introduction to clinical psychology science, practice and ethics chapter 10 psychotherapy: research...
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Introduction to
Clinical PsychologyScience, Practice and Ethics
Chapter 10
Psychotherapy: Research Issues and Efficacy
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Copyright ©Allyn & Bacon 2005
Copyright ©Allyn & Bacon 2005
Psychotherapy DefinitionPsychotherapy Definition
Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other person characteristics in directions that the participants deem desirable (Norcross, 1990, p.218)
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Copyright ©Allyn & Bacon 2005
Psychotherapy ParticipantsPsychotherapy Participants
Psychotherapy ClientPsychotherapistPsychotherapy Relationship
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Psychotherapy ClientPsychotherapy Client
People in distressPeople “in a state of incongruence”
(Rogers, 1957)Looking for help (most, but not all)Psychotherapy Clients vary in
– Age– Income– Ethnicity etc.
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Psychotherapy Client:Psychotherapy Client:Who Benefits?Who Benefits?
Depression Panic disorder Bulimia Nervosa Obsessive-compulsive disorder Specific phobia Headache Oppositional Children Marital distress
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Limitations of the “who gets Limitations of the “who gets better” approachbetter” approach
Not all people who seek psychotherapy fall neatly into one diagnostic category or another
Not all clients with these disorders improve
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Psychotherapy Client:Psychotherapy Client:Who seeks tx and who stays involved?Who seeks tx and who stays involved?
WhiteMiddle or upper middle classBetter educatedMexican and Asian Americans least likely
to seek tx
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Psychotherapy Client:Psychotherapy Client:Other Characteristics and their Other Characteristics and their
relationship to outcomerelationship to outcome
Age – unrelated to outcomeLevel of distress – evidence mixed but
generally more distress poorer outcomeEthnic Minority – unrelated to outcome (but
a match between therapist and client related to positive outcome)
SES – unrelated to outcome
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PsychotherapistsPsychotherapists
Training– Psychology– Psychiatry– Social work– Counseling– Nursing– “non-professional”
Experience
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PsychotherapistsPsychotherapists
Nonjudgmental Empathic Warm Caring Place client’s needs above their own Genuine Socially sanctioned healers These are not personality characteristics. They are
characteristics of therapists during the therapy hour.
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Psychotherapists Psychotherapists Characteristics and OutcomeCharacteristics and Outcome
Training – unrelated to outcome Experience – unrelated to outcome Gender – unrelated to outcome Age – unrelated to outcome Well-being – correlated with outcome Expectations about client – related to outcome Competence – related to outcome
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Psychotherapy RelationshipPsychotherapy Relationship
Takes place in a socially sanctioned place of healing
Frequency and length of meetings planned and limited
Goals of relationship are specifiedTherapeutic allianceConfidential
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Limits of ConfidentialityLimits of Confidentiality
With written consent of client Comply with reporting laws
• Child abuse• Abuse of disabled or elderly
Protect the client and others• “Tarasoff”• Suicide prevention
Mandated by court (subpoena) Consulting with colleagues
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Common FactorsCommon Factors
Therapist-offered conditions– Empathy, warmth, caring, nonjudgmental attitude
Expert Role Release of emotions Therapeutic Alliance Distress Reduction Rationale/insight Competence/mastery
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Psychotherapy ResearchPsychotherapy Research
“In the absence of science, opinion prevails.” (Nathan & Gorman, 1998)
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Goals of Psychotherapy Goals of Psychotherapy ResearchResearch
To understand the efficacy of various forms of treatment for various problems (e.g., does treatment A help people with problem B?). This is referred to as outcome research.
To understand the mechanisms by which treatment works (e.g., what causes people with problem B to get better when they receive treatment A?). This is referred to as process research.
To understand the factors that influence the efficacy of treatment (e.g., why do some people get better with treatment A and others don’t?).
