intro to clinical psych lesson 9-10

therapist-written case studies and client testimonials

In the early to mid-1900s, most psychotherapy effectiveness evidence was anecdotal, based on what

HANS EYSENCK

THE FIRST MAJOR EMPIRICAL CRITIQUE CAME FROM

THE FIRST MAJOR EMPIRICAL CRITIQUE CAME FROM HANS EYSENCK (1952)

• Most clients improve without psychotherapy.

• Psychotherapy was of little to no benefit.

meta-analysis

a statistical technique that aggregates data from multiple studies to assess overall treatment effects.

Meta-analytic findings

consistently showed that psychotherapy is effective, and helped restore credibility to the field by countering Eysenck's claims.

HANS STRUPP

identified three parties who have a stake in how well therapy works and who may have different opinions about what constitutes a successful therapy outcome.

CLIENT

THERAPIST

SOCIETY/OUTSIDERS

TRIPARTITE MODEL

CLIENT

• Has firsthand experience of change and therapy impact 

• May be biased 

  • Overly optimistic due to investment, or overly negative due to psychopathology like depression

therapist

a depressed client who tends to interpret events in an unrealistically negative way may apply that kind of distorted thinking to his or her therapy. So a researcher may choose to turn to the who—the second party—as another source of feedback.

THERAPIST

• Brings professional expertise.

• May also be biased-limited perspective outside sessions and personal stake in positive outcomes.

• witness only a fraction of clients’ lives, and they may feel that negative evaluations reflect poorly on their own therapeutic skills.

SOCIETY/OUTSIDERS

• third-party

• Includes family, legal systems, employers, or insurance companies.

SOCIETY/OUTSIDERS

• Focuses on observable, functional improvement (e g. social roles, job performance).

• bring a perspective that emphasizes the client’s ability to perform expected duties in a stable, predictable, unproblematic way.

POST-THERAPY

common, expecting immediate improvement.

LONG-TERM FOLLOW-UP

(e.g., 1-5 years) tests durability of effects.

BEST PRACTICE

Use multiple time points for a more comprehensive view.

SELF-REPORT TOOLS

Questionnaires, surveys, interviews from any of the three parties

POST-THERAPY

LONG-TERM FOLLOW-UP

MID-THERAPY OR PER SESSION

BEST PRACTICE

when should they ask?

SELF-REPORT TOOLS

BEHAVIORAL OBSERVATION

HOW SHOULD OUTCOME BE MEASURED?

BEHAVIORAL OBSERVATION

Objective tracking of behavioral changes in real-life settings

.85

a primary finding of a landmark meta-analysis of 475 psychotherapy efficacy studies was that the average effect size for psychotherapy was how many, indicating that “the average person who receives therapy is better off at the end of it than 80 percent of the persons who do not

YES, PSYCHOTHERAPY IS EFFECTIVE

supported by thousands of efficacy studies and hundreds of meta-analyses

80%

Clients who receive therapy are better off than how many of those who do not.

HOWEVER, NOT ALL OUTCOMES ARE POSITIVE

• Some clients worsen during therapy 

• Some drop out or experience short-lived benefits 

• These are exceptions, not the norm

TRADITIONAL EFFICACY STUDIES

TARGET SPECIFIC THERAPIES FOR SPECIFIC DISORDERS.

co-occur

But many disorders what, and similar therapies work for multiple issues.

A TRANSDIAGNOSTIC APPROACH FOCUSES ON

• Core pathologies like negative affect or neuroticism, rather than isolated symptoms 

• David Barlow and his colleagues

 EMOTIONAL DISORDERS such as Major depression, generalized anxiety disorder

transdiagnosting approach target what disorders

UNIFIED PROTOCOL BY BARLOW AND COLLEAGUES

• Reducing negative anticipatory thoughts.

• Preventing unhealthy emotional avoidance.

• Promoting behaviors that increase positive emotions

clinicians

who believe that who resist scientific data and refuse to update outdated practices.

Clinicians

argue that efficacy studies are too artificial or irrelevant to real-life practice.

clinicians

prioritize personal experience over research findings, even when they use evidence-supported methods

Manualized treatments

restrict flexibility.

