Transcript Interpersonal Therapy

Evaluating Psychological
Interventions
Empirically Supported Treatments
Needles and Shots Example
Cognitive-Behavioral Therapy
Gregg Selke, Ph.D.
PSY 4930
October 31st, 2006
Should we evaluate the effectiveness of
psychological interventions?
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Criticisms
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Patients are too heterogeneous to be evaluated
statistically
Psychotherapeutic interventions are too
individualized to be evaluated empirically
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Issues and desired outcome is different for every
patient
Difficult to define, quantify, and measure “process”
of therapy (e.g., rapport, empathy, transference)
Fear that “lists” of “effective” treatments will be
used by managed care to determine what will and
will not be paid for.
Should we evaluate the effectiveness of
psychological interventions?
Yes, and here is why!
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Estimated >400 forms of psychotherapy
1. Specificity
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Matching which interventions are most
effective to specific problems
2. Ethical Obligation
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Responsibility to clients to use best
treatments (supported by research)
Should we evaluate the effectiveness of
psychological interventions?
3. Field Advancement
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Increases credibility of field
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Refines our clinical skills and treatments
Better outcomes & cost efficiency
4. Support for Theory behind Intervention
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Evaluates validity of theoretical basis of an
intervention under evaluation
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(e.g., Cognitive Therapy: depression is due to
underlying negative thoughts and beliefs, so if
person becomes less depressed after changing
negative thought patterns, theory supported)
How should we evaluate and
measure effectiveness?
Rigorous Experimental Methods
1. Random Assignment to treatment groups
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Reduces risk of ending up with more severe patients
in one group
2. Using appropriate control or comparison
group(s)
3. Using valid and reliable outcome measures
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E.g., most sensitive test of depression
4. Consistency of therapist(s) across patients
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Pre- and Post-treatment evaluation
Three suggested methods for
measure effectiveness
1. Within-subjects designs
2. Between-subjects designs
3. Meta-analysis
Within-subjects designs
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Individual acts as own control by
undergoing each intervention or nonintervention condition
Single-Case & Group Experimental Designs
1) A-B-A-B design (A=no treatment; B=treatment)
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Ethics of withdrawing treatment (enuresis
vs. depression)
Not possible to withdraw some treatments
(Cognitive Therapy)
Within-subjects designs
Single-Case & Group Experimental Designs
2) Multiple Baseline Design
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Does not require withdrawal or reversal of
intervention
Stepwise introduction of components of
treatment (A  B  C)
E.G., hypothetical treatment for ODD
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Component A reduce verbal abuse
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Component B reduce noncompliance
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Component C reduce aggression
Can not definitively rule out improvements just
due to passage of time
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Between-subjects designs
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Groups of individuals undergo different or
no interventions
Increases support for improvement actually
being due to treatment
1) Nonrandomized Control Group Studies
 2 “naturally occurring” groups are compared
 E.g., ADHD: behavior therapy vs. meds
 Poor design! No way of knowing if groups
differed (in severity, SES) before
interventions
Between-subjects designs
2) Randomized Clinical Trials
 Subjects are randomly assigned to
different conditions/interventions
  likelihood groups will not differ
systematically, or differences will
occur more equally across groups
Between-subjects designs
2) Types of Randomized Clinical Trials
a) No-treatment control group (ethical issues)
b) Wait-list control group (get treatment later)
c) Placebo control group (e.g., double-blind
trials)
 E.g., nonspecific support in psychology
d) Comparing Multiple Interventions
 E.g., behavior therapy, meds, behavior
therapy+meds, wait-list control, & placebo
Meta-Analysis
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“Studies of studies”
Statistical procedure to combine the
findings of multiple studies
Uses the effect sizes (how big the average
change due to treatment was), and gives
more weight to studies with larger samples
Advantage: Studies do not have to use the
same measures
How do we determine if a treatment is
good enough (i.e., valid)?
APA Division 12 and 53
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Guidelines for identifying and promoting
empirically “validated” or supported
treatments in psychology.
Defining Interventions as
1. Best Support (“Well-Established
Treatments”)
2. Promising (“Probably Efficacious
Treatments”)
Criteria for
“Well-Established Treatments”
or Best Support
I. At least two good between group design
experiments demonstrating efficacy in one or
more of the following ways:
a. Superior to pill placebo, psychological
placebo, or another treatment.
b. Equivalent to an already established
treatment in experiments with adequate
statistical power (about 30 per group; cf.
Kazdin & Bass, 1989).
