Transcript Huffman PowerPoint Slides - HomePage Server for UT Psychology

Chapter 17
Outcomes and Issues
in
Psychological Intervention
Ch 17
Therapy Evaluation
• Evaluation of therapy assumes that one can
determine the specific procedures that are used in
the therapy
– How therapy is conducted in practice can be different
than what is specified in a therapy manual
– Randomized controlled trials (RCTs) vs. idiographic
analysis of a single clinical case, or replicated cases
• Efficacy refers to how well a therapy does in a
controlled clinical trial (i.e., an RCT)
• Effectiveness refers to how well a therapy does in
the real world of practice
Ch 17.1
Problems associated with clinical
trials
• The use of therapy manuals in psychotherapy research help
to standardize treatment.
– Increase internal validity
• However, reliance on therapy manuals in clinical trials may
reduce external validity of results.
– Therapy as actually practiced outside of clinical trials is
typically less standardized and often much more eclectic.
• Adherence to therapy manuals also intended to control
differences among therapists.
– These differences in therapist variables (e.g., empathy,
warmth, openness) play an important role in therapeutic
change process.
• The role of therapist variables in clinical trials deserves greater attention.
Limitations of Clinical Trials
• Volunteer participants are likely different from
general public.
– Will results from clinical trials based on these
participants generalize to other groups of patients?
• Use of DSM diagnostic categories to create
homogeneous groups may blur differences
between participants in groups.
– Is there room for idiographic analysis of individuals in
clinical trials?
The Challenge of Managed Care
• Managed care organizations (contracting with employers)
demand accountability from providers (MD and non-MD
clinicians)
• Evaluations of psychotherapy outcomes are not merely of
academic research interest, but have practical
implications for people in their daily lives.
• Providers are concerned about the potential for abuse of
patients’ privacy and denial of needed treatments
• Stepped Care: Beginning with the least intrusive, least
expensive level of care, and moving up only when
necessary. (Question: Does this increase drop out risk
compared to the initial use of the most powerful
intervention? B&N, 9th edition, pp. 568-569)
 More Scientifically Driven Treatments
 More Manualized Treatments
 Fewer Psychologists Providing
Treatment
 Briefer Therapies & Cost Containment
 Fewer Hospitalizations
 Greater Use of Medications
 Seligman (1995):
 Treatment Worked
 87% Improved
 Long Term
Treatment Better
than Short-Term
 Therapy vs. Therapy
Plus Meds Were
Similar
 Limit Care = Poor
Outcome
Consumer
Reports Magazine
Duration of Therapy
Consumer Reports, 2004
Survey
Psychoanalytic Concepts
• The core issue in psychoanalysis is the removal
of repressions that prevent the ego from
developing into a healthy person
• Psychoanalysis lifts repression via
– Dream analysis
– Free association
– Interpretation
• Psychoanalysis can be of long-duration or can be
a brief therapy
• Evaluation issue: Insight or social conversion
process?
Ch 17.2
Evaluation of Psychodynamic
Therapies
• Classical Psychoanalytic treatment has been evaluated in
only 4 studies
– These studies are limited by lack of a control group
• General findings:
– Patients with anxiety disorders do better in psychoanalysis than do
schizophrenic patients
– Better educated clients do better in therapy
– Interpretation by the therapist may not be helpful for the therapy
process
• Outcome research has demonstrated that brief
interpersonal therapy (IPT) is as effective as CBT for
depression and bulimia nervosa
• Process research in brief therapy has emphasized the
importance of the therapeutic working alliance
Ch 17.3
Evaluation of Client-Centered
Therapy
• Humanistic psychotherapy assumes that people
must be understood from their own point of view
– Psychological disorders arise when people fail to
appreciate their own internal worlds
– Therapist role is to be accepting of the client and to be
non-judgmental
• Positive outcomes are not always related to
therapist empathy
Ch 17.4
Evaluation of Gestalt Therapy
• Gestalt psychology holds that the goal of
therapy is to make people aware of their
own basic needs and desires
– People create their own existence
• There is a general lack of research on the
effectiveness of Gestalt therapy
– Some of the technique associated with Gestalt
therapy (e.g. the empty-chair) have been
shown to reduce self-rated anger