Therapeutic alliance

often underemphasized.

Efficacy studies

may not reflect diverse client population

case studies

data summaries

Therapists prefer what over what

short and low-cost

Willingness increases when training is what

Top-down mandates

can result in resistance from clinicians

direct-to-consumer marketing of ESTs

Creative solutions like what may help bridge the gap by increasing client demand

Stewart and Chambless (2010)

found case studies more persuasive than research reviews

Stewart, Chambless, and Baron (2012)

found that they are more willing to undergo training in an empirically supported treatment if the training was brief (i.e., 3 hours) and inexpensive, as opposed to lengthy (i.e., 1 to 3 days) and expensive.

Jensen-Doss, Hawley, Lopez, and Osterberg (2009)

found that an organization that forces its clinicians to use evidence-based treatments, especially without any attempt to get clinicians “on board” first, can encounter significant resistance and resentment.

direct-to-consumer marketing

help dissemination efforts—that way, therapists would feel not only a “push” from researchers, but a “pull” from clients who have learned about what works for a particular disorder.

PRACTICE-ORIENTED RESEARCH

If researchers and therapists could feel like partners throughout the process—from the inception of a research idea to its execution to its conclusions—therapists would be more likely to accept and apply the results

PRACTICE-RESEARCH NETWORKS

groups of therapists and researchers work as teammates in all phases of a research study

Effectiveness studies

efficacy studies

examine psychotherapy outcomes in real-world, naturalistic settings, unlike what that occur in controlled environments.

effectiveness studies

support the conclusion that psychotherapy is beneficial in everyday clinical practice

THE CONSUMER REPORTS STUDY (1995)

Conducted by Consumer Reports magazine, surveying subscribers about their psychotherapy experiences

"very poor"

Among 426 people who felt what at the start, 87% reported feeling very good, good, or at least so-so after therapy.

"fairly poor,"

Among 786 who felt what 92% improved to a similar degree

NO CONTROL GROUP

Cannot determine how many would have improved without therapy.

RETROSPECTIVE SELF-REPORT

introduces concerns about accuracy and memory over time.

HANS & HILLER CONDUCTED META-ANALYSES ON

• 71 effectiveness studies for anxiety disorders

• 34 effectiveness studies for depression

CBT

remained highly effective in real-world practice, only slightly less so than in controlled trials.

FMRI AND PET SCANS

NEUROIMAGING TOOLS LIKE what CONFIRM NEUROLOGICAL CHANGES AFTER THERAPY

caudate nucleus

in ocd, Behavioral therapy reduces metabolism in the what

dorsal striatum.

in depressionBehavioral activation impacts the what

CBT and Interpersonal Therapy

Decrease activity in dorsal frontal regions and increase activity in ventral frontal and subcortical regions

15.7%

Therapy clients had a how many reduction in medical costs.

12.3%

Control group clients had a how many increase in costs.

therapy clients

spent fewer days in the hospital.

Freudians, cognitivists, humanists, and behaviorists

Major "combatants" included what, especially the latter two

DODO BIRD VERDICT

Empirical studies comparing different therapies often find no clear winner-most perform equally well

Alice in Wonderland

This result was famously dubbed the "Dodo Bird Verdict", from what-"Everybody has won and all must have prizes"

DODO BIRD VERDICT

Studies across decades consistently show similar efficacy across various orientations

Rosenzweig

Despite theoretical differences, most therapies share common core components that explain similar results. This idea dates back to who(1936) and has since gained strong empirical support

 therapeutic relationship (or alliance)

the most consistently supported common factor in psychotherapy outcomes

warm and empathetic

evidence-based techniques

Clients often prefer therapists who are what over ones who strictly use what

work best together

Rather than debating whether techniques or relationship quality is more important, researchers emphasize that they what

HOPE/POSITIVE EXPECTATIONS

ATTENTION/HAWTHORNE EFFECT

OTHER COMMON FACTORS IN PSYCHOTHERAPY

HOPE/POSITIVE EXPECTATIONS

• A sense of hope or optimism is a widely recognized common factor that can contribute to improvement even before formal intervention begins 

• Just receiving a confident message that things will improve can activate positive change in clients.

