test results? How good are the tests? } Prognosis } Interventions : what treatments are effective for diagnosis?
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The Process of EBP: ACQUIRE } Acquire evidence } Use search engines (psychinfo, medline) } Cochrane reviews (www.cochrane.org) } Registry of clinical trials (e.g., NIH) } “ NICE: National Institute for Health and Clinical Excellence ” – tells you what to do (www.nice.org.uk)
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The Process of EBP: APPRAISE } Appraise evidence } Gold standard and good place to start = blind RCT } Lower-grades of evidence = quasi-experimental studies, case studies } Strength of the findings } Completion rates of treatment in the study } Any follow-up data?
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The Process of EBP: APPLY } Apply to my patient: } How similar is my patient to the sample in the study? } Use patient characteristics (e.g., severity of condition, age, etc.) to determine: } Treatment structure (e.g., # of sessions, booster sessions) } Delivery format (e.g., group, individual, phone, self-management) } Also, the clinician must be COMPETENT to provide the treatment
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The Process of EBP: ASSESS } Assess } At the beginning } Symptoms fitting with patterns/profiles? } Any change/progress? } If not working, might need to switch strategies, switch therapists or even stop therapy!
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EBP vs. EST } EBP } More comprehensive } Less rigid } Less prescriptive } Start with the patient and asks what research evidence will assist the therapist in achieving the best outcome } Encompasses a broader range of clinical activities } Integrates multiple streams of research evidence, including but not limited to RCTs
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EST and EBP: Controversies } EBP: Arguments in favor } Necessary to advance our status in medical settings } Scientific method is good enough for other sciences, good for us! } Meet aspiration to help people } “Treatment methods are not where all the action is in relation to outcome, but they are the logical place to intervene to improve care.”
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EST and EBP: Controversies } EBP: Arguments against } Bias in terms of what gets tested } Based on diagnosis; most clients walk in with several (plus other stuff) going on, or none. } Training in EST is not sufficient for expertise in therapy
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Summary } How do we know if therapy is working? } ESTs } Efficacy } Specificity } Effectiveness } Efficiency } Evidence-based practice in psychology } Clinical expertise, patient characteristics, and research evidence } Five As of EBPP
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Theories of Personality (MindTap Course List)
Psychology
ISBN:9781305652958
Author:Duane P. Schultz, Sydney Ellen Schultz
Publisher:Cengage Learning
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