Transcript What do We Know?.

Evidence Informed Couple and Family Therapy: A
dialogue between empirical and clinical voices
APA Division 43 Committee Work on Defining
“Evidence-based” Family Treatments
Jay Lebow
Defining the Boundaries of
Evidence-based Family
Treatments and the Complex
Contexts in which they are
Practiced
AFTA Clinical Research
Conference 2007
Address
Jay Lebow, Ph.D., ABPP
Family Institute at Northwestern
618 Library Place
Evanston, Illinois 60202
e-mail [email protected]
Goals for This Presentation
 Examine evidence based practice in couple and
family therapy and the interface between EBP and
systemic practice.
 Look at how clinicians can improve the process and
outcome of treatment by informing practice with
research findings and how researchers can make
their research more relevant to clinical practice
 Describe the dialogue among the Division of Family
Psychology’s Task Force on Evidence Based Couple
and Family Therapy and the Directions of the
Committee
Some Questions
 In what ways and how much does evidence based
methods add to the quality of the clinical practice of
couple and family therapy?
 How does evidence based practice interface with
systemic thinking? Is evidence based practice in the
context of a systemic understanding the equivalent of
an oxymoron?
 What are the best ways to apply evidence based
practice in different treatment contexts? Do these
ways vary across context and client population?
First Framework-Evidence based
Practice applied to Psychotherapy
 Practice is evidence based which utilizes
scientific research findings and/or
methods of assessing therapy process
and outcome in some way to inform
clinical practice.
Criteria for Effective Treatment
 The Standard of Common Practice
 The Principle of the Respectable Minority
 Scientific Evidence
Rationale for Evidence Based
Treatment
 Improve quality and accountability for health
care practice
 Develop shared vocabulary and concepts for
cross disciplinary, biopsychosocial practice,
research and health care policy
 Stimulate development of evidence base for
behavioral treatments
Kinds of Evidence Based Treatment
 Idiographic

Evidence based practice

Focus on decision making about individual clients
 Research informed practice
 Client Progress Research
 Nomothetic



Empirically Supported Treatments
Empirically Supported Relationships
Empirically Supported Principles of Practice
What’s an Empirically Supported
Therapy? (EST)
 Treatment that:



Aims at a specific disorder or difficulty.
Has a treatment manual that specifically
describes interventions and how decisions are
made to utilize them
Has evidence for efficacy established in a
randomized clinical trial, much like those to
establish the safety and effectiveness of
drugs.
Ests: Who Are Suggesting Practice
Guidelines?
 American Academy of Child and Adolescent
Psychiatry
 Center for Substance Abuse Treatment
 Various APA Divisions
 Various authors: Nathan & Gorman (1998)
-----------------------Roth & Fonagy (1996)
Criteria for Empirically Supported
Therapies: Society of Clinical
Psychology
 At least two good between group design experiments
demonstrating efficacy in one of more of the following
ways:


A. Superior to pill or psychological placebo or another
treatment
B. Equivalent to an already established treatment in
experiments with adequate sample size
 A large series of single case design experiments
(more than 9) demonstrating efficacy.


These must have good experimental design and
Compared the intervention to another treatment.
Strengths of ESTs
 Therapies have been demonstrated to work.

Clear evidence available for impact, not such claims of treatment
developer or ability to present or market the treatment.
 Therapies are specifically tailored to DSM diagnosis and/or
population
 Therapies are clearly described by manual
 Easily followed and disseminated.
 When pointing to effective special treatments for populations
known to be difficult to treat and to likely have poor outcomes that
are shown to be better than “treatment as usual” ESTs can
designate special powerful treatments

Examples


Family based psychoeducation/ medication/ individual skills
training integrative treatments for clients with schizophrenia
Cognitive behavioral treatments for severe forms of panic
disorder and obsessive compulsive disorder
Criticisms of ESTs
 DSM Focus does not speak to why most individuals enter
psychotherapy
 DSM focus ignores key client differences
 Co-morbidity

Real clients have multiple problems
 Disorder focus makes it difficult to evaluate overall effectiveness
of psychotherapy across difficulties
 Efficacy studies on which they are selected are not studies of
real world effectiveness in typical clinical settings



