Chapter 12

INTRODUCTION TO CLINICAL

PSYCHOLOGY, THIRD CANADIAN EDITION

by John Hunsley and Catherine M. Lee

• 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

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?

• 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

• 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

• 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

Garbage out

Unreliable conclusion

Meta-analysis

Garbage in Methodologically weak studies

Criticisms of Early Meta-Analyses

• It is not reasonable to include different constructs, measures and informants in the meta-analysis

Criticisms of Early Meta-Analyses (2)

• 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

• Initiatives

• Controversies

Evidence-Based Treatments

• 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

• Scientific soundness

• Impact on clinicians

Criticisms of EST Initiatives

• 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

• Available for most common mental disorders; fewer for personality disorders

• CBT

• Process-experiential

• Interpersonal

• Psychodynamic

Evidence-Based Psychological Treatments

• 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

• PsycINFO

• Cochrane Collaboration: www.cochranelibrary.com

• National Guideline Clearinghouse: www.guideline.gov

• Agency for Healthcare Research and Quality: http://www.ahrq.gov/

• National Institute for Health and Care Excellence: www.nice.org.uk

• Substance Abuse and Mental Health Services Administration: www.samhsa.gov

Searching for Evidence

• 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

• CBT for depression

• Prolonged exposure for PTSD

• EFT for couple distress

Examples of Evidence-Based Treatments

• 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

•Behavioural activation

•Altering negative automatic thoughts

•Altering dysfunctional beliefs

CBT for Depression: Phase 2

• Self monitoring to identify patterns

• Scheduling pleasant activities

Behavioural Activation

Examining Cognitions: Thought log

Situation What I did How I felt What I thought

• Gathering data

• Carrying out experiments

Challenging Cognitions

• 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

• Review gains & new skills

• Anticipate challenges

• Prepare for future stressors

Phase 3: Relapse Prevention

• 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

• 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

• 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

For next class…

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