ATTENTION/HAWTHORNE EFFECT

• Merely attending to a problem-through conversation and focused attention-can be healing (named after the what).

• Therapy gives clients the chance to acknowledge and explore problems they may have previously avoided.

• Listening and validating

• Offering new perspectives

• Encouraging action

SEQUENTIAL MODEL OF COMMON FACTORS MIRRORS HOW PEOPLE NATURALLY HELP FRIENDS

SUPPORT FACTORS STAGE

LEARNING FACTORS STAGE

ACTION FACTORS STAGE

SEQUENTIAL MODEL OF COMMON FACTORS

SUPPORT FACTORS STAGE

strong therapist–client relationship, therapist warmth and acceptance, and trust.

LEARNING FACTORS STAGE

changing expectations about oneself, changes in thought patterns, corrective emotional experiences, and new insights.

ACTION FACTORS STAGE

taking risks, facing fears, practicing and mastering new behaviors, and working through problems.

THE DODO BIRD VERDICT

that all forms of psychotherapy are equally effective-a conclusion drawn from numerous comparative studies

DIANNE CHAMBLESS

advocates for manualized, evidence-based treatments tailored to specific conditions

PROPONENTS OF COMMON FACTORS (E.G., THERAPEUTIC ALLIANCE, EMPATHY, GOALS CONSENSUS

These are the active ingredients in all successful therapy outcomes

coping style (externalizing vs. internalizing)

Respecting the client's what can impact therapy success

MIDDLE-GROUND PERSPECTIVES

Both specific treatments and common factors contribute to outcomes

specific symptom relie

For whatf, therapy techniques like cbt may be most predictive.

overall quality of life

common factors play a larger role.

• Client characteristics (e.g., motivation, resilience)

• Therapist characteristics (e.g., experience, interpersonal skill)

• Problem characteristics (e.g., severity, chronicity)

• Extratherapeutic factors like life events

BROADER CONTRIBUTORS TO PSYCHOTHERAPY SUCCESS INCLUDE

STANLEY MESSER AND BRUCE WAMPOLD

review the literature on therapy efficacy and conclude that “the preponderance of evidence points to the widespread operation of common factors such as therapist-client alliance . . . in determining treatment outcome”

PRESCRIPTIVE APPROACH

specific therapy techniques are viewed as the treatment of choice for specific disorders should be replaced by an approach that more broadly emphasizes common factors, especially the therapeutic relationship.

early stages (precontemplation or contemplation)

action stage

Most clients begin therapy in the what, not the what.

Eclectic/integrative therapy

cognitive therapy

the most popular orientation from 1960 until 2010 but was overtaken by what in 2010

psychologists as “mutts”

blend multiple approaches or use an assortment of therapies

psychologists as “purebreds”

practice one type exclusively.

combination of cognitive and behavioral techniques

the most common integrative practice

eclectic therapist

turns to the empirical literature as soon as the diagnosis is made and practices whatever technique the literature prescribes for that diagnosis.

cognitive therapy

Since the 1980s, what has grown in popularity and became the most commonly endorsed orientation in 2010

cognitive-behavioral therapy (CBT)

this orientation dominates therapist preferences.

Psychodynamic/psychoanalytic therapy

has declined since 1960, falling from a dominant position to 18% endorsement in 2010

Individual therapy

the most common, practiced by 98% of clinical psychologists

• Couples/marital therapy

• Family therapy

• Group therapy

Other formats include:

PRECONTEMPLATION

CONTEMPLATION

PREPARATION

ACTION

MAINTENANCE

STAGES OF CHANGE MODEL

PRECONTEMPLATION

• No intention to change; often unaware of problems.

• pressured to enter therapy by family or friends who are more aware than they are themselves.

CONTEMPLATION

• Aware of issues but ambivalent about taking action.

• not yet willing to give up the benefits of the behavior they recognize as somewhat problematic.