Treatments need to be time limited
Treatments can be much more intense than in practice
Clients in studies which exclude those with multiple
problems are atypical
Criticisms of ESTs-2
 Manuals limit therapist creativity
 Not an even playing field: Bias favors
cognitive-behavioral treatments.
 Too many therapies to learn
 No acknowledgement of the importance of
the therapist factors
 Not likely to be adopted by therapists of
different orientations
Synthesis-ESTS
 Crucial building blocks for the establishment
of the scientific basis for any endeavor
 Helpful in suggesting directions for clinical
practice
 Never should be seen as a panacea or able
to fully direct clinical practice
Alternatives: Other evidence based
frameworks
• Empirically Supported Relationships
 Focus on common factors at work across
psychotherapies and enhancing these factors
 Empirically Supported Principles of Practice
 Principles that transcend specific treatment contexts
 Progress Research
 Monitor client progress during treatment. Utilize
information of progress in relation to other similar
clients to assess whether treatment is effective/needs
to be altered.
Second framework-History of Evidence in
Couple and Family Therapy
 Couple and family therapy originally developed based principally in the
brilliance of systemic understandings and the writing and presentations
of its charismatic early leaders.
 Research has shown them to be right about some ideas-e.g. the power
of circular family processes;
 And wrong about others: the double bind hypothesis of schizophrenia;
the value of affectively charged treatments for treating families with
members with severe mental illness.
 Evidence for most approaches followed the development of those
approaches.
 A paradox-center of systemic view was about change in the family
system but these approaches have mostly been utilized to improve
the functioning of the individual (e.g. the schizophrenic client) or
sub-system in focus (e.g. the couple relationship) as well
 Question-Is the move toward a greater focus on achieving
outcomes in client focal problems progress or regression?
Evidence for the Impact of Couple and
Family therapy
 Reviews of the literature and meta-analyses have
established that couple and family therapies are
effective methods for intervening with a wide array of
difficulties




Gurman/Kniskern/Pinsof early reviews
More recent reviews by Lebow/Gurman; Alexander &
Holzworth-Monroe; Baucom, D. H., Shoham, V.,
Mueser, K. T., Daiuto, A. D., & Stickle, T. R.; Sexton &
Alexander, Snyder, Heyman, and Haynes
AAMFT Projects Effectiveness research in marriage
and family therapy edited by Pinsof & Wynne and by
Sprenkle
Meta-analyses by Shadish and others
History of Evidence in Couple and
Family Therapy-2




Shadish and Baldwin report effect sizes typically are in range of .65 at end of
treatment and .52 at follow-up. Effect sizes for marital therapy average at .85
and for family therapy at .58.
Some couple/family therapies now have considerable support in evidence
 Especially cognitive-behavioral marital therapy, emotion-focused couples
therapy, multi-system family treatments for adolescent
delinquency/substance abuse, psychoeducational treatments for severe
mental illness
Many other widely disseminated approaches have yet to be evaluated.
Family therapies have primarily been evaluated in relation to their impact on
individual disorders
 A by-product of funding priorities
 Impact of treatments on family is a secondary consideration in
research. Where assessed, family therapies impact on family process
as well as on disorder.
 Yet to be research on the impact of couple and family therapies on
family problems as primary target (e.g. intergenerational conflict)
except for marital distress.
ESTs: Marital distress
 Behavioral marital therapy: Neil Jacobson & Gayla




Margolin
Emotionally focused couples therapy: Les Greenberg
and Sue Johnson
Insight oriented couples therapy: Doug Snyder
Integrative behavioral couples therapy: Andy
Christenson & Neil Jacobson
Forgiveness based integrative couple therapy for
infidelity-Don Baucom, Kristi Gordon, Doug Snyder
ESTs:Adolescent substance use
 Brief strategic therapy: Jose Szapocznik, Dan
Santiesteban et al
 Functional family therapy: Jim Alexander and
Tom Sexton
 Multi-dimensional family therapy: Howard
Liddle, Gayle Dakof, Cynthia Rowe et al
 Multi-systemic family therapy: Scott
Henggeler
ESTs: Other Child and Family
Issues
 Parent Training Programs For Children With
Oppositional Disorder–Gerald Patterson et. al.
 Applied behavior analysis parent training for
Childhood Autism-Ivar Lovaas
 Family psycho-educational intervention for
schizophrenia and bi-polar disorder Ian Falloon,
Carol Anderson, Bill McFarland & David Miklowitz
 Behavioral Couple Therapy for depression for
partners in distressed relationships
Establishing Principles of Practice in
Couple and Family Therapy
 Client Factors
 Therapist Factors
 Relationship Factors
 Treatment Factors
 Interactions of these factors
CLIENT FACTORS
 Traditional client demographic characteristics are typically
unrelated to outcome
 There have been few studies of the kinds of characteristics
that are related to outcome in research on individual
therapy such as motivation to change. Examples of what
we have from this kind of research looks more promising:


Survey of couple therapists found partners’
inability/unwillingness to change, lack of commitment to
the relationship, and intensity and duration of problems to
be most frequent factors associated with poor outcome
(Whisman, Dixon, & Johnson, 1997)
In couple therapy for alcoholism, individuals who were
highly invested in their relationships and perceived high
levels of support from their spouse showed great
improvement as did those who reported low investment in
their relationships, but those with high levels of
relationship investment and low levels of support did less
well (Longabaugh, Beattie, Noel, Stout, & Malloy 1993).
THERAPIST
CHARACTERISTICS
 Have strong relationship to outcome
 In a study of Functional Family Therapy therapist
relationship skills (warmth, humor etc) accounted
for 45% of outcome variance (Alexander, Barton,
Schiavo, & Parson, 1977)
 Therapist defensiveness early in treatment
associated with negative outcome in couples
(Waldron, Turner, Barton, Alexander, & Cline, 1997)
 Emerge as important even in therapies thought to
have low therapist personal component such as
strategic therapies (Green & Herget, 1991)
RELATIONSHIP FACTORS
 Numerous studies show the importance of alliance to outcome in
couple and family therapy
 Alliance tends to be stronger predictor of outcome for men in
couple and family therapy than for women
 Longitudinal investigation shows that mid-treatment alliance
predicts outcome beyond that accounted for by early alliance
scores (Knobloch-Fedders, Pinsof, & Mann, 1994)
 Split alliance when family members don’t agree on the quality of
the alliance and unbalanced alliances are related to poorer
outcomes

For example, Robbins, Turner , Alexander, & Gonzolo show cases
in which fathers and adolescents have different alliances with
therapist have greater drop-out
EXPANDED ALLIANCE
 Each subsystem in family therapy has an alliance with the
therapist that is more than the sum of each person’s
alliance with the therapist (Pinsof, 1995)
 Pinsof & Catherall (1986) created the Couple and Family
Therapy Alliance Scales assess 4 relationship subsystems
as well as dimensions of tasks, bonds, and goals
 Self-therapist
 Other family members-therapist
 Entire family-therapist
 Self-family (within)
 Confirmatory factor analysis has validated the 3x4 structure
(Pinsof, Mann, Zinbarg, & Knobloch-Fedders, 2004)
ASSERTIVE ENGAGEMENT
 Couple and family therapy almost invariably
involve someone who is lower in motivation to
enter therapy
 Assertive methods of engagement that
include active joining, cultural sensitivity, and
a willingness to remain flexible in therapy
format vastly increase levels of engagement
and alliance (Research on Brief Strategic
Therapy)
SO WHAT DO WE KNOW ABOUT
COMMON FACTORS IN FT?
 Therapeutic relationship makes a difference
 Alliance in Family Therapy is more complex than
in individual therapy