Criteria for
“Well-Established Treatments”
or Best Support
OR
II. A large series of single case design
experiments (n > 9) demonstrating
efficacy. These experiments must have:
a. Used good experimental designs
b. Compared the intervention to another
treatment as in I.a. (superior to placebo,
etc.)
Criteria for
“Well-Established Treatments”
or Best Support
AND
Further criteria for both I and II:
III. Experiments must be conducted with
treatment manuals.
IV. Characteristics of the client samples must
be clearly specified.
V. Effects must have been demonstrated by
at least two different investigators or
teams of investigators.
Criteria for
“Probably Efficacious Treatments”
or Promising
I. Two experiments showing the
treatment is (statistically significantly)
superior to a waiting-list control
group.
 Manuals, specification of sample, and
independent investigators are not
required.
Criteria for
“Probably Efficacious Treatments”
or Promising
OR
II. One between group design experiment with
clear specification of group, use of manuals,
and demonstrating efficacy by either:
a.
Superior to pill placebo, psychological
placebo, or another treatment.
b. Equivalent to an already established
treatment in experiments with adequate
statistical power (about 30 per group; cf.
Kazdin & Bass, 1989).
Criteria for
“Probably Efficacious Treatments”
or Promising
OR
III. A small series of single case design
experiments (n > 3) with clear
specification of group, use of
manuals, good experimental designs,
and compared the intervention to pill
or psychological placebo or to
another treatment.
Example
Empirically Supported Treatment
Behavioral Distress in
Venipuncture and Immunizations
Background
• Venous blood sampling and immunizations are
potentially very painful and frightening to
children (and adults).
• Prevalence of Needle Phobics estimated to be
4.9% -9% (14/100 in 20 year olds).
• Nearly all Children in the U.S. are required to
receive immunization shots prior to preschool,
and have venipuncture at routine doctor visits.
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Fear of needles is a primary reason why
people are reluctant to donate blood.
Adult fear and avoidance of medical
care is associated with having had more
medical pain and fear in childhood.
Young children (Cohen, 1997)
 Rarely show spontaneous overt coping
behavior
 Have difficulty ignoring aversive stimuli
 Do not initiate internal coping strategies
(i.e., imagery) as easily as older
children and adults
Interventions to reduce associated
distress are not routinely used in standard
care.
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Research not well disseminated
Intervention seen as unnecessary for brief
procedures
Costs of training and equipment
What is Distress?
Indicators of Child Distress
 Crying, Screaming, Fussing/Whining, Verbal
Resistance, Verbal Pain, Verbal Emotion,
Request for Emotional Support, Verbal Fear,
Information Seeking , Physical
Resistance/Flailing, Kicking, Muscular Rigidity
 May increase procedure duration, the
experience of pain, potential for accidental
injury
Goals
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Distress,  Coping,  Cooperation
Intervene early to prevent future
distress
Find Practical, Cost-Effective Methods to
Alleviate Distress
Literature Review
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Reviewed Psychlit, Pubmed
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Over 20 Intervention Studies
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Wide range of treatment populations
Predominant Component: Distraction
Caveat: only reviewed up until 2001
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Different Types of Distraction
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Other Interventions
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Party Blower
Cartoon Movie
Kaleidoscope
Lullabies
Parental Non-Procedural Talk
Picture Book
Behavioral Education to Parents
Different Ways to Implement
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Parent Training
Nurse Training
Child Training
Manimala, Blount, Cohen. Effects of parental reassurance vs.
distraction on child distress and coping during immunization.
Children’s Health Care (2000)
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Subjects: Healthy, N=27-28 per group, preschool
immunizations, 3-5 years, clearly identified
Design: Between Group: 3 groups
Interventions
a) Standard
b) Prior to Procedure: Distraction with toys,
puzzles, coloring books, non-procedural talk
During Procedure: Parent Coaching of Party
Blower (Breathing /relaxation)
c) Parent Reassurance: trained/encouraged
Outcome:  restraint with Distraction + Coaching
 Reassurance 3X restraint & > Verbal Fear
than Distraction and Standard
Bowen, Dammeyer. Reducing Children’s Immunization Distress
in a primary care setting. J Ped Nursing (1999)
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Subjects: Healthy, N=80 (21, 29,30 per group),
3-6 years, clearly identified
Design: Between Group: 3 groups
Groups/Intervention (no coaching or training)
a) Standard
b) Party Blower (Deep Breathing Distraction)
c) Looking at or blowing a Pinwheel taped down
Outcome:  Distress with Blower compared to
standard or pinwheel,
Party Blower thought to be more distracting than
pinwheel b/c more sensory systems are involved.
