1. Class 11 and 12 Jacobson et al (1996) Spring 2016 1

2. 2 Experimental Between Group Designs 1. Post-Test Only Control 2. Pre-Test -- Post-Test Control 3. Solomon Four Group (combination of 1 and 2 above) Factorial Design more than one independent variable; interactions gender x treatment Dependent Sample Design (Matching) 2

3. 3 Experimental Between Group Designs Post-Test Only Control Pre-Test -- Post-Test Control Solomon Four Group Factorial Design (Treatment X Therapist) Dependent Sample Design (Matching) # of previous episodes and severity depression, presence of dysthimia, gender, marital stauts 3

4. Types Outcome Studies Kazdin (chap 18) 1. Treatment Package Strategy 2. Dismantling Strategy 3. Constructive Strategy 4. Parametric Strategy (structural components) 5. Common factors Control Group 6. Comparative Outcome Strategy 7. Client and Therapist Variation Strategy Moderation Designs

5. Types Outcome Studies Kazdin (chap 18) 1. Treatment Package Strategy 2. Dismantling Strategy What are the active ingredients ? 1. Constructive Strategy 2. Parametric Strategy (structural components) 3. Common factors Control Group 4. Comparative Outcome Strategy 5. Client and Therapist Variation Strategy Moderation Designs

6. IVsDVs Treatments:Outcome Measures BA- Behavioral Activation At Post Test AT - Automatic Thoughts BDI CT - Cognitive B Therapy HRSD Therapists 4 therapists Treatments X Therapists 6

7. Research Focus Identify change mechanisms Do specific ingredients work as expected? vs. How well treatment works 7

8. Change Mechanisms Activation Hypotheses ( BA) (activation) Change behaviors- become active and access sources of reinforcement- occurs early in therapy Coping Skills Hypotheses (AT) Learn effective cognitive coping strategies (coping + activation) Beck Hypotheses (CT) Change cognitive structures or core schemas (coping + activation + cognitive schemas) 8

9. Chapter 79 Treatment Groups BA Condition: Behavioral Activation Hypotheses: Behavioral Activation AT Condition: Coping Skills Hypotheses Behavioral Activation Coping Skills - Automatic Thoughts CT Condition: Cognitive Therapy Hypotheses Behavioral Activation Automatic Thoughts Core Schemas- Beck’s active mechanism 9

10. Chapter 710 Mechanisms of Change Construct Measure Behavioral Activation Dysfunctional Thinking Cognitive Schemas Pleasant Events Schedule Automatic Thoughts Q. Expanded Attributional Styles How did the authors examine if the mechanisms of change worked in therapy as predicted by theory? 10

11. How Treatment Effects Change To what extent treatment groups differed in post-test measures of each change mechanism Measure Ttreat. G Behavioral activation – Pleasant Event SCd BA Coping skills-- AT (Dist Thinking) AT Core schemas- Exp Attrb Style CT To what extent was there change from pre-to post- treatment in each change mechanism 11

12. How Well Treatments Work Which of the three treatment conditions yielded better outcomes regarding Depression at termination and at 6 month follow up? HRSD BDI Recovered Improved Rates 12

13. How Well Treatments Work Which of the three treatment conditions yielded better Depression outcomes at termination and at 6 month follow up? 3 X 4 MANCOVA IVS 3 Treatments (CT, AT, BA) 4 Therapists Treatment X Therapist (Interaction) DVs – Depression at Termination or 6 month Follow up HRSD – Clinician BDI - Self- Report Co-variates HRSD at Pre-Test or at Termination BDI at 13

14. Outcome: Post-Test Impact of Therapy at Termination ANCOVAS IV:Treatments DVs: Post-Test HRSD BDI Covariate: Pretest residualized change score 14

15. Outcome: Follow-up at 6 months Overall Impact of Therapy ANCOVAS IV:Treatments DVs: Follow-Up HRSD BDI Covariate: Pretest residualized change score Changes in Follow-up Time ( since termination ) ANCOVAS IV: Treatments DVs: Follow-Up HRSD BDI Covariate: Pre-test score 15

16. Which group to use in outcome analyses GroupSessions Intent-to treatTotal sample n = 149 Dropouts (not included in MANCOVA analyses; p. 299) 1<Sessions <12 n = 12 CompletersAt least 12/20 sessions n = 137 Maximum Completers20 sessions n = 129 16

17. Results MANCOVAsTreatment Outcome: Post- Test Depression Main Effect Treatment ? Main Effect Therapist ? Treatment X Therapist Interaction ? Results p. 300 -- ANOVAs Table 3 17

18. Table 3 -- ANCOVAS ?? 18

19. 19

20. Results MANCOVAs Treatment Outcome: Post- Test BID & HRSD Treatment Group N= 149 129 137 Main Effect Treatment NS NS NS Main Effect Therapist NS NS NS Treatment X Therapist NS NS NS Results p. 299- 300-- ANOVAs Table 3 20

21. 21 ANCOVA Post-Test Main Effects for Therapists Post-Test Measures DVs (regardless of treatment) TherapistsBDIHRSD TH-1 BDIT1HRSDT1 TH-2 BDIT2HRSDT2 TH-3 BDIT3HRSDT3 TH-4 BDIT4HRSDT4 21

22. 22 ANCOVA - Post-Test Effects Therapist X Treatment Interaction Therapist BDI Post-test Scores by Treatment HRSD Post-test Scores by Treatment BAATCTBAATCT TH-1 BDIT1 HRSDT1 TH-2 BDIT2 HRSDT2 TH-3 BDIT3 HRSDT3 TH-4 BDIT4 HRSDT4 22