Individual alliances with therapist
View of other family member’s alliances
Collective alliance with therapist
Alliance with one another
 Need to attend to these multiple alliances
 Assertive engagement helps
Integrating the findings of basic
research into practice
 Base of knowledge about family process,
social psychology, individual personality,
psychopathology, and social systems
Applying Research findings in
Specific Contexts : Marital
Therapy
 Pre-marital skill development has a profound effect
on the long term success of marriage. Therefore,
encourage such skill development.
 The presence of criticism, defense, contempt, and
stonewalling predicts relationship demise. Therefore,
if these patterns are evident, advise of the likelihood
of relationship dissolution and prioritize the changing
of these patterns.
 The ratio of positive to negative behaviors in happy
couples is overwhelmingly slanted toward the
positive. Therefore, encourage more positive
exchanges.
Applying Research findings in
Specific Contexts: Family Therapy
 Reducing expressed emotion helps in severe
mental illness
 Assertive engagement is clearly preferable in
certain client populations
 Certain family patterns of behavior, such as
high conflict, ultimately have profound
negative effects. When present, therapy
should at least in part focus on their
reduction.
Tracking Progress in
Psychotherapy
 Assess gains as each case progresses
 Utilize appropriate measures:
 OQ-45
 Compass
 HDI
 Systemic Inventory of Change (STIC)
 Compare with norms for comparable groups
 Provide feedback to clinicians-Increases
effectiveness
Stages of Therapy Progress:
Howard
 Feeling better happens quickly-Remoralization 10-15% by session 1, 55% by session 2-a few
sessions; if not by session 10, unlikely to improve
 Followed by symptom change-remediation
 55% at session 2, 80% at session 10
 typically require 16 sessions
 Followed by change in current life functioning
 time depends on kind of problem-typically
6months to a year
 self-esteem slower to change 25% by session 2 but
only 50% by session 48
Place of Couple/Family Therapies in
Efforts to Designate Evidence Based
Practice
 Typically an afterthought recognizing only the
couple/family therapies with the most research
studies


e.g. Division of Clinical Psychology list which ignores
several prominent well studied couple and family
therapies
e.g. Division of Child and Adolescent Clinical
Psychology listing which accentuates individual
interventions in children and adolescents
 Some overviews/examinations don’t even look at
couple/family treatments
 Family concerns and systemic considerations
typically not mentioned.
Need for A Family Psychology Task
Force
 To examine place of evidence based practice in couple/family






therapy
To establish couple/family therapies place in world of evidence
based practice
To identify those treatments and treatment methods that are well
established
To bring nuances of systemic viewpoint to the assessment of
evidence based practice
To bring a balanced scientist-practitioner view to such efforts.
To suggest directions for further research on couple and family
therapy
To bring nuances of systemic viewpoint to this effort
Origin of the Task Force
 Division of Family Psychology of the
American Psychological Association appoints
task force to examine evidence based
practice with Kristi Gordon as chair.
Criteria for Composition
of Task Force and Advisory Panel




Diversity of orientations
Diversity of interests
Ethnic and Gender diversity
Demonstrated commitment to both science
and practice
 Experience with evaluating and/or conducting
treatment outcome studies
 Openness to varying points of views
Members of Task force
 Kristina Gordon
 Alan Gurman
 Amy Holtzworth-Munroe
 Sue Johnson
 Jay Lebow
 Tom Sexton
Advisory Panel Members
 Andrew Christensen
 Daniel Santiesteban
 Don David Lusterman
 James Dobbins
 Jaslean LaTaillade
 Peter Chang
The domain
 The clinical treatments that fall under the domain of
Couple and Family Therapy


emphasize those aspects of the part of the therapy
process that focuses on and works through the
relational systems of couples and families as the basis
of clinical assessment and intervention
focus on multisystemic relational systems for
intervention and aim for clinically relevant changes in
individual, couple, and family functioning at both broad
and specific levels, considered from multiple
perspectives with work often involving multiple
systems.
Goal of the Guidelines
 The purpose of these guidelines is to offer a
system of organizing the research such that the
knowledge base can be reviewed and effective
treatments and interventions in family psychology
identified that can serve as a resource for
consumers and practitioners.
 In a way that orders the reliability of empirically
findings so that effective programs/interventions
are identified and attends to the complexities of
practice by considering variations in that evidence
due to diverse clients, therapists, and contexts.
Important Notes
 It is important to note that our primary assumption
is that clients will only be helped through the use
of both the wisdom of good professional practice
and the guidance of clinical intervention research
if effective treatments are to be delivered reliably
to diverse clients across the various settings in
which Family Psychologists practice.
 As a group of researchers, practitioners, and
trainers, the Task Force was sensitive to and
constructed these guidelines appreciative of the
need to attend to both the artfulness and
individuality of effective clinical work AND the
invaluable role of research at all levels of clinical
decision-making.
Important Notes
 We would suggest a more substantial place
for research in the clinical decision making
process.
 If research evidence exists and that evidence
comes from quality studies, it should carry the
primary weight in clients, therapists, and
systems choosing intervention and/or
treatment programs.
Dimensions of Evidence-based Treatments

