What is evidence-based practice?

Louis Castonguay The Pennsylvania State University CA-SPR Montreal 2009

1

The Early Participants in the Debate



Those who argue for Treatments That Work (Division 12; Nathan & Gorman, 1998; 2002; Chambless & Crits-Christoph, 2005)



Those that argue for Relationships that work (Division 29; Norcross, 2002; Norcross & Lambert, 2005)



Those who argue for Participant Factors that work (Bohart, 2005; Wampold, 2001; 2005)

2

Recognized False Dichotomies

 “It is important to note that the effective practice of evidence-based psychotherapy involves more than the mastery of specific procedures outlined in EST manuals. Almost all ESTs rely on therapists’ having good nonspecific therapy skills” Chambless & Ollendick (2001) -therapists’ competence -client’s ability to form an alliance -client’s initial functioning - interaction of client characteristics and treatment approaches 3

Recognized False Dichotomies

 “The therapeutic relationship acts in concert with discrete interventions, patient characteristics, and clinician qualities in determining treatment effectiveness. A comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations” (Norcross, 2002) 4

An Alternative, Integrative Position



Division 12 (APA) and North American Society for Psychotherapy Research Joint Task Force on Identifying Therapeutic Principles that Work.

–

Castonguay, L. G., & Beutler, L. E. (Eds)(2005).

Principles of Therapeutic Change that Work

. New York: Oxford University Press.

5

Mission of Joint Task Force



To integrate participant, relationship, and treatment factors and consolidate them into working principles that are grounded in research.

6

Strategy of Joint Task Force

To extract from previous Task Force Reports on Relationship Factors and Treatments that work, common and specific principles of treatment that are “empirically-informed”.

7

Composition of Task Force



24 Senior Scholars who were “assigned” in pairs to work with one another, based on having variable and contrasting viewpoints.



21 Associated Scholars picked by chapter authors to assist in the literature reviews and writing.

8

Partici Pants

Task Force Structure

PD Dysph Subs Anx Relation Ships Techniques

9

Procedure



Review extant literature cited in relevant chapters of Division 12 and Division 29 task force reports and the

Handbook of Psychotherapy and Behavior Change,

1994 and 2004 editions



Summarize results for studies relevant to a specific disorder



Extract principles that are supported by a “preponderance of evidence”

10

Seeking Consensus



Meeting of representatives of all chapters – June, 2003.

–

Common Principles---those that cut across disorders, within a variable domain

–

Unique Principles---The remaining principles that are specific to one disorder, representing each domain (participants, relationships, treatment techniques/models)

11

Summary of Results



26 “Common” and 35 “Unique” Principles

–

Participant Principles



16 on Observed and 12 on Inferred Qualities



5 Common and 23 Unique

–

Relationship Principles



9 Common and 2 Unique Principles

–

Treatment Principles



12 Common and 10 Unique

12

Conclusions



When properly applied, principles of change will allow clinicians to operate research informed practices, to enhance their ability to serve a wider range of patients, and to use an eclectic array of empirically based clinical methods.

13

Therapeutic principles of change in the treatment of depression.

14

PRINCIPLES REGARDING PATIENT PROGNOSIS REGARDLESS OF TREATMENT TYPE*…

1.

Patients representing underserved ethnic or racial group achieve fewer benefits than Anglo-American groups, from conventional psychotherapy. 2.

If patients and therapists come from the same or similar racial/ethnic backgrounds, drop out rates are positively affected and improvement is enhanced.

3.

If psychotherapists are open, informed, and tolerant of various religious views, treatment effects are likely to be enhanced.

4. Co-morbid personality disorders, are negative prognostic indicators in the psychological treatment of depressed patients.

*Beutler et al (2005) 15

PRINCIPLES REGARDING PATIENT PROGNOSIS REGARDLESS OF TREATMENT TYPE* continued

5.

Age is a negative predictor of a patient’s response to general psychotherapy. 6.

Patients who enter treatment with high levels of functional impairment, tend to do poorly relative to other patients.

7.

A secure attachment pattern in both patient and therapist appears to facilitate the treatment process .

8.

The most effective treatments are likely to be those that do not induce patient resistance.

*Beutler et al (2005) 16

PRINCIPLES RELATING TO MATCHING THERAPY TO A PARTICULAR CHARACTERISTIC OF THE CLIENT*…

1.Benefit may be enhanced when the interventions selected are responsive to and consistent with the patient’s level of problem assimilation. 2. If patients have a preference for religiously oriented psychotherapy, treatment benefit is enhanced if therapists accommodate this preference.

3. In dealing with the resistant patient, the therapist’s use of directive therapeutic interventions should be planned to inversely correspond with the patient’s manifest level of resistant traits and states.

*Beutler et al (2005) 17

PRINCIPLES RELATING TO MATCHING THERAPY TO A PARTICULAR CHARACTERISTIC OF THE CLIENT* continued

4.