Based on 2 studies, Party Blower Procedure may
meet criteria for “Well-Established”
Gonzalez, Routh, Armstrong. Effects of maternal distraction
versus reassurance on children’s reactions to injections.
JPP (1993)
•Subjects: Healthy, N=42 (14/group), primary care
Ages: 3-7 years, clearly specified
•Design: B-G, 3 Groups
•Groups/Intervention
a) Minimal Treatment Control
b) Parental Reassurance
c) Maternal Non-Procedural Talk (Distraction)
Outcome: Distraction Associated with  Distress &
 Crying, compared to Reassurance & Control
“Promising”
Inadequate sample size per group
Cohen, Blount, Panopoulos. Nurse coaching and cartoon
distraction: an effective and practical intervention to reduce
child, parent and nurse distress during immunization. JPP
(1997)
•Subjects: Healthy, N=92 (about 30/group)
Ages: 4-6, clearly identified
•Design: B-G, protocol used
•Groups/Intervention
a) Standard
b) Nurse Coach: coach to watch cartoon movie
c) Nurse + Parent/Child Intervention:
- modeling and role playing prior
- nurse + parent coaching during movie
Outcome: both interventions
Distress,  restraint,  coping
Cohen, Blount, Cohen, Schaen, Zaff. Comparative study of
distraction vs. topical anaesthesia for pediatric pain management
during immunization. Health Psych (1999)
•Subjects: Healthy, N=39, at school health clinic
8-11 years, low SES, clearly identified
•Design: 3 conditions, Within Subjects, 3 Hep shots
•Groups/Intervention
a) Standard
b) Distraction + Nurse Coach: cartoon movie
c) EMLA: lidocane + prilocane applied 1hr prior
Outcome:
Distress,  coping: cartoon + coaching
Children coped better with standard than EMLA
Coaching to watch cartoon “Promising” b/c lack of
multiple research teams/authors
Conclusions
Behaviors Associated with High Levels of
Distress: Cohen,1997
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Reassurance, too much empathy, apologies,
criticism, giving child control over start of
the procedure, parental anxiety.
Reducing Distress
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Distraction, Straightforward Information,
Parent and Nursing Coaching, Teaching
coping strategies
100s of estimated forms of psychotherapy
How many empirically
supported treatments do you
think there are for children and
adolescents who have
psychological/psychiatric
disorders?
Anxiety
Disorders
“Well-Established
Treatments”
“Probably Efficacious
Treatments”
Specific
Phobia
1.Participant Modeling*
2.Reinforced Practice*
1.Cognitive Behavior Therapy
2.Systematic Desensitization*
Generalized
Anxiety Dx
(GAD)
None
1.
2.
3.
4.
5.
6.
Separation
Anxiety
None
Same 6 treatments as GAD
Agoraphobia
None
None
OCD
None
None
Panic Disorder None
None
PTSD
None
None
Social Phobia
None
None
Cognitive Behavior Therapy
Modeling*
In Vivo Exposure*
Relaxation Training*
Reinforced Practice*
Family Anxiety Management
* These can be considered components of CBT
Depressive
Disorders
“Well-Established
Treatments”
“Probably
Efficacious
Treatments”
Major Depressive
Disorder
1. Interpersonal
Therapy
1. CBT
2. Psychotropic
Medications
Dysthymic Disorder
1. Interpersonal
Therapy
1. CBT
2. Psych Med
Adjustment Disorder 1. Interpersonal
1. CBT
2. Psych Med
Therapy
ADHD
“Well-Established
Treatments”
1. Stimulant Meds
“Probably
Efficacious
Treatments”
1. Social Skills
Training with
2. Behavioral Parent
Generalization
Training
Components
3. Behavioral
2. Summer
Classroom
Treatment
Interventions
Programs
ODD
&
CD
“Well-Established
Treatments”
1. Parent Training
Based on the
book Living with
Children
2. Videotape
Modeling Parent
Training
“Probably
Efficacious
Treatments”
For Pre-school Age Children:
1.
Parent-Child
Interaction Therapy
2.
Time-Out Plus Signal Seat
Treatment
3.
Parent Training Program
4.
Delinquency Prevention
Program
For School Aged Children:
1.
Anger Coping Therapy
2.
Problem Solving Skills
Training
For Adolescents:
1.
Anger Control Training with
Stress Inoculation
2.
Assertiveness Training
3.
Multisystemic Therapy
4.
Rational Emotive Therapy
Cognitive Behavioral Therapy
“Probably Efficacious Treatment”
 Specific Phobia
 Generalized Anxiety Disorder (GAD)
 Separation Anxiety
 Major Depressive Disorder
 Dysthymic Disorder
 Adjustment Disorder
While not meet EST criteria, also often used for
 Agoraphobia, OCD, Panic Disorder, PTSD, Social
Phobia
What is CBT?
