Transcript Social Work Research

SOWK6190/SOWK6127
Cognitive Behavioural Therapy and Cognitive Behavioural Intervention
Week 1 - Psychological treatments that work – and
what convinces us they do? The empirical status of
cognitive-behavioral therapy
Dr. Paul Wong, D.Psyc.(Clinical)
Lecture 1
How I teach?
Overview of course
Evidence-based practice
The empirical status of cognitive-behavioral
therapy
Homework
How I teach?
• Two major principles:
1. Based on a "Tell me, I'll forget. Show me,
I'll remember. Involve me, I'll understand"
principle. Thus, I will do some lecturing,
you will have many opportunities to
discuss, practice, interact during the
lectures.
How I teach?
• 2. Principle of adult learning (Field, 1990):
– Become ready to learn when they recognize a deficiency in their
own skills and accept that they need to take action to remedy it;
– Want learning to be problem-based, leading to the solution of
particular problems facing the individual;
– Want to be treated as adults, enjoying the respect of the
instructor and of other learners, and to have the experience they
bring with them accepted as valid;
– Bring to the learning situation their unique mix of characteristics
such as self-confidence and self-image, learning style, and
personality.
Overview of the course
Please read the course outline
carefully
Evidence-based Practice
Why Evidence-based practice?
• increase understanding of health
pathologies that produce the foundation in
developing precisely targeted interventions.
• advancement in clinical research
methodologies that produce new evidence
for effectiveness of interventions
• global concerns over expenses of health
care (Huppert, Fabbro, & Barlow, 2006).
• implications over legal concern (Havighurst,
Hutt, McNeil & Miller, 2001).
EBM as “the integration
of best research
evidence with
clinical expertise
and patient values”
Components of Clinical Expertise
• assessment, diagnostic judgment, systematic case
formulation, and treatment planning
• clinical decision making, treatment implementation, and
monitoring of patient progress
• interpersonal expertise
• continual self-reflection and acquisition of skills
• appropriate evaluation and use of research evidence in
both basic and applied psychological science
• understanding the influence of individual and cultural
differences on treatment
• seeking available resources
• having a cogent rationale for clinical strategies
Patient characteristics, culture, and
preferences
• exploring “what works for whom”
• patient characteristics: functional status, readiness to
change, and level of social support,
• social factors and cultural background
• familial factors
• current environment context, stressors
• developmental considerations
• problem variations: comorbidity and polysymptomatic
presentations
• personal preferences, values, and preferences related to
treatment (goals, beliefs, worldviews, and treatment
expectations)
Evidence-based Practice
• de-emphasizes intuition, unsystematic
clinical experience, and pathophysiologic
rationale as sufficient grounds for clinical
decision making and
• stresses the examination of evidence from
clinical research. (Evidence-Based Medicine Working
Group, 1992)
Evidence-Based Practice in Psychology (EBPP)
(Levant, 2005)
• APA Presidential Task Force on
Evidence-Based Practice in 2005
• ‘ the purpose …to promote effective
psychological practice and enhance
public health by applying empirically
supported principles of psychological
assessment, case formulation,
therapeutic relationship, and
intervention (p. 5)
Evidence-based practice in Social Work
• The NASW Code of Ethics states that "Social
workers should critically examine and keep
current with emerging knowledge relevant to
social work and fully use evaluation and
research evidence in their professional
practice" (5.02(c)).
• This guideline also pertains to the ethical
mandate of informed consent, because
professionals need to know the evidentiary basis
for alternative practices and policies in order to
fully honor the informed consent principle
(Gambrill, 2003)."
Steps in evidence-based practice
1. Formulate a question to answer
practice needs;
2. Search for the evidence;
3. Critically appraise the relevant studies
you find;
4. Determine which evidence-based
intervention is most appropriate for your
particular client;
5. Apply the evidence-based intervention;
and
6. Evaluate and feedback
Level and Quality of Evidences
UK: 5 Levels of Evidence (Centre for
Evidence-based Medicine, University of
Oxford, 2009)
http://www.cebm.net/index.aspx?o=1025
Challenges in applying EBP in counseling settings
• Based on studies of clients unlike those
typically encountered in everyday life
practice;
• Lack of evidences over choices of multiple
evidences;
• Manualized brief intervention vs processoriented intervention
• Technicalization vs professionalism
• Use of RCT in clinical settings
• Knowledge, skills and attitudes (of you and
your supervisors/organizations)
The work of Hans Eysenck (1952, 1960, 1969) – “The Effects of
Psychotherapy”
http://psychclassics.asu.edu/Eysenck/psychotherapy.htm
• Reviewed 24 treatment studies of 7000 treated
patients and concluded:
– “Roughly two-thirds of a group of neurotic patients will recover or
improve to a marked extent within about two years of the onset of their
illness (compared with the psychotherapy group)”
– “patients treated by means of psychoanalysis improved to the extent of
44%......, patients treated only custodially or by general practitioners
improved to the extent of 72%. There thus appears to be an inverse
correlation between recovery and psychotherapy”
• In 1960, he wrote “the therapeutic effects of psychotherapy are
small or non-existent, and do not in any demonstrable way add to
the non-specific effects of routine medical treatment, or to such
events as occurs in patients’ everyday experience”.
Meta-analysis of Psychotherapy Outcome Studies
(Smith and Glass, 1977)
• Effect size = mean (case-control)/SD control
• Analyzed 833 treatment studies
• 16 independent variables, e.g., type of therapy, its
duration, group vs individual, professional identity, age
and IQ of patients etc.