Patients with high levels of initial impairment respond better when offered long term, intensive treatment, than when they receive non-intensive and brief treatments, regardless of the particular model and type of treatment assigned. Patients with low impairment, seem to do equally well in high and low intensive treatments 5.

Patients whose personalities are characterized by impulsivity, social gregariousness, and external blame for problems, benefit more from direct behavioral change and symptom reduction efforts, including building new skills, and managing impulses, than they do from procedures that are designed to facilitate insight and self-awareness.

6.

Patients whose personalities are characterized by low levels of impulsivity, indecisiveness, self-inspection, and over control, tend to benefit more from procedures that foster self-understanding, insight, interpersonal attachments, and self-esteem, than they do from procedures the aim at directly altering symptoms and building new social skills *Beutler et al (2005) 18

PRINCIPLES RELATED TO THERAPEUTIC RELATIONSHIP*…

1.

When working with clients with dysphoric disorders, therapists should strive to develop and maintain a positive working alliance with their clients .

2. When conducting group therapy with depressed individuals, therapists should foster a strong level of cohesiveness within the group.

3. Therapists working with depressed individuals should attempt to facilitate their engagement during and between sessions.

4. When working with depressed individuals, therapists should relate to their clients in an empathic way.

5. When adopted by therapists, an attitude of caring, warmth, and acceptance is likely to be helpful in facilitating therapeutic change in depressed clients.

• *Castonguay et al (2005) 19

PRINCIPLES RELATED TO THERAPEUTIC RELATIONSHIP* continued

6.

When working with individuals suffering from depressive symptoms, therapists are likely to facilitate change when adopting an attitude of congruence or authenticity.

7.

Therapists working with depressed individuals may find it helpful to adopt an empathic and nondefensive (or nonrigid) attitude when attempting to repair alliance ruptures .

8.

When working with depressed clients, therapists' use of self-disclosure is likely to be helpful. This may be especially the case for reassuring and supportive self disclosures, as opposed to challenging self-disclosures.

9.

When working with depressed clients, therapists should avoid high levels of relational interpretations.

10.

When making relational interpretations, therapists should strive to accurately address client's central interpersonal themes, as a high level of accuracy (or quality) with regard to these interpretations is likely to be beneficial for the client.

*Castonguay et al (2005) 20

1.

PRINCIPLES RELATED TO THERAPEUTIC TECHNIQUES*

Challenge cognitive appraisals and behavior with new experience.

2.

Increase and diversify the patient's access to contingent positive reinforcement for depressive and avoidant behaviors.

3.

Improve the patient's interpersonal social functioning.

4.

Improve marital, family, and social environment to reduce the establishment, maintenance, or recurrence of depressive behaviors.

5.

Improve awareness, acceptance, and regulation of emotion and promote change in maladaptive emotional responses.

21

TENTATIVE PRINCIPLES REGARDING PARTICIPANT FACTORS*

1.

Research on gender effects is insufficient for a clear judgment of effects on treatment of depressed patients to be made. 2. Principles related to preference and expectance are not sufficiently well defined to be applied to the clinical treatment of depressed patients. 3. Insufficient research has been conducted on SES to determine if it is a contributor to treatment outcome for depressed patients.

4. Patient stage of change is a promising (but not proven) variable for fitting patient and treatment and for predicting the level of intervention in which to engage the patient.

*Beutler et al (2005) 22

TENTATIVE PRINCIPLES RELATED TO THERAPEUTIC RELATIONSHIP*

1.

Repairing alliance ruptures that emerge during treatment is likely to be helpful when working with depressed clients .

2.

Depressed clients are likely to benefit from receiving feedback from their therapists.

3.

When working with depressed clients, therapists are likely to be more effective when they adequately manage their countertransference reactions toward their clients.

• *Castonguay et al (2005) 23

Current Developments in Psychotherapy Integration

1) 2) 3) 4) 5) Theoretical Integration Eclecticism Common Factors Integrative Approaches for Specific Clinical Problems Improvement of Major Systems of Psychotherapy

24

Sequence of Events for Dropouts (Piper et al., 1999 )

         The patient voiced thoughts about dropping out The patient expressed frustration The therapist focused on the transference The patient resisted focus on the transference The therapist persisted A power struggle developed The patient continued to resist The patient reluctantly agreed to return The patient never returned 25

Technique and relationship in Psychodynamic therapy (Schut et al. 2006)

   Interpretation Disaffiliative processes Interpretation and disaffiliative processes 26

Integrative Cognitive Therapy (Castonguay et al., 2004)

 CT manual (Beck et al., 1979)  Identification of alliance ruptures – Empathy scale (Burns, 1990) – Markers of ruptures (Safran & Segal, 1990)  Strategies to repair alliance ruptures (Burns. 1990; Safran & Segal, 1990) – Invitation to explore ruptures – Empathic response – Disarming 27

