Effectiveness of Therapy and Nonspecific Factors

Is Therapy Effective?

Is Therapy Effective? Does it work? Who does it work for? If it does work, why does it work? What is it doing? What parts work and what parts don’t work? What is responsible for the most variance in change?

The Consumer Reports Study In 1994, Consumer Reports decides to evaluate psychotherapy by surveying users in the same way that it does for other goods & services The CR conclusions are controversial and generate much discussion regarding the nature of scientific therapies and methodology for clinical psychology

What are the CR findings? 90% of people find therapy useful Long-term therapy was more useful than short-term therapy There is no difference between therapy alone and therapy + meds Psychologists, psychiatrists, and social workers all perform equally well Family doctors do well in short-term

What Are the CR Findings? All service providers perform better than marriage counselors AA did very well Active shoppers of therapy do better than passive recipients No specific therapy did better than the others Limitations due to insurance are associated with worse outcomes

What’s the Problem with the CR study? Most therapies being practiced do not have scientific support Many consumers may not even be aware of what type of therapy they received or who provided it It raises issues regarding the proper way to evaluate therapy outcomes

How Do we Know if Therapy works? We can do two different types of studies to assess the outcomes of therapy: Efficacy Studies Effectiveness Studies

Efficacy Studies Therapy is demonstrated to work in a: Randomized control trial With manualized treatment and a fixed # of sessions A well-defined outcome Double-blind raters Clean samples Efficacy studies have maximum internal validity

Efficacy Studies Psychologists who are part of the clinical science model (and also the scientist-practitioner model) consider therapies that “survive” 2 RTC trials to be “empirically supported” Or “gold standard” Ethically, many would argue, the gold-standard should always be used if there is one Others argue this criteria is arbitrary

Effectiveness Studies Therapy is demonstrated to work in the ‘real life’ conditions common to most patients Not clean diagnosis or multiple problems Changing number of sessions Loosely or no manualized treatment Clients choose their own therapies and self-correct Focus on improvement, not symptom reduction Effectiveness studies maximize on external validity

The CR Controversy The CR study is purely an effectiveness study, and many scientists question its results

Seligman- Support of CR Study Seligman (who is APA president) argues that efficacy studies leave out too many components to draw good conclusions He thinks the CR is a good study: Sample represents those who use therapy Naturalistic treatment course Self-correcting Unbiased

Jacobsen & Christensen - Questioning the Conclusions Others question the methodology Study is retrospective (conclusions are uncorroborated, possibly distorted or inaccurate) CR measures were unreliable and not that informative Did not assess which therapies improve which problems

Which is Better? Both types of studies are useful for a treatment to have solid support, it should be shown to work in both

Does Therapy Work? Yes, in general Sometimes our effect sizes are not large Certain disorders are treated mainly with therapy, we may have no other way to help: Borderline Personality Disorder

Does Therapy Work? For some therapies, relapse rates can be high Depression (some estimate up to 50%) For some disorders, we have little to no treatment Personality disorders Pervasive developmental disorders

Is it the Specifics? Or the NonSpecifics? A specific component of a therapy that theoretically is necessary (e.g. Exposure) Nonspecifics: Factors common to all therapies that could explain outcomes

Factors Influencing Outcome Can be divided into 4 components: Extratherapeutic factors Expectancy Effects Specific therapy techniques Common Factors (Lambert & Barley, 2002)

Factors Influencing Outcome Extratherapeutic Factors: Spontaneous recovery or remission Fortunate events Social support Expectancy Effects: Placebo effects The Dodo bird hypothesis

Factors Influencing Outcome Specific Therapy Techniques: Exposure Changing cognitions (CBT) biofeedback Common Factors Relationship with therapist Support Hopefulness

Factors Influencing Outcome

What Nonspecifics Help? Orlinsky, Grave & Parks (1994): Therapist credibility Therapist skills Empathetic understanding

What Nonspecifics Help? Affirmation Ability to engage patient Focus on patient’s problems, direct patient

Humanistic Therapies If you recall, humanistic therapies consist of many nonspecifics: Unconditional positive regard Caring, respect Being genuine

What Are the Implications? Much of the variance in outcome is accounted for by nonspecifics Stay up to date and use ESTs Remember the importance of therapeutic relationship & alliance, the interpersonal nature of therapy The relationship provides the context for specific techniques to work

How Do We know Which One it Is (Specifics or Nonspecifics)? Treatment studies always have a control group. May include a group who receives all the nonspecifics of the treatment group

How Do We know Which One it Is (Specifics or Nonspecifics)? If the treatment group improves, above and beyond the control group, we know more than nonspecifics are at work

How Do We Know Which Part of Therapy works? Component studies Attempt to isolate effective “ingredients” Dismantling designs & additive designs Dismantling: compare entire Tx and Tx with the hypothesized critical variable removed Additive: compare entire Tx and Tx + another component

How do We Know Which it is? Dismantling: If removing a component = worse patients, then that component is responsible Additive: If adding a component = better patients, then that component is responsible