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Psychotherapy Research Psychotherapy Research StrategiesStrategies
True experiments– Participants carefully selected– Participants are randomly assigned– Treatment integrity
Quasi-experiments– Non-random assignment
Passive-observational– Only one condition – no assignment– Often naturalistic
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Single Subject and Small N Single Subject and Small N DesignsDesigns
Single subject experimental designAssumption: changes in dependent variable
(outcome) are unlikely to occur with the introduction (or removal) of the treatment by chance
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Single Subject Design: Essential Single Subject Design: Essential RequirementsRequirements
Repeated assessment of behavior of interestEstablishment of a baselineTreatment clearly specifiedReplicationA/B/A/B design
– A = baseline (no treatment– B = treatment
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Single Case Experimental DesignSingle Case Experimental Design
0
10
20
30
40
50
60
70
Baseline Reinforce Reversal Reinforce
Percentage of Class Time in Seat
A B A B
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Multiple Baseline DesignMultiple Baseline Design
Measure same behavior over a small group of participants (e.g., three)
For example: Three hyperactive kids: Mick, Keith, and Ron– Mick – one week of baseline assessment– Keith – two weeks of baseline assessment– Ron – three weeks of baseline assessment
Look for change occurring with the introduction of treatment
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Between Group DesignsBetween Group Designs
Participants are randomly assigned to treatment and control conditions
Assume that random assignment controls for nuisance variables
Assume differences are due to treatment
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Control GroupsControl Groups
No treatmentWait list“Placebo”
– Credible but should not work – according to theory
– “Common factors”
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Research questions and Research questions and research designsresearch designs
Does treatment A work?– Treatment A versus control
What components of treatment lead to therapeutic change?– Dismantling design
Can the effects of treatment be enhanced?– Constructive design
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More research questions and More research questions and research designsresearch designs
Which treatment works best?– Comparative Design
Which treatment works best and is the combination better than each one alone?– Factorial Design
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Example factorial designExample factorial design
No medication
No psychotherapy
A
Medication
No Psychotherapy
B
Psychotherapy
No Medication
C
Psychotherapy
Medication
D
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Single Subject and Small N Single Subject and Small N Experimental DesignExperimental Design
Can be used to evaluate any type of psychotherapy
Has been used most frequently to evaluate behavior therapies– Intervention is clearly specified– Overt behavior is of primary interest
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Analogue ResearchAnalogue Research
In psychotherapy research, typically testing a psychotherapy under very carefully controlled circumstances with an analogue (i.e., nonclinical) sample
For example – college students with mild phobias, moderate depression, or excessive body image concerns but not an eating disorder
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Analogue ResearchAnalogue Research
Advantages– Can study clinically relevant phenomena in a
controlled setting– Can use large n– Strong internal validity
Disadvantages– Questionable external validity
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Analogue versus Clinical Analogue versus Clinical ResearchResearch
A false dichotomy More a matter of degree All psychotherapy research is analogue to a
certain degree Psychotherapy studies differ from clinical practice
in – How subjects are recruited– Types of clients treated– Assessment procedures– How treatment is delivered
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Validity of Psychotherapy Validity of Psychotherapy ResearchResearch
Internal validity– Confidence that treatment caused change in outcome variables
External validity– Confidence that results can be generalized outside of the research
setting Construct validity
– Confidence that change occurred for the reasons the researcher thinks it occurred
Statistical conclusion validity– Confidence that statistical analysis led to correct conclusion
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Measuring outcome in Measuring outcome in psychotherapy studiespsychotherapy studies
Statistical significance– The difference between the mean score of the
treatment group and the mean score of the control group is larger than would be expected to occur by chance
Clinical Significance– The practical value of the effect of an
intervention. (Does it make a “real” difference?)
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Measuring clinical significanceMeasuring clinical significance
What percentage of clients who receive the treatment are like normal people?
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Client scores within 1 sd of the Client scores within 1 sd of the meanmean
Distribution of Normal People on Variable of Interest
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Measuring clinical significanceMeasuring clinical significance
What percentage of clients who receive the treatment are like normal people?
What percentage of clients who receive the treatment are no longer like abnormal people?
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Client score outside of 2 sd of the Client score outside of 2 sd of the mean of abnormal samplemean of abnormal sample
Distribution of Abnormal People on Variable of Interest
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Measuring clinical significanceMeasuring clinical significance
What percentage of clients who receive the treatment are like normal people?
What percentage of clients who receive the treatment are no longer like abnormal people?
Subjective EvaluationQuality of life (or similar broad measure)Social Impact
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Does Psychotherapy Work?Does Psychotherapy Work?
Eysenck (1952)Smith & Glass (1977) – meta-analysisEmpirically Supported (or Empirically
Validated) Treatments (Barlow – Task Force, 1995)
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Efficacy vs. Effectiveness Efficacy vs. Effectiveness ResearchResearch
Efficacy– Tightly controlled, strong on internal validity
Effectiveness– Examine effectiveness of psychotherapy as
delivered in the field
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