28

Table 1. Symptomatic Measures at Pre- and Post-test n ICT M SD n WL M SD n CT-NIMH M SD BDI Pre-test Post-test HDRS Pre-test Post-test GAF Pre-test Post-test 11 11 11 11 11 11 27.36

4.82

15.00

4.05

53.09

78.36

4.34

3.66

4.40

2.53

7.01

8.91

10 10 10 10 10 10 27.50

17.50

18.00

11.70

54.20

67.20

5.28

8.80

2.66

5.89

5.73

15.11

37 37 37 37 37 37 26.8

10.81

19.2

7.81

52.8

69.19

8.4

11.94

3.6

6.80

7.2

12.04

Note: ICT: Integrative Cognitive Therapy; WL= Waiting List condition; CT-NIMH: Cognitive Therapy Condition of the NIMH Collaborative Study; ICT post WL: Group of participants who received ICT after completing WL and meeting study’s inclusion criteria before beginning treatment.

29

CBT for GAD



More efficacious than no treatment, analytic psychotherapy, pill placebo, nondirective therapy, and placebo therapy

(Borkovec & Ruscio, 2001) 

Smallest percentage of high endstate functioning compared to other anxiety disorders

(Brown, Barlow & Liebowitz, 1994) 

Alternatives?

30

Rationale for adding I/EP to CBT

 

Applied and basic research has suggested that a focus on dimensions of functioning that are not typically or appropriately addressed by CBT may improve treatment efficacy with GAD: Interpersonal Issues a) Interpersonal Problems b) Developmental Problems c) Problems in the therapeutic relationship Emotional Issues

31

Current GAD CBT protocols fail to address emotion avoidance and interpersonal problems

 Reflective listening significantly superior to CBT on depth of emotional processing (Borkovec & Costello, 1993)  CBT failed to make a significant change in 6 of 8 IIP-C scales (Borkovec, Newman, Lytle, & Pincus, 2002)  Interpersonal problems not successfully treated by CBT at post-assessment were predictive of failure to maintain follow up gains (Borkovec et al., 2002) 32

PI>CBT process features Blagys & Hilsenroth (2000)

       Focus on affect and expression of emotions Exploration of avoidance or hindering of treatment progress Identification of patterns (actions, thoughts, feelings, relationship) Emphasis on past experience Focus on interpersonal experience Emphasis on therapeutic relationship Exploration of wishes, dreams or fantasies 33

         

Jones & Pulos (1993) Psychodynamic Techniques Factors

T emphasizes P feelings to help him/her experience them more deeply T is neutral T interprets warded-off unconscious wishes, feelings, or ideas T points out P’s use of defensive maneuvers P feelings or perceptions are linked to situations or behaviors of the past T draws attention to feelings regarded by P as unacceptable Memories or reconstruction of infancy and childhood are topics of discussion T draws connections between therapeutic relationship and other relationships P’s behavior during the hour is reformulated by T in a way not explicitly recognized T identifies a recurrent theme in P experience or conduct 34

Integrative Treatment for GAD

GAD IV: CBT + I/EP GAD V: CBT + I/EP VS CBT + SL

35

GAD IV Newman, Castonguay, Borkovec, Fisher, Nordberg, 2007

36

Average Within-Group Effect Sizes at Post Therapy and Follow-up for Commonly Used Measures of Anxiety (Assessor Severity Rating, Hamilton Anxiety, Stai-Trait) and Depression (Hamilton Depression and Beck Depression Inventory) Therapy Condition Post Therapy Follow-up Extant GAD Outcome Studies (N = 11) 2.48

2.44

GAD III CT SCD CBT 2.94

2.38

2.80

2.48

2.43

2.43

GADIV CBT/IEP 3.15

3.56

37

GAD V Newman, Castonguay, Fisher, & Borkovec, 2008

38

Conclusions

 Results highlight the importance of long-term follow-up assessments  Our data replicate studies showing different Attachment profiles in GAD  Suggests that one theory to describe GAD functioning and one treatment for all people with GAD may not be optimal  Future studies should examine whether assignment to therapy based on pre-treatment attachment profile leads to better outcome 39

Conclusions

 People with Enmeshment attachment Profile:  Tend to be overemotional and disregarding of cognitions  Tend to be interpersonally unable to extract self from others  People with a Dismissing/Derogating attachment profile :  Tend to be emotionally avoidant and overly cognitive  Tend to be interpersonally overly autonomous and believe can’t depend on anyone but themselves 40

New directions to improve the field

   Integrating practice and research Integrating theoretical perspectives Integrating research domains 41

Integrating research domains

   Bringing psychopathology and psychotherapy research together (Castonguay & Oltmanns, in preparation) Deriving clinical guidelines (assessment foci and principles of change) from basic research Improving case formulations and treatment plans based on empirical information that cut across theoretical orientations 42