Therapeutic technique that uses a combination of
A. Cognitive Strategies
 Alter, manipulate, and restructure distorted and
unhealthy thoughts, images, and beliefs.
 Assumes that unhealthy thoughts lead to
maladaptive behavior, and positive changes in
thinking will produce positive changes in
emotions and behavior.
B. Behavioral Strategies
 CBT procedures link cognitive strategies with
behavioral strategies
 Assumes that by making direct positive changes
in behavior, will result in positive changes in
thoughts and emotions (e.g., anxiety, depression)
Early Foundations of CBT
(behavioral aspects)
Developed out of Learning Theories
 Classical conditioning (Pavlov, Watson):
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Focuses on the antecedent of behavior or what
occurred before behavior (possible cause)
Learning occurs through association
Conditioning that pairs a previously neutral stimulus
with a stimulus that evokes a reflexive response; the
stimulus that evokes the response is given whether or
not the conditioned response occurs until eventually
the neutral stimulus comes to evoke the response
e.g., Pavlovian dogs, Little Albert
Particularly relevant for phobias, PTSD, panic disorder
Early Foundations of CBT
(behavioral aspects)
Learning Theories
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Operant Conditioning (Skinner, Thorndike)
 Focuses on the consequences of behavior
 A process of behavior modification in which the likelihood of
a specific behavior is increased or decreased through
positive or negative reinforcement each time the behavior is
exhibited, so that the subject comes to associate the
pleasure or displeasure of the reinforcement with the
behavior.
 Positive consequences or removal of negative stimuli
increase the likelihood of behavior happening again
 Negative consequences decrease the likelihood of a future
occurrence
 E.g., time out for aggression, ending time out for sitting
quietly in time out, getting a sticker for using manners
Early Foundations of CBT
(behavioral aspects)
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Social Learning Theory (Bandura):
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Focuses on modeling
Learning occurs through modeling or
vicarious learning
No direct reinforcement is necessary
E.g., Bobo doll experiments; witnessing
violence in media or community or family
Early Foundations of CBT
(cognitive aspects)
Beck (1960s-1970s)
 Individuals are affected by objective
world AND their subjective perceptions
and interpretations
 Negative perceptions of events is more
likely to lead to depression or anxiety
 Even though cognitions or thoughts
cannot be directly observed (like
behaviors), they can be changed
Cognitive Theories
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Beck developed cognitive therapy after
noticing that depressed patients had
cognitions regarding:
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Loss
Failure
Abandonment
Rejection
Negative thoughts play a role in the
onset and maintenance of depression
Cognitive Theory
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The Cognitive Triad
1. Negative view of themselves (e.g., inadequate)
2. Negative view of the world (e.g., unfair)
3. Negative view of the future (e.g., I will always fail)
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Negative Schemas
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Cognitive Distortions/Maladaptive Thoughts
Ways of thinking that lead individuals to perceive and
interpret experiences in a negative manner
Automatic: often occur very rapidly in certain situations
and may be outside of person’s awareness
Involve discrete predictions or interpretations of a given
situation
Develop out of negative experiences
Cognitive Theory
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Ellis’s A-B-C theory
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A-activating events
B-irrational beliefs
C-emotional consequences
When A occurs, an individual
automatically engages in negative
beliefs/thoughts about the event
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E.g., walk by “friend”, you say hi, they do
not respond……
Cognitive Theory
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Examples of irrational beliefs:
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When things do not go the way I would
like, life is awful, terrible, horrible, or
catastrophic
Unhappiness is caused by uncontrollable
external events
I must have sincere love and approval from
all significant people in my life
From Cognitive Theory
to Intervention
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Ellis’ A-B-C-D-E theory
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D-dispute irrational beliefs
E-evaluate effects (reduction of depression,
anxiety)
D-dispute irrational beliefs
Cognitive Reframing
Goal of Cognitive Therapy
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Must first increase awareness of types of automatic
negative thoughts one has
Then learn to pursue thought until arriving at
context or prediction that is contributing to it.
Then replace or reframe cognitive
distortions/maladaptive thoughts with more
balanced and realistic thoughts and beliefs
about oneself, the future, and the world around us.
 negative & ↑ positive feelings and behaviors
Possible Components of CBT
or Techniques used as part of CBT
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Cognitive Reframing
Relaxation Training
1.
2.
3.
4.