23. Outcome: Follow-up 6 months Overall Impact of Therapy ANCOVAS IV:Treatments DVs: Follow-Up HRSD BDI Covariate: Pretest Score Changes in Follow-up Time ANCOVAS IV: Treatments DVs: Follow-Up HRSD BDI Covariate: ??? 23

24. Clinical Significance: Termination Improved Recovered 24

25. Clinical Significance: Termination Improved No major depression at post-test: LIFE Interview: psychiatric rating Recovered No major depression and BDI<8 25

26. Differences Non significant 26

27. Clinical Significance: Mean Improvement/Recovered Rates across Treatments – Post -Test (p.299 text) Group ImprovedRecovered Intent-to treat Total sample (149) 62.3%51.5% Partial Completers 12/20 N=37 58.3%^ Maximum Completers N = 129 66.0% * 54.5%* Dropouts N=12 16.7%*^5.6%*^ 27

28. 28 Based on Life Interview -

29. Table 5 29

30. Conclusion 30

31. Conclusion 12 to 20 therapy sessions of either Behavioral Activation (BA), Automatic Thoughts (AT) and BA or Schema Restructuring and BA and AT results in similar outcome in treating depression for adult clients who meet inclusion/exclusion criteria and were treated by highly trained and monitored therapists. Regarding the mechanisms of change in CBT?? 31

32. Chapter 732 Mechanisms of Change Construct Measure Behavioral Activation Dysfunctional Thinking Cognitive Schemas Pleasant Events Schedule Automatic Thoughts Q. Expanded Attributional Styles How did the authors examine to what extent the mechanisms of change worked in therapy as predicted by theory? 32

33. How Treatment Effects Change To what extent treatment groups differed in post-test measures of each change mechanism Measure Ttreat. Grps Behavioral activation – Pleasant Event SCd BA Coping skills-- AT (Dist Thinking) AT Core schemas- Exp Attrb Style CT To what extent was there change from pre-to post- treatment in each change mechanism 33

34. Paired T Tests: Pre-test/Post-test Change Treatment Pleasant Events Schedule Automatic Thoughts Questionnaires Expanded Attributional Styles Behavioral Activation PESch**ATQEAS Automatic Thoughts PESch**ATQ**EAS Cognitive Therapy PESch**ATQ**EAS** Clients in all conditions significantly improved on the three measures (p. 301) 34

35. Threats to Statistical Conclusion Validity Jacobson et al. (1996) Are the observed relations among variables accurate? 1.Power 2.Unreliability of Treatment Implementation 35

36. Threats to Statistical Conclusion Validity Are the observed relations among variables accurate? 1.Power N=149 and 3 groups/about 50 participants per group. Large N for an Exp study (+) Outcome measures are well-known – high internal reliability (+) No information is given about alphas with study sample Power analyses not reported 2.Unreliability of Treatment Implementation Therapists were experienced in CT and trained for study (+) Training followed a manual prepared for each treatment group (+) Therapy tapes were listened on an on- going basis and therapists flagged if they deviated (+) Analyses of adherence 27 taped sessions: treatments were distinct and consistent with their respective protocols (+) 4 therapist administered all treatments and Moderation analyses no th. outcome effect 36

37. Threats to Statistical Conclusion Validity Are the observed relations among variables accurate? 3.Extraneous Variance in the Experimental Setting 4.Heterogeneity of Participants 37

38. Threats to Statistical Conclusion Validity Are the observed relations among variables accurate? 3.Extraneous Variance in the Experimental Setting Do not appear to be any – The same four therapists administered all treatments However procedures and settings are not described in detail + 4.Heterogeneity of Participants Study had many exclusion criteria including co-morbidity, taking psychotropic medication, suicidal… p. 296. (+) However, don’t know #s in pool of volunteers from which the 152 accepted patients were taken from 72% were women, prim. White (+) No info regarding SES (-) 38

39. Threats to Internal Validity Can we conclude that there is a causal relation between the IV and the DV? 1.Selection to Treat. Groups 2.History 3.Attrition 4.Repeated Testing Effects 5.Reaction to Control Group Assignment 39

40. Threats to Internal Validity Can we conclude that there is a causal relation between the IV and the DV? 1.Selection to Treat. Groups Used Randomization after matching for episodes dep., dysthimia, severity of depression, gender, marital status (+) 2.History Therapy appeared to occur for everyone at once – but this is not addressed 3.Attrition Small -only 15 out of 152 - 8% -Attrition during acute treatment was comparable across treatment conditions – p.296 right (+) 4.Repeated Testing Effects Five administration of measures – at pre-test; post –test and 6, 12, 18 month follow-up (-) 5.Reaction to Control Group Assignment No placebo or no-treatment control group (+) Every one received treatment (+). Maybe some realized not receiving whole treatment (?) 40

41. Threats to Construct Validity To what extent variables capture desired constructs 1.Mono-Operation Bias 2. Mono-Method Bias 3.Experimenter Expectancies 41

42. Threats to Construct Validity To what extent variables capture desired constructs 1.Mono-Operation Bias Used two measures to assess outcome: Depression (+) 2. Mono-Method Bias HRSD is interview based and BDI is self-report (+) 3.Experimenter Expectancies Potential risk (-) Should have worked in favor of the CT condition that included all aspects of CBT-- therapists and researchers were aligned with CBT 42

43. Threats to External Validity Can we generalize observed relations across persons, settings and times 1.Person-Units 2. Outcome Measures 4.Settings 43

44. Threats to External Validity Can we generalize observed relations across persons, settings and times 1.Person-Units Highly selected sample – p. 296 (-) Exclusionary criteria (-) Primarily female = 73% (-) No info regarding race/ethnicity, SES (-) 2. Outcome Measures They used interview based and self report measures of Depression + Examined outcome using clinical significance index + 4.Settings Empirical Question….. 44