Psychotherapy outcome research: A “look and see” approach

Does Psychotherapy “Work”? In 24 studies focusing on efficacy of psychoanalytic and “eclectic” therapeutic approaches, 44% and 66% of patients improved, respectively. By contrast, 72% of patients receiving “custodial” care in an inpatient setting improved and were released. H.J. Eysenck (1952) The effects of psychotherapy Not exactly a ringing endorsement of psychotherapy!

“Look and See” Approach to Evaluating Therapy Effectiveness What is therapy? What prompts change in therapy? Does therapy really work? When should therapy end?

What is psychotherapy? 1. A healing agent 2. A sufferer who seeks relief 3. A healing relationship Jerome Frank (1973) Persuasion and Healing

What prompts change in psychotherapy? Whereas clinical theories attempt to illustrate what psychotherapy ought to be, process- outcome research aims to determine what therapy is and does. The master question guiding process-outcome research is ‘What is effectively therapeutic about psychotherapy?’ Orlinsky, Grawe, and Parks (1994) Handbook of Psychotherapy and Behavior Change

What prompts change in psychotherapy? Therapist-client relationship Interpretation, insight, understanding Cognitive modifications Catharsis, emotional expression and release Reinforcement Desensitization Relaxation Information Reassurance and support Expectancies of change Exposure and confronting a problem Time Placebo response

Is Interpretation, Insight, and Understanding really important? Many therapies think it is important But, each has a different view of its significance And no therapy is better than others So how important can interpretation, insight, and understanding really be?

Is Interpretation, Insight, and Understanding really important? Many therapies think it is important But, each has a different view of its significance And no therapy, on average, is better than others So how important can interpretation, insight, and understanding really be important? Or maybe our theories of psychotherapy are not really accurate representations of what really goes on in therapy!

Interpretation, Insight, and Understanding in Different Types of Therapy Interpretations offered in psychoanalytic - psychodynamic therapy help the client go beyond “surface” awareness. In client-centered therapy, insights follow changes in self. In cognitive-behavioral therapy understanding distortions is a shared or common task (as in teaching).

Perhaps Value of Interpretation, Insight, Understanding is Overated? “…based on a survey of 168 psychotherapists covering a variety of orientations…two of five state that ‘under the proper conditions, an incorrect interpretation, not even near to the actual facts, can have a real and long-lasting therapeutic effect.” Paul Meehl (1960) The cognitive activity of the clinician

“Despite many years and several excellent studies, there is no strong support for the accuracy of interpretation as an important process variable in therapy. The correct interpretation, after all, is determined by some authority or group of judges in terms of a specific theoretical orientation. Since “all dodo’s win prizes”, that is, there are roughly comparable results for different forms of psychotherapy, it is difficult to accept the importance of the correct interpretation.” Saul Garfield (1980) Psychotherapy Seminar Washington University

Psychotherapy outcome research: A “look and see” approach (Part II) Efficacy and Effectiveness Studies Common and Specific Factors

Two types of outcome studies Efficacy study (Blinded, comparative trials; effects “averaged” in meta-analysis) vs. Effectiveness study (“Consumer Reports” survey)

What constitutes an efficacy study?  At least two conditions  Random assignment  Participants blinded to condition  At least two assessments: Pre- and Post-treatment

What counts as a “control” condition in a psychotherapy efficacy study?  Two weeks at “Club Med”?  Doing nothing but telling people they are on the “Wait list” for treatment? (Is this a blinded study?)  Another form of treatment?  A drug?  A drug placebo?

When do you assess outcomes?

