1. Effectiveness of Therapy and Nonspecific Factors

2. Is Therapy Effective?

3. 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?

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

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

16. 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

17. 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

18. 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

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

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

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

22. Factors Influencing Outcome

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

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

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

26. 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

27. 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

28. 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

29. 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

30. 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