Greatest hits


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In this presentation, Barry Duncan surveys the last 25 years of psychotherapy research and identifies its greatest hits and disasters.

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Greatest hits

  1. 1. 6/10/2010 Psychotherapy Research’s Greatest Hits The Most Important Findings of the Last 30 Years Barry Duncan, Psy.D. Psy.D. 954.721.2981 1
  2. 2. 6/10/2010 2
  3. 3. 6/10/2010 Psychotherapy Research’s Greatest Hits The Four Greatest Hits The Two Greatest Disasters Psychotherapy Research’s Greatest Hits Number 4 The Dodo Bird Verdict 3
  4. 4. 6/10/2010 The Dodo Verdict •With few exceptions, partisan studies designed to prove the unique effects of a given model have found no differences— differences—nor has recent meta- meta- analyses…The analyses…The Dodo Verdict—the Verdict— most replicated finding in the psychological literature “Everybody has won and all must have prizes.” Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215. The Treatment of Depression Collaborative Research Project (TDCRP) •Considered to be the most sophisticated comparative clinical trial ever conducted: •Four approaches (CBT, IPT, Drug, Placebo). •No difference in outcome between approaches •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. •Tx model accounted for (0-2% of the variance… (0- Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. 4
  5. 5. 6/10/2010 Project MATCH and the Alliance •The largest study ever conducted on the treatment of problem drinking: •Three different treatment approaches studied (CBT, 12-step, 12- and Motivational Interviewing). •NO difference in outcome between approaches. •The client’s rating of the therapeutic alliance the best predictor of: •Treatment participation; •Drinking behavior during treatment; •Drinking at 12-month follow-up. 12- follow- Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29. 58, 7- Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK. Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and and outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98. 65(4), 588- The Dodo Also Rules Family Therapy Cannabis Youth Treatment Project •600 Adolescents marijuana users: •Significant co-morbidity (3-12 problems). co- (3- •Two arms (dose, type) and one of three types of treatment in each arm: •Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Support Network (12 wks)+MET+CBT; •Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks). Approach accounted for 0% of the variance in outcome. Ratings of the alliance predicted: Premature drop-out; Substance abuse and dependency drop- symptoms post-treatment, and cannabis use at 3 and 6 month follow-up. post- follow- 5
  6. 6. 6/10/2010 Tired of RCTs…The Dodo in the Real World  1999 study of 2000 providers and over 20,000 clients; 13 different orientations including CBT, SFBT, family therapy, medication, and eclectic…  2006 study of 1309 clients compared six groups: CBT, PCT or PDT only, and one of these plus one additional approach (integrative, supportive, art)  NO DIFFERENCE! In the UK study, all groups made marked improvement (ES = 1.36). Approach and purity accounted for tiny proportions of variance (1% & 0.5%. Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health Service settings Psychological medicine 36, 555-566. Brown, J., Dreis, S., & Nace, D.K. (1999). What really makes a difference in psychotherapy outcome? Why does managed care wa nt to know? In M.A. Hubble, B.L. Duncan, and S.D. Miller (Eds.). The heart and soul of change: What works in therapy.. Washington, D.C.: APA Press, pp. 389-406. Implications of the Dodo Bird Verdict All approaches work because of factors common to all: Of the client’s abilities Client resources transcend model differences Time better spent recruiting what clients already have than assessing what they need 6
  7. 7. 6/10/2010 Factors Accounting for Successful Outcome 40.0% Spontaneous Remission Client/Extratherapeutic Common Factors Relationship Models/Techniques 30.0% 15.0% Placebo/Hope/Expectancy 15.0% Lambert, M. (1986). Implications of Psychotherapy Outcome Research for Eclectic Psychotherapy. In J. Norcross (Ed.) Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel. Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) 30-?% 7
  8. 8. 6/10/2010 The Killer D’s of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged Not Reliable or Valid None ever related to outcome Clients Are the Lions of Change Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb 8
