Introduction to Clinical Psychology Science, Practice and Ethics Chapter 10 Psychotherapy: Research...

Introduction to

Clinical PsychologyScience, Practice and Ethics

Chapter 10

Psychotherapy: Research Issues and Efficacy

This multimedia product and its contents are protected under copyright law. The following are prohibited by law:•Any public performance or display, including transmission of any image over a network;•Preparation of any derivative work, including the extraction, in whole or in part, of any images;•Any rental, lease, or lending of the program

Copyright ©Allyn & Bacon 2005


Psychotherapy DefinitionPsychotherapy Definition

Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other person characteristics in directions that the participants deem desirable (Norcross, 1990, p.218)



Psychotherapy ParticipantsPsychotherapy Participants

Psychotherapy ClientPsychotherapistPsychotherapy Relationship


Psychotherapy ClientPsychotherapy Client

People in distressPeople “in a state of incongruence”

(Rogers, 1957)Looking for help (most, but not all)Psychotherapy Clients vary in

– Age– Income– Ethnicity etc.


Psychotherapy Client:Psychotherapy Client:Who Benefits?Who Benefits?

Depression Panic disorder Bulimia Nervosa Obsessive-compulsive disorder Specific phobia Headache Oppositional Children Marital distress


Limitations of the “who gets Limitations of the “who gets better” approachbetter” approach

Not all people who seek psychotherapy fall neatly into one diagnostic category or another

Not all clients with these disorders improve


Psychotherapy Client:Psychotherapy Client:Who seeks tx and who stays involved?Who seeks tx and who stays involved?

WhiteMiddle or upper middle classBetter educatedMexican and Asian Americans least likely

to seek tx


Psychotherapy Client:Psychotherapy Client:Other Characteristics and their Other Characteristics and their

relationship to outcomerelationship to outcome

Age – unrelated to outcomeLevel of distress – evidence mixed but

generally more distress poorer outcomeEthnic Minority – unrelated to outcome (but

a match between therapist and client related to positive outcome)

SES – unrelated to outcome


PsychotherapistsPsychotherapists

Training– Psychology– Psychiatry– Social work– Counseling– Nursing– “non-professional”

Experience


PsychotherapistsPsychotherapists

Nonjudgmental Empathic Warm Caring Place client’s needs above their own Genuine Socially sanctioned healers These are not personality characteristics. They are

characteristics of therapists during the therapy hour.


Psychotherapists Psychotherapists Characteristics and OutcomeCharacteristics and Outcome

Training – unrelated to outcome Experience – unrelated to outcome Gender – unrelated to outcome Age – unrelated to outcome Well-being – correlated with outcome Expectations about client – related to outcome Competence – related to outcome


Psychotherapy RelationshipPsychotherapy Relationship

Takes place in a socially sanctioned place of healing

Frequency and length of meetings planned and limited

Goals of relationship are specifiedTherapeutic allianceConfidential


Limits of ConfidentialityLimits of Confidentiality

With written consent of client Comply with reporting laws

• Child abuse• Abuse of disabled or elderly

Protect the client and others• “Tarasoff”• Suicide prevention

Mandated by court (subpoena) Consulting with colleagues


Common FactorsCommon Factors

Therapist-offered conditions– Empathy, warmth, caring, nonjudgmental attitude

Expert Role Release of emotions Therapeutic Alliance Distress Reduction Rationale/insight Competence/mastery


Psychotherapy ResearchPsychotherapy Research

“In the absence of science, opinion prevails.” (Nathan & Gorman, 1998)


Goals of Psychotherapy Goals of Psychotherapy ResearchResearch

To understand the efficacy of various forms of treatment for various problems (e.g., does treatment A help people with problem B?). This is referred to as outcome research.

To understand the mechanisms by which treatment works (e.g., what causes people with problem B to get better when they receive treatment A?). This is referred to as process research.

To understand the factors that influence the efficacy of treatment (e.g., why do some people get better with treatment A and others don’t?).


