Defining the Boundaries of Evidence-based Family Treatments and the Complex Contexts in which they are Practiced AFTA Cl

1. 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

2. Address Jay Lebow, Ph.D., ABPP Family Institute at Northwestern 618 Library Place Evanston, Illinois 60202 e-mail j-lebow@northwestern.edu

3. 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

4. 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?

5. 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.

6. Criteria for Effective Treatment • The Standard of Common Practice • The Principle of the Respectable Minority • Scientific Evidence

7. 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

8. 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

9. 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.

10. 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)

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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.

17. 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?

18. 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

19. 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.

20. 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

21. 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

22. ESTs:OtherChild 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

23. Establishing Principles of Practice in Couple and Family Therapy • Client Factors • Therapist Factors • Relationship Factors • Treatment Factors • Interactions of these factors

24. 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).

25. 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)

26. 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

27. 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)

28. 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)

29. 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

30. Integrating the findings of basic research into practice • Base of knowledge about family process, social psychology, individual personality, psychopathology, and social systems

31. 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.

32. 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.

33. 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

34. 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

35. 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.

36. 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

37. 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.

38. 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

39. Members of Task force • Kristina Gordon • Alan Gurman • Amy Holtzworth-Munroe • Sue Johnson • Jay Lebow • Tom Sexton

40. Advisory Panel Members • Andrew Christensen • Daniel Santiesteban • Don David Lusterman • James Dobbins • Jaslean LaTaillade • Peter Chang

41. 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.

42. 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.

43. 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.

44. 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.

45. Dimensions of Evidence-based Treatments • Broad theoretical approach (traditional broad theory-based approach) • Common factors that are in existence in all good therapy approaches (typically considered non-specific 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) Broad/ Non-specific Specific

46. 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)

47. 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 • Qualitativeand Meta-analytic research reviews

48. 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.

49. 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

50. 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.