  9. 9. 6/10/2010 Psychotherapy Research’s Greatest Hits Number 3 The Power of the Alliance Relationship Factors The Alliance: • Relational Bond • Agreement on goals 38- 38-54% • Agreement on tasks Seven Times the Impact of Model/Technique…Accounts for Most of Therapist Variance Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass 9
  10. 10. 6/10/2010 The Alliance: Over 1000 Research Findings  Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline-- recall TDCRP, MATCH, CYT.  Clients rarely report negative reactions before deciding to terminate.  Same holds true for youth and family therapy Research into Practice The Alliance •Increasingly, the relationship is viewed as merely “setting the stage” for the “real” treatment: •Confronting distorted thoughts; •Recovering forgotten memories; •Asking special questions; •Tapping on or waving fingers in front of the face…but the data say: •The alliance deserves far more RESPECT… Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA. 10
  11. 11. 6/10/2010 Psychotherapy Research’s Greatest Hits: The Alliance Client’s Theory of Change Molly: Goals, A Client Example Meaning or Means or Methods Purpose Client’s View of the Therapeutic Relationship Psychotherapy Research’s Greatest Hits Number 2 The Predictive Power of Early Change 11
  12. 12. 6/10/2010 Psychotherapy Research’s Greatest Hits : Project Match Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113. Alcoholism. Psychotherapy Research’s Greatest Hits: Early Change Cannabis Youth Treatment Project Approach Dose 12
  13. 13. 6/10/2010 Early Change Predicts…  In a study of more than 2000 therapists, Brown found that if no improvement occurred by the sixth visit, then no improvement was likely over the entire course of treatment.  Clients who worsened by the third visit were twice as likely to drop out than those reporting progress.  Variables such as diagnosis, severity, and type of therapy were, “not . . . as important [in predicting eventual outcome] as knowing whether or not the treatment being provided [was] actually working.” Implications  Feedback about outcome is essential for clinical decision making.  Do not need to know what tx to use for a given diagnosis as much as whether the current relationship is a good fit and providing benefit, and, if not, to adjust early to maximize the chances of success. 13
  14. 14. 6/10/2010 Psychotherapy Research’s Greatest Hits Number 1 Client Feedback Dramatically Improves Effectiveness and Efficiency (more than anything else) Psychotherapy Research’s Greatest Hits: Client Feedback  One study of 6224 clients, Miller, Duncan et al (2006) provided therapists with real-time feedback regarding the client’s experience of the alliance and progress.  This “practice-based evidence” not only resulted in higher retention rates but also doubled the overall effect size of services offered (baseline ES = .37 v. final phase ES = .79; p < .001). Download these measures for free… 14
  15. 15. 6/10/2010 The Revolutionary Benefits  As incredible as the results appear, they are entirely consistent with other findings.  Lambert et al. (2003) reported that those relationships at risk which received formal feedback were better off than 65% of those without feedback (Average ES = .39!).  Whipple et al. (2003) found that clients whose therapists had access to outcome and alliance info were less likely to deteriorate, and twice as likely to achieve change.  Obtained without any attempt to control treatment process. Effects on Efficiency Cancellations, No Shows, LOS  Claude (2004) compared the ave. # of sessions, canc., no shows, and % of long- term cases before and after OM. Sample: 2130 closed cases seen in a public CMHC.  Ave. # of sessions dropped 40% (10 to 6) while outcomes improved by 7%; canc. and no show rates were reduced by 40% and 25%; and % of long term null cases diminished by 80% (10% to 2%).  An estimated savings of $489,600. Such cost savings did not come at the expense of client satisfaction with services—during the same period satisfaction rates improved significantly. 15
  16. 16. 6/10/2010 Psychotherapy Research’s Greatest Disasters Number 2 Diagnosis Diagnosis “I have found little that is good about human beings. In my experience, most of them are trash.” --Sigmund Freud, M.D. 16
  17. 17. 6/10/2010 Sicker With Each Passing Year DSM 1952 - 1994 400 397 350 300 261 250 206 200 150 111 66 100 50 0 DSM I DSM II DSM DSM DSM III III R IV Educate the People: You Are Sick  Now "free mental health check ups” like National Depression Day or National Anxiety Day.  Largely funded by drug companies and sponsored by MH prof. org—should be telling.  Cultivated a curious change. Unhappiness not shaped by diverse forces. No, problems are because people are diseased, disordered, dysfunctional, disabled, and have deficits…the Killer Ds 17