Psychotherapy Research Psychotherapy Research StrategiesStrategies

True experiments– Participants carefully selected– Participants are randomly assigned– Treatment integrity

Quasi-experiments– Non-random assignment

Passive-observational– Only one condition – no assignment– Often naturalistic


Single Subject and Small N Single Subject and Small N DesignsDesigns

Single subject experimental designAssumption: changes in dependent variable

(outcome) are unlikely to occur with the introduction (or removal) of the treatment by chance


Single Subject Design: Essential Single Subject Design: Essential RequirementsRequirements

Repeated assessment of behavior of interestEstablishment of a baselineTreatment clearly specifiedReplicationA/B/A/B design

– A = baseline (no treatment– B = treatment


Single Case Experimental DesignSingle Case Experimental Design

0

10

20

30

40

50

60

70

Baseline Reinforce Reversal Reinforce

Percentage of Class Time in Seat

A B A B


Multiple Baseline DesignMultiple Baseline Design

Measure same behavior over a small group of participants (e.g., three)

For example: Three hyperactive kids: Mick, Keith, and Ron– Mick – one week of baseline assessment– Keith – two weeks of baseline assessment– Ron – three weeks of baseline assessment

Look for change occurring with the introduction of treatment


Between Group DesignsBetween Group Designs

Participants are randomly assigned to treatment and control conditions

Assume that random assignment controls for nuisance variables

Assume differences are due to treatment


Control GroupsControl Groups

No treatmentWait list“Placebo”

– Credible but should not work – according to theory

– “Common factors”


Research questions and Research questions and research designsresearch designs

Does treatment A work?– Treatment A versus control

What components of treatment lead to therapeutic change?– Dismantling design

Can the effects of treatment be enhanced?– Constructive design


More research questions and More research questions and research designsresearch designs

Which treatment works best?– Comparative Design

Which treatment works best and is the combination better than each one alone?– Factorial Design


Example factorial designExample factorial design

No medication

No psychotherapy

A

Medication

No Psychotherapy

B

Psychotherapy

No Medication

C

Psychotherapy

Medication

D


Single Subject and Small N Single Subject and Small N Experimental DesignExperimental Design

Can be used to evaluate any type of psychotherapy

Has been used most frequently to evaluate behavior therapies– Intervention is clearly specified– Overt behavior is of primary interest


Analogue ResearchAnalogue Research

In psychotherapy research, typically testing a psychotherapy under very carefully controlled circumstances with an analogue (i.e., nonclinical) sample

For example – college students with mild phobias, moderate depression, or excessive body image concerns but not an eating disorder


Analogue ResearchAnalogue Research

Advantages– Can study clinically relevant phenomena in a

controlled setting– Can use large n– Strong internal validity

Disadvantages– Questionable external validity


Analogue versus Clinical Analogue versus Clinical ResearchResearch

A false dichotomy More a matter of degree All psychotherapy research is analogue to a

certain degree Psychotherapy studies differ from clinical practice

in – How subjects are recruited– Types of clients treated– Assessment procedures– How treatment is delivered


Validity of Psychotherapy Validity of Psychotherapy ResearchResearch

Internal validity– Confidence that treatment caused change in outcome variables

External validity– Confidence that results can be generalized outside of the research

setting Construct validity

– Confidence that change occurred for the reasons the researcher thinks it occurred

Statistical conclusion validity– Confidence that statistical analysis led to correct conclusion


Measuring outcome in Measuring outcome in psychotherapy studiespsychotherapy studies

Statistical significance– The difference between the mean score of the

treatment group and the mean score of the control group is larger than would be expected to occur by chance

Clinical Significance– The practical value of the effect of an

intervention. (Does it make a “real” difference?)


Measuring clinical significanceMeasuring clinical significance

What percentage of clients who receive the treatment are like normal people?


Client scores within 1 sd of the Client scores within 1 sd of the meanmean

Distribution of Normal People on Variable of Interest




What percentage of clients who receive the treatment are no longer like abnormal people?


Client score outside of 2 sd of the Client score outside of 2 sd of the mean of abnormal samplemean of abnormal sample

Distribution of Abnormal People on Variable of Interest




What percentage of clients who receive the treatment are no longer like abnormal people?

Subjective EvaluationQuality of life (or similar broad measure)Social Impact


Does Psychotherapy Work?Does Psychotherapy Work?

Eysenck (1952)Smith & Glass (1977) – meta-analysisEmpirically Supported (or Empirically

Validated) Treatments (Barlow – Task Force, 1995)


Efficacy vs. Effectiveness Efficacy vs. Effectiveness ResearchResearch

Efficacy– Tightly controlled, strong on internal validity

Effectiveness– Examine effectiveness of psychotherapy as

delivered in the field


Are psychotherapies equally Are psychotherapies equally effective?effective?

“dodo-bird conclusion”– Sloane et al. (1975)– NIMH-TDCRP

Common factors

Introduction to Clinical Psychology Science, Practice and Ethics Chapter 10 Psychotherapy: Research...

Documents

Transcript of Introduction to Clinical Psychology Science, Practice and Ethics Chapter 10 Psychotherapy: Research...