Empirically Supported Psychological Treatment

C. Ervin Davis III, Ph.D.Assistant Professor

Department of Psychology East Carolina University

daviscl@ecu.eduhttp://core.ecu.edu/psyc/daviscl/

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

Part I. The Research METHODS

What is Empirically Supported Treatment? (EST)

• For psychotherapy, does EST mean anything?

• Or, have we been played for a Fool?

• Medical Model

• Science & Art

What is Psychotherapy Research?

• First – some definitions– Empirical– Psychotherapy– Theory– Hypothesis– Empirical Support– Efficacy & Effectiveness

• Second – Methods of research

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

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)

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

Theory & Hypotheses

Theory: set of ideas, principlesto explain & predict

Hypotheses: tentative, statements based on theory that can be testedempirically

Theory

Hypothesis

Hypothesis

Hypothesis

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"

Efficacy or Effectiveness

• Efficacy – In the Lab – Analog Therapy – Not real therapists, Not real patients, Not real world

• Effectiveness – In the real world

Vs.

Most of the research on psychotherapy has been of efficacy.

Lab Reality

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

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-treatmentStandard treatment (TAU))Blinding?

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”

Effect Size

• 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 / where (between 2 conditions)

= [(X - M)² / N] (standard deviation)– where X is the raw score, M is the mean, and

N is the number of cases.

How much did these groups (means) differ?

The Research problem

Client Problems (diagnosis)

X

Client Personal Characteristics

X

Therapy Approaches

X

Therapist Characteristics

X

Situation/ Circumstances10 x 10 x 10 x 10 x 10 = 100,000 combinations!

How big is this question about psychotherapy research?

“She’s BIG problem quicksdraw”

Big cube

Part II. The Research RESULTS

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)

History 101-- Psychotherapy Research

• See your Timeline

Where’dthat

therapist go?

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

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

Results

• 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?

A large body of research has addressed the following questions:

Remember the “fool” and the 100,000 combinations.

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)

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

Seligman, 1995 – Consumer Reports Survey

Seligman, 1995 – Consumer Reports Survey

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

Underdog.wav

27 effect sizes.05 – 4.34

Lambert, 2004

Lambert, 2004

59 effects, -.19 to 3.45

APA Task Force Report

2 group studies

>Placebo or other Tx.

Adequate powerOr large seriessingle case

manualized

Samples defined

2 group studies

>Waiting-list

Sample heterogeneous

Or small seriessingle case

Or 2 by same lab or 1 good

Does therapist experience matter?

• Strupp & Hadley, 1979 Therapists vs. College Professors

• Stein & Lambert, 1995 Meta Analysis, 33 studies--more training correlated with lower dropout, more satisfaction & better outcome

M.A.

M.S.W.

PsyDR.N

M.D.

Ph.D.

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 DepressionSingle & 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

•NIMH Depression Collaborative Research Program -- (Elkin, Gibbons, Shea, Sotsky, & et al., 1995)

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.

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.

“Lower is better”

PLA-CM, CBT

IMI-CM IPT

IPTIMI-CM

CBT

PLA-CM

More severely depressed patients

Thase, 1997

Meta analysisIn 6 studies

No sigDiff.

Sig.Diff.

Therapy aloneor combined with medication

(Reynolds et al., 1999)

107 pts fully recovered from depression at BL, Age > 59

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.

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

Lambert, Hansen, & Finch, 2001Meta Analysis

6,072 patients

Are specific ingredients therapeutic?

• (Ahn & Wampold, 2001)– Meta Analysis of 27 studies

comparing a treatment and a treatment without a therapeutically important component

Ahn & Wampold, 2001

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

Common Factors

From Lambert (2004)

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)

Jarrett et al., 2001

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

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