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Diaphragmatic Breathing
Imagery
Progressive Muscle Relaxation
Iatrogenic Relaxation
Modeling
In vivo exposure
Reinforced practice
Social and Communication skills training
Problem-solving training
Anger-management training
Behavioral Strategies
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Generally, behavior therapy emphasizes
changing behavior by changing the
antecedents or consequences, or
learning new behavior-based skills
Behavioral Strategies
Relaxation Training
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Management of anxiety, pain, anger,
stress, emotional reactivity, depression,
fatigue, etc.
1. Diaphragmatic Breathing
2. Guided Imagery - visualization
3. Progressive Muscle Relaxation
4. Autogenic Relaxation
5. Biofeedback
Behavioral Strategies
In Vivo Exposure
 Real-life exposure
 Practicing approaching and confronting a
feared situation or object (e.g., driving,
germs)
 Sessions should begin with easy situations
and gradually work its way up to scarier and
harder situations.
 OCD, phobias
 Extreme versions: implosive therapy, flooding
Behavioral Strategies
Modeling
 Involves demonstrating non-fearful
behavior in a feared situation and
showing the child or adolescent a more
appropriate response for dealing with a
feared object or event
 E.g., social situation, dogs
Behavioral Strategies
Participant Modeling
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Combines modeling and in vivo exposure
1.
Model (e.g. therapist, friend, or peer)
demonstrates fearlessness and coping
responses when confronting a feared
situation or object
2.
The model assists the child in practicing
approaching and confronting the feared
situation or object.
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Sessions should begin with easy situations
and gradually work its way up to scarier and
harder situations.
Behavioral Strategies
Reinforced Practice
 Combines in vivo exposure with a
feared situation or object and rewards
(e.g. praise, tokens, toys, hugs, etc.) for
approaching and confronting a feared
situation or object.
 Child is rewarded for practicing
approaching and confronting a feared
situation or object.
Behavioral Strategies
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Contingency management
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Shaping
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Changing behavior by controlling it’s
consequences
PCIT
Reinforcing successive approximations of a
behavior
e.g. sitting on toilet for toilet training
Token economy programs
Behavioral Strategies
Aversive Conditioning
 Reducing unwanted behaviors by
pairing it with a negative stimulus
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Electric shock
Unpleasant tasting liquid
In children, usually only used with selfinjurious behavior
Usually used as a last resort
Behavioral/Cognitive Strategies
Systematic Desensitization
 Child or adolescent imagines feared object or
situation while he/she is engaged in a
response that is incompatible with anxiety
(e.g. relaxation or play).
 Based on the theory of reciprocal inhibition—
one cannot be anxious and relaxed at the
same time (Wolpe, 1958)
 Unlike participant modeling and reinforced
practice, the feared object or situation is
presented in imagination rather than real life.
Behavioral/Cognitive Strategies
Anger Coping Therapy
 Designed to address deficiencies in thinking and
problem-solving exhibited by aggressive children
 Children learn to
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Establish group rules and generate reinforcers
Use self-statements to inhibit impulsive behaviors
Identify problems and take other perspectives
Generate alternate solutions and be aware of consequences
of their actions
Model videotapes and become more aware of physical
symptoms involved in anger
Make their own video of problem-solving and self-inhibiting
statements
Role-playing to solve current anger problems
Behavioral/Cognitive Strategies
Problem Solving Skills Training
 Teaches children skills to solve problems
better
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Developing alternative solutions, anticipating
consequences, and taking others’ perspectives
Parents taught to manage their children’s
behavior using time-out, positive
reinforcement, negotiating, and other
strategies.
Teaching methods included role-playing,
corrective feedback, practice, modeling, and
token economy.
Behavioral/Cognitive Strategies
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Social Skills Training
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Used with patients with depression,
anxiety, social phobia, schizophrenia
Focuses on verbal and nonverbal behaviors
Uses behavioral techniques such as
modeling, role play, rehearsal
Patient begins to be positively reinforced
for social skills
Behavioral/Cognitive Strategies
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Social Skills Training may focus on:
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Maintaining eye contact
Smiling at appropriate times
Matching tone of voice to content
Accurately perceiving the emotions of others
Interpreting nonverbal behaviors
Making requests of others
Standing up for their rights
Maintaining a conversation
Timing responses appropriately
Progressive Muscle Relaxation
In-Class Exercise
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Systematic tensing and relaxation of
major muscle groups of whole body
With practice, goal is to learn to
become deeply relaxed fairly rapidly
Impossible to be tense and relaxed at
same time, can implement skill when
noticing that you are starting to become
tense and anxious
HAPPY
HALLOWEEN