Ch 17.5
Evaluation of Counterconditioning /
Exposure Methods
• Counterconditioning involves imaginal and/or reallife exposure to threat stimuli
• Systematic desensitization involves having a
deeply relaxed person imagine a series of fearinducing situations
• Systematic desensitization / exposure methods
are effective for the treatment of anxiety-related
problems
–
–
–
–
Simple phobias, agoraphobia
PTSD
Obsessive-compulsive disorder
Panic disorder
Ch 17.6
Evaluation of Operant
Methods
• Operant methods involve the systematic
rewarding of desirable behaviors and
extinguishing undesirable behaviors
• Operant methods are effective for a wide range of
behavioral problems, particularly in children
• Caveat: The problem behavior must be an
operant (i.e. under the control of a contingent
reinforcer)
Ch 17.7
Evaluation of RationalEmotive Behavior Therapy
• Rational-emotive behavior therapy (REBT) acts to
remove unreasonable cognitive beliefs
• REBT has been shown to
–
–
–
–
Reduce self-reports of anxiety
Improve self-reports of social anxiety
Reduce anger, depression and antisocial behavior
Reduce the Type A behavior pattern
Ch 17.8
Evaluation of Beck’s Cognitive
Therapy
• People in emotional distress operate under
cognitive schemas that are disabling
– The goal of Beck’s cognitive-behavioral therapy (CBT)
is to challenge these schemas
• CBT has been shown to
– Improve depression and to prevent future depression
episodes
– Be comparable to drug therapy in overall effectiveness
for the treatment of depression
• See pp. 581-582, for comparison with Ellis’ REBT
Ch 17.9
Generalization/Maintenance of
Treatment Effects
• Generalization seeks to identify the factors that allow
clients to maintain treatment-related gains while in the real
world
– Using intermittent and natural reinforcers is helpful
– Eliminating secondary gain (through use of paradox)
– Reducing the likelihood of relapse by encouraging
clients to attribute their slips to external, unstable,
specific and controllable factors
– Attribution of treatment gains to oneself may be useful
for the person(e.g., self-control strategies)
• Some basic issues in cognitive and behavioral therapy
– Internal behavior and cognition
– Importance of relationship factors (the therapeutic alliance)
Ch 17.10
Evaluation of Couples and
Marital Therapy
• The focus of couples and family therapy is on
improving communication
• Family/couples therapy is
– More successful in conjoint therapy than individual
therapy
– Successful in reducing relationship stress
– Not always clinically significant
• Depression, “emotional disengagement”, and low frequency of
sexual behavior can be predictors of poor outcome
Ch 17.11
Review of Community
Psychology
• The focus of community psychology is prevention
of disorder
• Community psychology has been useful in
– Prevention of cigarette smoking
– Prevention of HIV infection
– Reducing the risk of cardiovascular disease
• Community psychology efforts do not work when
the disorder of interest is not subject to
social/environmental change
Ch 17.12
Psychotherapy Integration
• Integration seeks to determine the common
ground among the various therapy schools
– Technical eclecticism refers to a situation in which a
therapist uses techniques from other disciplines,
without adopting the theories that spawned them
– Common factorism seeks strategies that are common
to all therapy schools
– Theoretical integration attempts to synthesize both
theory and technique across schools
Ch 17.13
Cultural Issues in Therapy
• Cultural diversity is the norm in the United States
– There is an assumption, not proven, that clients do
better in therapy with therapists who are similar to the
client in cultural and ethnic background
• Therapists need to
– Understand unique problems experienced by clients
from diverse groups.
– Develop sensitivity to the cultural background of each
patient.
Ch 17.14
Cultural Issues in Therapy
• African Americans tend to have better rapport with African
American therapists than white therapists
– More guarded and less open with white therapists
– However, therapists who are highly empathic are rated as more
helpful.
• Latinos
– Latino clients are themselves a diverse group based on their
geographical roots.
• Be careful not to generalize from one group to all Latinos.
– Cultural barrier to “seeking help”, especially for Latino men.
– Importance of religion, socioeconomic level, and any language
differences need to be taken into consideration.
– CBT with its emphasis on guidance and problem solving may be
more acceptable to Latinos.