Evaluating Psychological Interventions Empirically Supported ...

Evaluating Psychological Interventions

Empirically Supported Treatments Needles and Shots Example Cognitive-Behavioral Therapy

Gregg Selke, Ph.D.PSY 4930

October 31st, 2006

Should we evaluate the effectiveness of psychological

interventions?

Criticisms Patients are too heterogeneous to be

evaluated statistically Psychotherapeutic interventions are too

individualized to be evaluated empirically Issues and desired outcome is different for

every patient Difficult to define, quantify, and measure

“process” of therapy (e.g., rapport, empathy, transference)

Fear that “lists” of “effective” treatments will be used by managed care to determine what will and will not be paid for.


interventions?

Yes, and here is why! Estimated >400 forms of

psychotherapy1. Specificity

Matching which interventions are most effective to specific problems

2. Ethical Obligation Responsibility to clients to use best

treatments (supported by research)


interventions?

3. Field Advancement Increases credibility of field

Refines our clinical skills and treatments Better outcomes & cost efficiency

4. Support for Theory behind Intervention Evaluates validity of theoretical basis of

an intervention under evaluation (e.g., Cognitive Therapy: depression is due to

underlying negative thoughts and beliefs, so if person becomes less depressed after changing negative thought patterns, theory supported)

How should we evaluate and measure effectiveness?

Rigorous Experimental Methods1. Random Assignment to treatment groups

Reduces risk of ending up with more severe patients in one group

2. Using appropriate control or comparison group(s)

3. Using valid and reliable outcome measures E.g., most sensitive test of depression

4. Consistency of therapist(s) across patients Pre- and Post-treatment evaluation

1. Within-subjects designs2. Between-subjects designs3. Meta-analysis

Three suggested methods for measure effectiveness

Within-subjects designs

Individual acts as own control by undergoing each intervention or non-intervention condition

Single-Case & Group Experimental Designs

1) A-B-A-B design (A=no treatment; B=treatment) Ethics of withdrawing treatment

(enuresis vs. depression) Not possible to withdraw some

treatments (Cognitive Therapy)

Within-subjects designs

Single-Case & Group Experimental Designs2) Multiple Baseline Design

Does not require withdrawal or reversal of intervention

Stepwise introduction of components of treatment (A B C)

E.G., hypothetical treatment for ODD Component A reduce verbal abuse Component B reduce noncompliance Component C reduce aggression

Can not definitively rule out improvements just due to passage of time

Between-subjects designs

Groups of individuals undergo different or no interventions

Increases support for improvement actually being due to treatment

1) Nonrandomized Control Group Studies 2 “naturally occurring” groups are

compared E.g., ADHD: behavior therapy vs. meds Poor design! No way of knowing if groups

differed (in severity, SES) before interventions


2) Randomized Clinical Trials Subjects are randomly assigned

to different conditions/interventions

likelihood groups will not differ systematically, or differences will occur more equally across groups


2) Types of Randomized Clinical Trialsa) No-treatment control group (ethical issues)b) Wait-list control group (get treatment later)c) Placebo control group (e.g., double-blind

trials) E.g., nonspecific support in psychology

d) Comparing Multiple Interventions E.g., behavior therapy, meds, behavior

therapy+meds, wait-list control, & placebo

Meta-Analysis

“Studies of studies” Statistical procedure to combine the

findings of multiple studies Uses the effect sizes (how big the

average change due to treatment was), and gives more weight to studies with larger samples

Advantage: Studies do not have to use the same measures

How do we determine if a treatment is good enough (i.e.,

valid)?

APA Division 12 and 53 Guidelines for identifying and

promoting empirically “validated” or supported treatments in psychology.

Defining Interventions as1.1. Best Support (“Well-Established Best Support (“Well-Established

Treatments”)Treatments”)

2.2. Promising (“Probably Efficacious Promising (“Probably Efficacious Treatments”)Treatments”)

Criteria for “Well-Established

Treatments” or Best Support

I. At least two good between group design experiments demonstrating efficacy in one or more of the following ways:a. Superior to pill placebo, psychological

placebo, or another treatment.b. Equivalent to an already established

treatment in experiments with adequate statistical power (about 30 per group; cf. Kazdin & Bass, 1989).

Criteria for “Well-Established Treatments”

or Best Support

ORII. A large series of single case design

experiments (n > 9) demonstrating efficacy. These experiments must have:a. Used good experimental designsb. Compared the intervention to another

treatment as in I.a. (superior to placebo, etc.)

Criteria for “Well-Established Treatments”

or Best Support

ANDFurther criteria for both I and II:III. Experiments must be conducted with

treatment manuals.IV. Characteristics of the client samples

must be clearly specified.V. Effects must have been

demonstrated by at least two different investigators or teams of investigators.