  18. 18. 6/10/2010 Mental Health Screening Test 1. Lift your right foot off the floor and make clockwise circles. 2. Now, while doing this, draw the number "6" in the air with your right hand. 3. If your foot changes direction, you need drugs or therapy or both. And the Message Works! If drug txs for mental “disorders” were books, they would be runaway bestsellers. Last year, more than 150 million pres. were written for anti-dep.— more than $14 billion spent; 20 million pres. for Ritalin, surpassing the amount spent for antibiotics! 18
  19. 19. 6/10/2010 Diagnostic Dys- Order Dys- Poor Reliability Unknown Validity Does not predict LOS or outcome Little help in treatment selection Surveys consistently find that therapists do not like it or find it useful Kirk, S.A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass. Psychotherapy Research’s Greatest Disasters Number 1 Evidence Based Practice 19
  20. 20. 6/10/2010 Evidence Based Practice  The intent here is not to demonize EBP—any approach can be just the ticket for a particular client— but rather expose its limitations because it is often wielded as a mandate for competent and ethical practice. Such edicts are gross misrepresentations of the data and blatant misuses of the evidence. Psychotherapy Research’s Greatest Disasters: EBP •Dodo Verdict highlights fatal flaw: Efficacy over placebo or TAU is not efficacy over other approaches; and unremarkable; •The differences which have been found: •Do not exceed what would be expected by chance; •Accounts for 1% of the variance. •And as a mandate Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. 6, 412- Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, meta- "All must have prizes." Psychological Bulletin, 122(3), 203-215. 122(3), 203- 20
  21. 21. 6/10/2010 A Mountain of Manure The “Evidence” of Evidence Based Practice  Must always ask, “Whose” evidence is it? and  “What kind” of evidence is it? (Is it just efficacy over placebo?)  Because… 21
  22. 22. 6/10/2010 Superiority Claims: Like Bikini Wear —notable for what is concealed rather than what is exposed. Bikinis and Allegiance: Whose Evidence Is It?  At least 40% of any observed effect is attributable to the belief in (allegiance to) the approach by the researchers  Even meager differences disappear when researcher allegiance is controlled… 22
  23. 23. 6/10/2010 Bikinis and Unfair Comparisons: What Kind of Evidence Is It?  Is the study really a fair contest? E.g., CBT v PDT  TAU: Pet approach of the researcher, handpicked and trained therapists with special supervision (reduced caseloads) will always outperform TAU.  The exorbitant cost better spent on reducing caseloads, supporting ther. with sup., feedback about outcome, and training in models of their choice. Smoke and Mirrors Dialetical BT for “BPD”  Of 382 eligible by dx, only 25 (6.5%) thought it was for them; 25% of those dropped out before program started; another 25% dropped out.  For those remaining, was effective, but once again, not fitting the hype or the expense of implementation  And the conclusion… 23
  24. 24. 6/10/2010 EBP Is A Humbug APA Definition of EBP Evidence-based practice is the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences (American Psychologist, May 2006). 24
  25. 25. 6/10/2010 APA Recommendations  Clinical decisions should be made in collaboration with the client, based on the best clinically relevant evidence, and with consideration for the probable costs, benefits, and available resources and options  Services are most effective when responsive to the client’s specific problems, strengths, personality, sociocultural context, and preferences.  The application of research evidence always involves probabilistic inferences. Therefore, ongoing monitoring of client progress and adjustment of treatment as needed are essential. Final Thoughts: The Borg?  No--need not be warring factions; Captain Picard not really fighting the Borg  EBP is a worthy endeavor--but broaden the definition (APA)  Evidence based on 40 years of outcome research and the known predictors of success  And the best evidence of all— the feedback about fit and progress we get from clients 25
  26. 26. 6/10/2010 Psychotherapy Research’s Greatest Hits: Summary No One Approach Works Better than Another...the Client Is The Lion of Change The Alliance Predicts Outcome… Early Change Predicts Outcome… Using Client Feedback, or PBE, Improves Effectiveness and Efficiency 26