Broad/
Non-specific

Specific

Broad theoretical approach (traditional broad
theory-based approach)
Common factors that are in existence in all good
therapy approaches (typically considered nonspecific factors)—in couple and family therapy
common factors are not enough, but only a
starting point for therapy.
Specific clinical interventions (specific clinical
procedures)
Specific Treatment Model (with clearly defined
model-based principles, systematic approach to
treatment-manual driven, specific change
mechanism-based intervention strategies)
Dimensions of Evidence-based Treatments
2. A range of research methodologies



Family Psychology is a complex endeavor
and must consider various forms of
systematic study in order to capture that
complexity
More important is that type of study fit the
question
Regardless of the type, studies considered
must be systematic and clinically relevant and
of high methodological rigor (for that specific
type of research)
Types of Evidence in Evidence-based
Treatments



Multiple case studies
Comparison trials
Clinical trials

Within these…..
 Efficacy studies
 Effectiveness studies
 Process-to-outcome


Transportability studies
Qualitative and Meta-analytic research
reviews
Dimensions of Evidence-based Treatments
 Scientific evidence must meet high standards of
methodological rigor
 no single standard of methodological excellence.
Instead, the standard used to evaluate evidence must
match the type of study.
 should include measures of:
 intervention/model fidelity (therapist adherence or
competence),
 clear identification of client problems,
 complete descriptions of service delivery contexts in
which the intervention/treatment is tested, and
 use of specific and well accepted measures of
clinical outcomes.
 In intervention research important to account for
dropout (attrition) and follow-up outcome.
Dimensions of Evidence-based Treatments
3. Multiple definitions of clinical outcomes

Broad non-specific outcomes (e. g. general measure
of functioning)

Specific defined clinical syndromes usually defined by
DSM-IV criteria

Specific measures, or theory-specific measures of
individual, couple, or family functioning (recidivism
changes, relapse levels, cognitive changes, object
relations changes, etc).

Cost benefit analysis for specific models in specific
treatment delivery settings
Broad/
Non-specific
Specific
Dimensions of Evidence-based Treatments
 Outcomes must be compared to understand nature
of outcome



Absolute effectiveness is a measure of the success of
the intervention/treatment compared to no treatment.
Such a comparison is useful in determining if an
intervention/treatment can even be considered
evidence-based.
Relative efficacy is comparison of an
intervention/treatment to a reasonable alternative
(common factors, a treatment of a different modality,
or a different intervention/treatment). Relative efficacy
is critical to establish that a treatment is the best
choice for a specific client/problem.
Contextual efficacy, the degree to which an
intervention/treatment is effective in varying
community contexts, is a critical third dimension.
Standards of Evidence-based Treatment in
Family/Couple Therapy
 Levels of Evidence informed/based
interventions/treatments




Pre-evidence informed
interventions/treatments
Level I: Evidence-informed
interventions/treatments
Level II: Promising interventions/treatments
Level III: Evidence-based Treatments
Standards of Evidence-based Treatment in
Family/Couple Therapy
 Pre-Evidence Informed
Intervention/Treatments

Interventions and intervention approaches
without evidence, or without a basis in
empirically based intervention/models

May use basic general principles that are
common to all models yet the way they do it has
yet to be systematically evaluated and tested
Standards of Evidence-based Treatment
Level I: Evidence-informed
Interventions/Treatments




Informed by previous research/basic psychological
research, or common factors perspective.
Factors/elements in the treatment are explicitly linked
aspects of the model that is proposed.
Specific treatment programs that have evidence for
portions of the program to suggest that they have an
evidence base.
Maybe a common factor, or a single intervention,
however, the intervention needs to be specifically
defined.
Standards of Evidence-based Treatment
Level II: Promising Interventions/Treatments

Specific interventions (meets the criteria for a
defined intervention) that have comparison studies
of high quality but no further evidence or specific
outcomes with specific populations.

Specific intervention/treatment programs (meets
the definitions above) that have studies with
specific outcomes with specific populations.