Criteria for “Probably Efficacious Treatments”

or Promising

I. Two experiments showing the treatment is (statistically significantly) superior to a waiting-list control group. Manuals, specification of sample,

and independent investigators are not required.


or Promising

ORII. One between group design experiment

with clear specification of group, use of manuals, and demonstrating efficacy by either:

a. Superior to pill placebo, psychological placebo, or another treatment.

b. Equivalent to an already established treatment in experiments with adequate statistical power (about 30 per group; cf. Kazdin & Bass, 1989).


or Promising

ORIII. A small series of single case

design experiments (n > 3) with clear specification of group, use of manuals, good experimental designs, and compared the intervention to pill or psychological placebo or to another treatment.

ExampleEmpirically Supported Treatment

Behavioral Distress in

Venipuncture and Immunizations

Background

•Venous blood sampling and immunizations are potentially very painful and frightening to children (and adults).

•Prevalence of Needle Phobics estimated to be 4.9% -9% (14/100 in 20 year olds).

•Nearly all Children in the U.S. are required to receive immunization shots prior to preschool, and have venipuncture at routine doctor visits.

Fear of needles is a primary reason why people are reluctant to donate blood.

Adult fear and avoidance of medical care is associated with having had more medical pain and fear in childhood.

Young children (Cohen, 1997) Rarely show spontaneous overt

coping behavior Have difficulty ignoring aversive

stimuli Do not initiate internal coping

strategies (i.e., imagery) as easily as older children and adults

Interventions to reduce associated distress are not routinely used in standard care.

Research not well disseminated Intervention seen as unnecessary for

brief procedures Costs of training and equipment

What is Distress?

Indicators of Child Distress Crying, Screaming, Fussing/Whining,

Verbal Resistance, Verbal Pain, Verbal Emotion, Request for Emotional Support, Verbal Fear, Information Seeking , Physical Resistance/Flailing, Kicking, Muscular Rigidity

May increase procedure duration, the experience of pain, potential for accidental injury

Goals

Distress, Coping, Cooperation

Intervene early to prevent future distress

Find Practical, Cost-Effective Methods to Alleviate Distress

Reviewed Psychlit, Pubmed

Over 20 Intervention Studies Wide range of treatment populations Predominant Component: Distraction

Caveat: only reviewed up until 2001

Literature Review

Different Types of Distraction Party Blower Cartoon Movie Kaleidoscope Lullabies Parental Non-Procedural Talk

Other Interventions Picture Book Behavioral Education to Parents

Different Ways to Implement Parent Training Nurse Training Child Training

Manimala, Blount, Cohen. Effects of parental reassurance vs. distraction on child distress and coping during immunization. Children’s Health Care (2000)

• Subjects: Healthy, N=27-28 per group, preschool immunizations, 3-5 years, clearly identified

• Design: Between Group: 3 groups• Interventions a) Standard

b) Prior to Procedure: Distraction with toys,

puzzles, coloring books, non-procedural talk During Procedure: Parent Coaching of Party

Blower (Breathing /relaxation) c) Parent Reassurance: trained/encouraged Outcome: restraint with Distraction + Coaching

Reassurance 3X restraint & > Verbal Fear than Distraction and Standard

Bowen, Dammeyer. Reducing Children’s Immunization Distress

in a primary care setting. J Ped Nursing (1999)

• Subjects: Healthy, N=80 (21, 29,30 per group), 3-6 years, clearly identified

• Design: Between Group: 3 groups• Groups/Intervention (no coaching or training) a) Standard

b) Party Blower (Deep Breathing Distraction) c) Looking at or blowing a Pinwheel taped

down

Outcome: Distress with Blower compared to standard or pinwheel,

Party Blower thought to be more distracting than pinwheel b/c more sensory systems are involved.

Based on 2 studies, Party Blower Procedure may meet criteria for “Well-Established”

Gonzalez, Routh, Armstrong. Effects of maternal distraction versus reassurance on children’s reactions to injections. JPP (1993)

•Subjects: Healthy, N=42 (14/group), primary care Ages: 3-7 years, clearly specified

•Design: B-G, 3 Groups•Groups/Intervention

a) Minimal Treatment Control b) Parental Reassurancec) Maternal Non-Procedural Talk (Distraction)

Outcome: Distraction Associated with Distress & Crying, compared to Reassurance & Control

“Promising” Inadequate sample size per group

Cohen, Blount, Panopoulos. Nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent and nurse distress during immunization. JPP (1997)

•Subjects: Healthy, N=92 (about 30/group) Ages: 4-6, clearly identified

•Design: B-G, protocol used•Groups/Intervention

a) Standard b) Nurse Coach: coach to watch cartoon

moviec) Nurse + Parent/Child Intervention:

- modeling and role playing prior- nurse + parent coaching during movie

Outcome: both interventions Distress, restraint, coping

Cohen, Blount, Cohen, Schaen, Zaff. Comparative study of distraction vs. topical anaesthesia for pediatric pain management during immunization. Health Psych (1999)

•Subjects: Healthy, N=39, at school health clinic 8-11 years, low SES, clearly identified

•Design: 3 conditions, Within Subjects, 3 Hep shots •Groups/Intervention

a) Standardb) Distraction + Nurse Coach: cartoon moviec) EMLA: lidocane + prilocane applied 1hr prior

Outcome:Distress, coping: cartoon + coachingChildren coped better with standard than EMLA

Coaching to watch cartoon “Promising” b/c lack of multiple research teams/authors

Behaviors Associated with High Levels of Distress: Cohen,1997 Reassurance, too much empathy,

apologies, criticism, giving child control over start of the procedure, parental anxiety.

