1. Chapter 12 INTRODUCTION TO CLINICAL PSYCHOLOGY, THIRD CANADIAN EDITION by John Hunsley and Catherine M. Lee

2. Questions Does psychotherapy work? Meta-analysis and psychotherapy research Evidence-based treatment Clinical practice guidelines Examples of evidence-based treatments Effectiveness trials Adoption of evidence-based treatments For next class Overview

3. Clinical experience; case accounts; narrative reviews of uncontrolled studies Meta-analyses of overall effects of psychotherapy Meta-analyses of treatments for specific disorders and subgroups of clients Does psychotherapy work?

4. Proponents of psychodynamic and eclectic therapy make claims based on clinical experience and case examples Eysenck (1952) reviews uncontrolled studies and concludes effects are poorer than no-treatment Validity of the conclusion? – What about equivalence of groups pre-treatment? Initial Evaluation

5. Inclusion of studies based on explicit criteria Effect size: d and r – d =.4 indicates a difference between groups of two-fifths of a standard deviation – d =.4 indicates that 66% of patients in treated group score below the mean of untreated participants Takes sample size into account, so small studies influence findings less than do large studies Meta-Analysis & Psychotherapy Research

6. Smith & Glass (1977) d =.68 Average person receiving treatment was better off at the end of treatment than 74% of those who did not get treatment Overall Effects of Psychotherapy

7. Garbage out Unreliable conclusion Meta-analysis Garbage in Methodologically weak studies Criticisms of Early Meta-Analyses

8. It is not reasonable to include different constructs, measures and informants in the meta-analysis Criticisms of Early Meta-Analyses (2)

9. Like any statistical procedure, it has become more refined as developers respond to criticisms and problems d comparing a treatment to no treatment will almost always be larger than d comparing two active treatments Hoffman et al. (2012): 269 meta-analyses published since 2000 on the efficacy of CBT Quality of the meta-analysis depends on the methodological decisions made by meta-analyst Meta-Analysis

10. Initiatives Controversies Evidence-Based Treatments

11. Early 1990s, APA, Society for Clinical Psychology task force lead by Dianne Chambless Established criteria for designating a treatment as efficacious or probably efficacious, including demonstration of improvement in RCT, controlled single case experiment or time series design 1995 report 1998 special issue of Journal of Consulting & Clinical Psychology More stringent criteria than for ‘evidence-based’ Empirically Supported Treatments

12. Scientific soundness Impact on clinicians Criticisms of EST Initiatives

13. Australia & New Zealand: Quality Assurance Project Germany: Access to services with an evidence base United Kingdom: Roth & Fonagy United States: Nathan & Gorman International Efforts on Evidence-Based Psychological Services

14. Available for most common mental disorders; fewer for personality disorders CBT Process-experiential Interpersonal Psychodynamic Evidence-Based Psychological Treatments

15. American Psychological Association, 2006 Integration of best available research evidence and clinical expertise within the context of patient values and preferences Canadian Psychological Association, 2012 Emphasis on (a) published, peer reviewed research to inform treatment options and (b) use of ongoing monitoring of treatment effects Task Forces on Evidence-Based Practice

16. PsycINFO Cochrane Collaboration: www.cochranelibrary.comwww.cochranelibrary.com National Guideline Clearinghouse: www.guideline.govwww.guideline.gov Agency for Healthcare Research and Quality: http://www.ahrq.gov/http://www.ahrq.gov/ National Institute for Health and Care Excellence: www.nice.org.ukwww.nice.org.uk Substance Abuse and Mental Health Services Administration: www.samhsa.gov www.samhsa.gov Searching for Evidence

20. Interdisciplinary Substance Abuse and Mental Health Services Administration (USA) National Institute for Health and Care Excellence (UK) Institut national d’excellence en santé et services sociaux (Quebec) Disciplinary Canadian Psychiatric Association Clinical Practice Guidelines

21. CBT for depression Prolonged exposure for PTSD EFT for couple distress Examples of Evidence-Based Treatments

22. Assessment – Diagnosis and comorbidity – Life circumstances: relationships & social functioning – Resources and strengths – Recent precipitating events and stressors Information on depression Case formulation Treatment options CBT for Depression: Phase 1

23. Behavioural activationAltering negative automatic thoughtsAltering dysfunctional beliefs CBT for Depression: Phase 2

24. Self monitoring to identify patterns Scheduling pleasant activities Behavioural Activation

25. Examining Cognitions: Thought log SituationWhat I didHow I feltWhat I thought

26. Gathering data Carrying out experiments Challenging Cognitions

27. I am not good at anything I do not deserve to be in a relationship If bad things happen to me, I must deserve them Longstanding Beliefs

28. Review gains & new skills Anticipate challenges Prepare for future stressors Phase 3: Relapse Prevention

29. Effectiveness studies key to evaluating whether evidence-based treatments work well in routine clinical settings Evidence to date, both for the treatment of depression (Hans & Hiller, 2013) and anxiety disorders (Stewart & Chambless, 2009), indicates effectiveness of CBT interventions Increasing use of a benchmarking strategy of drawing data from empirical studies to provide a comparison against which the effectiveness of clinical services can be gauged Effectiveness Trials

30. Relatively slow uptake of training in EBTs in many clinical psychology training programs (e.g., Weissman et al., 2006) For both clinicians and clinical psychology trainees, research support for a treatment appears to be important in determining whether to provide a treatment, but may not be the most important determinant Eating disorder treatment example – Previously many clinicians had no training in EBTs (Mussell et al., 2000) – More recently, use of EBTs appears to have increased, but a significant minority refuse to provide these treatments (von Ransom et al., 2013) Adoption of Evidence-Based Treatments

31. US Department of Veterans’ Affairs – Roll out of treatments for PTSD Insomnia Depression – Training & supervision – Monitoring Improving Access to Psychological Therapies (UK) – train new therapists in evidence-based treatments (2 for depression & at least 1 for an anxiety disorder) – Stepped care with low intensity & regular services – In 2013 two-thirds of those treated through IAPT services showed reliable improvement – www.iapt.nhs.uk Efforts to Disseminate Evidence-Based Treatments

32. For next class…

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