Stanford Comparative Trial: Psychotherapy for Geriatric Depression ( Thompson, Gallagher, & Breckenridge, 1987)  Three modalities: Cognitive, Behavioral, Psychodynamic  Tx,16-20 weeks; 6 week control  91 MDD RDC, over 60 yrs old  Participants blinded, randomized  10 therapists, Ph.D. or M.D. trained  Pre, 6 week, Post, 12 Month, 24 Month

Questions Behavioral and Psychodynamic Orientations Might Address Behavioral Focusing on actions  Are there positive actions you might want to increase?  Are there unwanted actions you might want to decrease? Reinforcement patterns  What consequences are currently blocking the actions you want to increase?  What can we do to help you gain rewards from these desirable actions?  What consequences are currently rewarding the actions you want to decrease?  What can we do to decrease the rewards for unwanted actions? Stimulus-response patterns  Are you experiencing responses to situations that you don’t understand or want to change?  Do you know when or why these reactions may have become paired with these situations? Psychodynamic-Interpersonal Interpersonal Wish  What did you want from your relationship with this person at this time?  What did you hope for when you interacted with this person? Response from other  What did you think might happen in this situation?  How did the other person respond?  Did you have any fears or fantasies about this relationship?  What might happen if you acted on your impulses? Response of self  Based on this person’s response to you, how did you end up feeling and acting?  What were your feelings about their response?  How did you act in response to these feelings?

Strategies used by Behavioral and Psychodynamic Orientations in Therapy Sessions Behavioral 1. Clarifying the impact of actions 2. Illuminating reinforcement and conditioning 3. Identifying target behaviors 4. Determining baselines 5. Encouraging active choices 6. Assessing stages of change 7. Establishing schedules of reinforcement 8. Assigning homework 9. Constructing a hierarchy 10. Exposing clients to images or experiences 11. Fostering acceptance 12. Encouraging commitments 13. Providing skills training and rehearsal 14. Coaching and shaping Psychodynamic-Interpersonal 1. Listening to narratives 2. Encouraging free association 3. Identifying relationship themes 4. Making interpersonal interpretations 5. Honoring resistance 6. Exploring childhood experiences 7. Working through past conflicts 8. Identifying attachment styles 9. Observing the therapeutic relationship 10. Attending to subjective responses 11. Resolving conflicts in the therapeutic relationship 12. Modifying relational interactions 13. Interpreting dreams 14. Adapting to interpersonal losses or disputes 15. Encouraging new relationships 16. Learning from termination

Comparative efficacy of psychotherapy for late-life depression Thompson, Gallagher, Breckenridge (1987, 1991)

Meta-analysis of efficacy studies: Is psychotherapy efficacious?  Comparison across different studies that address a common question  Use of a common metric: effect size – e.g., difference in means between treated and untreated groups divided by standard deviation

Meta-analysis of efficacy studies: Is psychotherapy efficacious? (cont’d)  Smith and Glass (1977); Smith, Glass, & Miller (1980) studies;.85 sd difference between treated and untreated groups.  Criticisms: Mixing dissimilar studies Publication bias Poor studies included in sample of studies

Meta-analysis of efficacy studies: Is psychotherapy efficacious? (cont’d)  Advantages Power Generalizability across samples, researchers, etc.

Summary of findings from Efficacy Studies 1. Treatment superior to no treatment ( sd) 2. Treatment superior to placebo (.60 sd) 3. Small differences among different treatments 4. Patients maintain their gains and may improve without additional therapy.

“Everybody has won, and all must have prizes.” The Dodo Bird Alice in Wonderland “…There is little evidence that specific ingredients are necessary to produce psychotherapeutic change.” Bruce Wampold (1991) The Great Psychotherapy Debate

Expectancies, placebos, “common factors” in efficacy studies  Frank’s Persuasion and Healing: Therapist, motivated client, compelling explanation.  Sloane, Staples etal. (1975) – Behavioral (e.g., Lewinsohn, 1974) vs. Psychodynamic (e.g., Horowitz, 1978)

Therapist and client: “Specific factors”  Characteristics of the therapist, e.g., age, training, etc., don’t make much difference in outcome across studies.  Certain personality features that facilitate a working relationship do make a difference, e.g., empathy, warmth, genuineness.  Aspects of the client make a difference, e.g., education, compliance, but not others, e.g., age, race, sex, etc.

Are there “specific factors” in treatment modalities? Therapeutic modalities can be applied effectively across problem types and diagnoses. At present, there are few empirically-validated, problem-specific treatments.

Expectancy Studies: The Consumer Reports Study  Survey of 4000 readers who sought aid for a psychological problem; median age 46  Psychotherapy resulted in some improvement for majority  All health professionals produced comparable results  Longer treatment, more improvement