Might be either limited number of studies, or studies
at either at a single site or of less methodological
rigor.
Standards of Evidence-based Treatment
Level III: Evidence-Based Treatments




Evidence based treatments/interventions have different
levels of evidence, specificity and applicability. Three
categories define these differences
To be considered an evidence-based
intervention/treatment, it is necessary to meet the
criteria for category 1.
Assumption is that to reach this level needs to have
more than single intervention but to be embedded
within the conceptual and theoretical aspects of a
treatment package.
Multiple studies, at a single site with high level
methodological rigor
Standards of Evidence-based Treatment
Category 1: Absolute efficacy/effectiveness

Specific treatment intervention
models/programs that meet the criteria above
(theoretical principles, specific clinical
procedures, theoretically articulated change
mechanisms) that have:


Efficacy studies with comparison, clinical trial
evidence that shows clinically significant effects
with specific clinical outcomes that have clinical
relevance.
This would suggest that this treatment is a useful
treatment for a specific class of clinical problems
Standards of Evidence-based Treatment
Category 2: Relative efficacy/effectiveness

Specific treatment intervention models/programs that
meet the criteria above (theoretical/conceputal
principles, specific clinical procedures, identified
change mechanisms) that have:
 Efficacy studies with clinical trial evidence that show
clinically significant effects with specific clinical
outcomes with clinical relevance as compared to other
reasonable treatments.
 This would suggest that this treatment is a preferred
treatment for a specific class of clinical problems
 Specific evidence of evaluated or verified change
mechanisms that are expected and proposed by the
treatment model
Standards of Evidence-based Treatment
Category 3: Effective models with verified
mechanisms of action


Specific treatment intervention
models/programs that meet the criteria above
(theoretical principles, specific clinical
procedures, identified change mechanisms)
that have:
Specific evidence of evaluated or verified
change mechanisms that are expected and
proposed by the treatment model
Standards of Evidence-based Treatment
Category 4: Contextual efficacy

Specific treatment intervention models/programs that
meet the criteria above (theoretical principles, specific
clinical procedures, identified change mechanisms)
that have:
 Efficacy studies AND effectiveness studies in
community settings that show clinically significant
effects with specific clinical outcomes with clinical
relevance as compared to other reasonable treatment
alternatives.
 Specific evidence of evaluated or verified change
mechanisms that are expected and proposed by the
treatment model. Where it is designed to work.
 Evaluated according to a “matrix” logic model
Standards of Evidence-based Treatment
 Logic
 Criteria should reflect the notion that “evidence based”
models have different uses/applications based on the
evidence
 Reliable and valid evidence in different areas are
important for different decisions
 For example:
 Evidence in different contexts will lead to different clinical
decisions (what to use with what client) and administrative
decisions (what system the intervention program has
demonstrated outcomes)
 Evidence with different outcomes will lead to different
decision regarding confidence/use for different
clinical/administrative applications

Matrix approach allows for the “holes” in research
evidence to be identified and thus, create needed
future research agendas
Decision Making “Matrix”
Specific Intervention Model
Context
Level of Efficacy/Effectiveness
Absolute/Relative
Client factors
-gender
-Ethnicity
-culture
Service Delivery/
Settings
(e. g. mental health
Center/private practice)
Social/Cultural
Context
(e. g. urban/rural/
US/International)
(demonstrated evidence)*
Type of demonstrated Outcomes
(e. g. satifaction, cost/benefit/durability)
Final comments
 Aim to produce more comprehensive guidelines to
help clinicians better match treatments to problems
and researchers identify needs – and present this
information in a user friendly format via web and print
 Next step – what are cross-cutting therapeutic
principles and how are these principles used in
existing treatments?
 Plan for how to consider evidence over time
 Be less concerned with which treatments are
ahead now than place of evidence over time
 Present accidents of funding priorities exert
influence in what is known but other evidence will
fill in over time.
More Questions
 What to do with evolving methods-How much of a treatment






needs to be the same for it to count as an example of a
treatment?
An emphasis on principles or on treatments?
 Different routes to the same therapeutic change process
Valid key measures for assessing change or arbitrary metrics?
What status to designate problems never addressed in funding
priorities-e.g.. relational difficulties
How much demonstration needed in a specific context or
culture?
How important is the therapist in treatment success?
What’s the balance of client values/clinical expertise in relation
to research evidence.
 Perhaps evidence more important when there is a specified
target problem rather than therapy as a multi-faceted
process of development; e.g. overcoming panic attacks vs.
decisions about marriage