1. Introduction to Clinical Psychology Science, 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

2. Psychotherapy 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) Copyright ©Allyn & Bacon 2005

3. Psychotherapy Participants Psychotherapy Client Psychotherapist Psychotherapy Relationship

4. Copyright ©Allyn & Bacon 2005 Psychotherapy Client People in distress People “in a state of incongruence” (Rogers, 1957) Looking for help (most, but not all) Psychotherapy Clients vary in – Age – Income – Ethnicity etc.

5. Copyright ©Allyn & Bacon 2005 Psychotherapy Client: Who Benefits? Depression Panic disorder Bulimia Nervosa Obsessive-compulsive disorder Specific phobia Headache Oppositional Children Marital distress

6. Copyright ©Allyn & Bacon 2005 Limitations of the “who gets better” approach Not all people who seek psychotherapy fall neatly into one diagnostic category or another Not all clients with these disorders improve

7. Copyright ©Allyn & Bacon 2005 Psychotherapy Client: Who seeks tx and who stays involved? White Middle or upper middle class Better educated Mexican and Asian Americans least likely to seek tx

8. Copyright ©Allyn & Bacon 2005 Psychotherapy Client: Other Characteristics and their relationship to outcome Age – unrelated to outcome Level of distress – evidence mixed but generally more distress poorer outcome Ethnic Minority – unrelated to outcome (but a match between therapist and client related to positive outcome) SES – unrelated to outcome

9. Copyright ©Allyn & Bacon 2005 Psychotherapists Training – Psychology – Psychiatry – Social work – Counseling – Nursing – “non-professional” Experience

10. Copyright ©Allyn & Bacon 2005 Psychotherapists 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.

11. Copyright ©Allyn & Bacon 2005 Psychotherapists Characteristics 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

12. Copyright ©Allyn & Bacon 2005 Psychotherapy Relationship Takes place in a socially sanctioned place of healing Frequency and length of meetings planned and limited Goals of relationship are specified Therapeutic alliance Confidential

13. Copyright ©Allyn & Bacon 2005 Limits 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

14. Copyright ©Allyn & Bacon 2005 Common Factors Therapist-offered conditions – Empathy, warmth, caring, nonjudgmental attitude Expert Role Release of emotions Therapeutic Alliance Distress Reduction Rationale/insight Competence/mastery

15. Copyright ©Allyn & Bacon 2005 Psychotherapy Research “In the absence of science, opinion prevails.” (Nathan & Gorman, 1998)

16. Copyright ©Allyn & Bacon 2005 Goals of Psychotherapy Research 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?).

17. Copyright ©Allyn & Bacon 2005 Psychotherapy Research Strategies 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

18. Copyright ©Allyn & Bacon 2005 Single Subject and Small N Designs Single subject experimental design Assumption: changes in dependent variable (outcome) are unlikely to occur with the introduction (or removal) of the treatment by chance

19. Copyright ©Allyn & Bacon 2005 Single Subject Design: Essential Requirements Repeated assessment of behavior of interest Establishment of a baseline Treatment clearly specified Replication A/B/A/B design – A = baseline (no treatment – B = treatment

20. Copyright ©Allyn & Bacon 2005 Single Case Experimental Design Percentage of Class Time in Seat A B A B

21. Copyright ©Allyn & Bacon 2005 Multiple 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

22. Copyright ©Allyn & Bacon 2005 Between 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

23. Copyright ©Allyn & Bacon 2005 Control Groups No treatment Wait list “Placebo” – Credible but should not work – according to theory – “Common factors”

24. Copyright ©Allyn & Bacon 2005 Research questions and research 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

25. Copyright ©Allyn & Bacon 2005 More research questions and research designs Which treatment works best? – Comparative Design Which treatment works best and is the combination better than each one alone? – Factorial Design

26. Copyright ©Allyn & Bacon 2005 Example factorial design No medication No psychotherapy A Medication No Psychotherapy B Psychotherapy No Medication C Psychotherapy Medication D

27. Copyright ©Allyn & Bacon 2005 Single Subject and Small N Experimental 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

28. Copyright ©Allyn & Bacon 2005 Analogue 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

29. Copyright ©Allyn & Bacon 2005 Analogue Research Advantages – Can study clinically relevant phenomena in a controlled setting – Can use large n – Strong internal validity Disadvantages – Questionable external validity

30. Copyright ©Allyn & Bacon 2005 Analogue versus Clinical Research 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

31. Copyright ©Allyn & Bacon 2005 Validity of Psychotherapy Research 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

32. Copyright ©Allyn & Bacon 2005 Measuring outcome in psychotherapy 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?)

33. Copyright ©Allyn & Bacon 2005 Measuring clinical significance What percentage of clients who receive the treatment are like normal people?

34. Copyright ©Allyn & Bacon 2005 Client scores within 1 sd of the mean Distribution of Normal People on Variable of Interest

35. Copyright ©Allyn & Bacon 2005 Measuring clinical significance What percentage of clients who receive the treatment are like normal people? What percentage of clients who receive the treatment are no longer like abnormal people?

36. Copyright ©Allyn & Bacon 2005 Client score outside of 2 sd of the mean of abnormal sample Distribution of Abnormal People on Variable of Interest

37. Copyright ©Allyn & Bacon 2005 Measuring clinical significance What percentage of clients who receive the treatment are like normal people? What percentage of clients who receive the treatment are no longer like abnormal people? Subjective Evaluation Quality of life (or similar broad measure) Social Impact

38. Copyright ©Allyn & Bacon 2005 Does Psychotherapy Work? Eysenck (1952) Smith & Glass (1977) – meta-analysis Empirically Supported (or Empirically Validated) Treatments (Barlow – Task Force, 1995)

39. Copyright ©Allyn & Bacon 2005 Efficacy vs. Effectiveness Research Efficacy – Tightly controlled, strong on internal validity Effectiveness – Examine effectiveness of psychotherapy as delivered in the field

40. Copyright ©Allyn & Bacon 2005 Are psychotherapies equally effective? “dodo-bird conclusion” – Sloane et al. (1975) – NIMH-TDCRP Common factors