• Average study showed .68 of a SD over control types of
therapy studied, average effect size for best therapies
were:
Meta-analysis of Psychotherapy Outcome
Studies (Smith and Glass, 1972), cont.
.9 systematic desensitization
.77 for rational emotive therapy
.76 for behaviour modification
.63 for client-centred therapy
.59 for psychodynamic therapy
• “outcomes of psychotherapy remains controversial”
“Mental Health: Does Therapy Help?” – Martin Seligman (1995)
http://horan.asu.edu/cpy702readings/seligman/seligman.html
Psychotherapy does work as people report fewer symptoms and a
better life after therapy than before
Methodological problems also raises questions of efficacy vs.
effectiveness
Efficacy – how well does a treatment work under optimum conditions
Effectiveness – how well does it work in the general community after
disseminations for others to follow
“Mental Health: Does Therapy Help?” – Martin Seligman
(1995)
•
180,000 readers of Consumer Reports, 7000 replies to the survey, 2900
saw a mental health professional, and concluded:
– Level of satisfaction with therapy was equivalent whether respondents saw a
social worker, psychologist, or psychiatrist; those who saw a marriage counselor,
however, were somewhat less likely to report having benefited from therapy;
– Respondents who sought therapy from a family doctor reported doing well, but
those who saw a mental health professional for more than 6 months reported
doing much better;
– Psychotherapy alone worked as well as combined psychotherapy and
pharmacotherapy; while most persons who took prescribed medication found it
helpful, many reported side effects; and
– Respondents who had tried self-help groups, especially Alcoholic Anonymous,
felt especially good about the experience.
All of these works lead to the
development and the pursue of
“empirically-validated treatments”
The empirical status of cognitivebehavioural therapy: a review of
meta-analyses
How to read the findings of meta-analyses
• In meta-analysis, treatment efficacy is quantified in terms of an
effect size (ES). An ES indicates the magnitude of an observed
effect in a standard unit of measurement (e.g., a standard deviation
or correlation coefficient).
• Effect sizes have been categorized along a continuum of no effect
(ES<0.2), low (0.2-0.5), medium (0.5-0.8) and high (>0.8) (Cohen,
1988).
• Hence, the strength of meta-analysis comes from the use of a
standardized unit to compare outcomes from studies that may use
different measures. Also, by averaging effect sizes across different
studies and comparisons, meta-analysis increases the effective
sample size and minimizes the influence of extraneous factors.
• U3 represents the percentage of the scores in the lower-meaned
group that was exceeded by the average score in the highermeaned group (Cohen, 1988).
• The relationship between ES and U3 is important to understand
when interpreting the findings from meta-analyses.
• For example, an ES of 0.0 would indicate no treatment effect. It
converts into a U3 of 50%, which in this review would indicate that
the average CT patient did as well as the average control group
member.
• A controlled ES of 1.0 would represent a large treatment effect and
would translate into a U3 of 84%, indicating that the average CT
patient had an outcome superior to that of 84% of the control group.
Discussions
• CT is highly effective for adult unipolar depression, adolescent
unipolar depression, generalized anxiety disorder, panic disorder
with or without agoraphobia, social phobia, PTSD, and childhood
depressive and anxiety disorders.
• Significant evidence for long-term effectiveness was found for
depression, generalized anxiety, panic, social phobia, OCD, sexual
offending, schizophrenia, and childhood internalizing disorders. In
the cases of depression and panic, there appears to be robust and
convergent meta-analytic evidence that CT produces vastly superior
long-term persistence of effects, with relapse rates half those of
pharmacotherapy.
• In addition, CT appears to show greater long-term effects in the
treatment of generalized anxiety disorder as compared to applied
relaxation.
Homework
Please find and read Bulter’s article
and this one –
Beck, A. (2005). The Current State of
Cognitive Therapy - A 40-Year
Retrospective. Arch Gen Psychiatry.
2005;62:953-959
References
Butler, A., Chapman, J., Forman, E.M. & Beck, A. (2006). The empirical status of
cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review,
26, 17-31.
Evidence-Based Medicine Working Group (1992). Evidence-Based Medicine: A New
Approach to Teaching the Practice of Medicine. JAMA, 268(17):2420-2425.
Gambrill, E. (2003). Evidence-based practice: Sea change or the emperor's new clothes?
Journal of Social Work Education, 39(1), 3-23. Havighurst, C. C., Hutt, P. B., McNeil,
B. J., & Miller, W. (2001). Evidence: Its meanings in health care and in law. Journal in
Health Politics, Policy and Law. 21(2), 195-215.
Huppert, J. D., Fabbro, A., & Barlow, D. H. (2006). Evidence-based practice and
psychological treatment. In G. M. Reed & E. Eisman (eds.) Evidence-based
psychotherapy: Where practice and research meets (p. 131 – 152). Washington, DC:
American Psychological Association.
Levant, R. F. (2005, July 1). Report of the 2005 presidential task force on evidencebased practice. Retrieved June 20, 2008 from
http://www.apa.org/practice/ebpreport.pdf
McNeece, C. A. & Thyer, B. A. (2004). Evidence based practice and social work. Journal
of Evidence-Based Social Work. 1(1), 7 - 25.
Nathan P. & Gorman J. (1998). Treatments that work – and what convinces us they do
(pp.3-25). In P. Nathan & J. Gorman. A guide to treatment that work. Oxford: Oxford
University Press.
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S.
(1996). Editorial: Evidence based Medicine: what it is and what it isn't. BMJ, 312, p.
71-72.