Transcript Effectiveness of Therapy and Nonspecific Factors

Effectiveness of
Therapy and
Nonspecific Factors
Is Therapy Effective?
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?
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
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
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
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
How Do we Know if Therapy
works?
2.
We can do two different types of studies to
assess the outcomes of therapy:
Efficacy Studies
Effectiveness Studies

(and meta-analyses of the above)

1.
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
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
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 selfcorrect
Focus on improvement, not symptom reduction
Effectiveness studies maximize on external
validity
The CR Controversy

The CR study is purely
an effectiveness study,
and many scientists
question its results
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
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
Which is Better?

Both types of studies
are useful and for a
treatment to have solid
support, it should be
shown to work in both
efficacy and
effectiveness trials
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
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
Is it the Specifics? Or the
NonSpecifics?

Specifics:


A specific component of a therapy that
theoretically is necessary (e.g. Exposure)
Nonspecifics:

Factors common to all therapies that could
explain outcomes
Factors Influencing Outcome

1.
2.
3.
4.
Can be divided into 4 components:
Extratherapeutic factors
Expectancy Effects
Specific therapy techniques
Common Factors
(Lambert & Barley, 2002)
Factors Influencing Outcome




Extratherapeutic
Factors:
Spontaneous recovery
or remission
Fortunate events
Social support



Expectancy Effects:
Placebo effects
The Dodo bird
hypothesis
Factors Influencing Outcome




Specific Therapy
Techniques:
Exposure
Changing cognitions
(CBT)
biofeedback




Common Factors
Relationship with
therapist
Support
Hopefulness
Factors Influencing Outcome
30%
40%
15%
15%
Extrather.
Expectancy
Specifics
Common
What Nonspecifics Help?




Orlinsky, Grave & Parks
(1994):
Therapist credibility
Therapist skills
Empathetic
understanding
What Nonspecifics Help?



Affirmation
Ability to engage
patient
Focus on patient’s
problems, direct patient
Humanistic Therapies

If you recall, humanistic therapies consist of many
nonspecifics:



Unconditional positive regard
Caring, respect
Being genuine
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
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
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
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
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
Where Are the Specific
Ingredients?


Ahn & Wampold, 2001
A meta-analysis


Looks at effects in many many studies
What Are the Results?


There is no evidence for specific ingredients!!
So, no specific ingredient is responsible
* note: You can find lots of counter-studies