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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?.

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Effectiveness of Therapy and Nonspecific Factors

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  1. Effectiveness of Therapy and Nonspecific Factors

  2. Is Therapy Effective?

  3. 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?

  4. 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

  5. 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

  6. 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

  7. 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

  8. How Do we Know if Therapy works? • We can do two different types of studies to assess the outcomes of therapy: • Efficacy Studies • Effectiveness Studies

  9. 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

  10. 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

  11. 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 self-correct • Focus on improvement, not symptom reduction • Effectiveness studies maximize on external validity

  12. The CR Controversy • The CR study is purely an effectiveness study, and many scientists question its results

  13. 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

  14. 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

  15. Which is Better? • Both types of studies are useful • for a treatment to have solid support, it should be shown to work in both

  16. 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

  17. 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

  18. 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

  19. Factors Influencing Outcome • Can be divided into 4 components: • Extratherapeutic factors • Expectancy Effects • Specific therapy techniques • Common Factors (Lambert & Barley, 2002)

  20. Extratherapeutic Factors: Spontaneous recovery or remission Fortunate events Social support Expectancy Effects: Placebo effects The Dodo bird hypothesis Factors Influencing Outcome

  21. Specific Therapy Techniques: Exposure Changing cognitions (CBT) biofeedback Common Factors Relationship with therapist Support Hopefulness Factors Influencing Outcome

  22. Factors Influencing Outcome

  23. What Nonspecifics Help? • Orlinsky, Grave & Parks (1994): • Therapist credibility • Therapist skills • Empathetic understanding

  24. What Nonspecifics Help? • Affirmation • Ability to engage patient • Focus on patient’s problems, direct patient

  25. Humanistic Therapies • If you recall, humanistic therapies consist of many nonspecifics: • Unconditional positive regard • Caring, respect • Being genuine

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

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