Reducing Distress Distraction, Straightforward Information,

Parent and Nursing Coaching, Teaching coping strategies

Conclusions

How many empirically supported treatments do you think there are for

children and adolescents who have

psychological/psychiatric disorders?

100s of estimated forms of psychotherapy

Anxiety Disorders

“Well-Established Treatments”

“Probably Efficacious Treatments”

Specific Phobia

1. Participant Modeling*2. Reinforced Practice*

1. Cognitive Behavior Therapy2. Systematic Desensitization*

Generalized Anxiety Dx(GAD)

None 1. Cognitive Behavior Therapy2. Modeling*3. In Vivo Exposure*4. Relaxation Training*5. Reinforced Practice*6. Family Anxiety Management

Separation Anxiety

None Same 6 treatments as GAD

Agoraphobia None None

OCD None None

Panic Disorder None None

PTSD None None

Social Phobia None None

* These can be considered components of CBT

Depressive Disorders


“Probably Efficacious

Treatments”

Major Depressive Disorder

1. Interpersonal Therapy

1. CBT2. Psychotropic

MedicationsDysthymic Disorder 1. Interpersonal

Therapy1.CBT2.Psych Med

Adjustment Disorder 1. Interpersonal Therapy

1.CBT2.Psych Med

ADHD “Well-Established Treatments”


Treatments”

1. Stimulant Meds

2. Behavioral Parent Training

3. Behavioral Classroom Interventions

1. Social Skills Training with Generalization Components

2. Summer Treatment Programs

ODD & CD



Treatments”

1. Parent Training Based on the book Living with Children

2. Videotape Modeling Parent Training

For Pre-school Age Children:

1. Parent-Child Interaction Therapy

2. Time-Out Plus Signal Seat Treatment

3. Parent Training Program

4. Delinquency Prevention Program

For School Aged Children:1. Anger Coping Therapy2. Problem Solving Skills

TrainingFor Adolescents:1. Anger Control Training

with Stress Inoculation2. Assertiveness Training3. Multisystemic Therapy4. Rational Emotive

Therapy

Cognitive Behavioral Therapy

“Probably Efficacious Treatment” Specific Phobia Generalized Anxiety Disorder (GAD) Separation Anxiety Major Depressive Disorder Dysthymic Disorder Adjustment DisorderWhile not meet EST criteria, also often used for Agoraphobia, OCD, Panic Disorder, PTSD,

Social Phobia

What is CBT?

Therapeutic technique that uses a combination ofA. Cognitive Strategies

Alter, manipulate, and restructure distorted and unhealthy thoughts, images, and beliefs.

Assumes that unhealthy thoughts lead to maladaptive behavior, and positive changes in thinking will produce positive changes in emotions and behavior.

B. Behavioral Strategies CBT procedures link cognitive strategies with

behavioral strategies Assumes that by making direct positive

changes in behavior, will result in positive changes in thoughts and emotions (e.g., anxiety, depression)

Early Foundations of CBT(behavioral aspects)

Developed out of Learning Theories Classical conditioning (Pavlov, Watson):

Focuses on the antecedent of behavior or what occurred before behavior (possible cause)

Learning occurs through association Conditioning that pairs a previously neutral

stimulus with a stimulus that evokes a reflexive response; the stimulus that evokes the response is given whether or not the conditioned response occurs until eventually the neutral stimulus comes to evoke the response

e.g., Pavlovian dogs, Little Albert Particularly relevant for phobias, PTSD, panic

disorder


Learning Theories Operant Conditioning (Skinner, Thorndike)

Focuses on the consequences of behavior A process of behavior modification in which the

likelihood of a specific behavior is increased or decreased through positive or negative reinforcement each time the behavior is exhibited, so that the subject comes to associate the pleasure or displeasure of the reinforcement with the behavior.

Positive consequences or removal of negative stimuli increase the likelihood of behavior happening again

Negative consequences decrease the likelihood of a future occurrence

E.g., time out for aggression, ending time out for sitting quietly in time out, getting a sticker for using manners


Social Learning Theory (Bandura): Focuses on modeling Learning occurs through modeling or

vicarious learning No direct reinforcement is necessary E.g., Bobo doll experiments;

witnessing violence in media or community or family

Early Foundations of CBT(cognitive aspects)

Beck (1960s-1970s) Individuals are affected by objective

world AND their subjective perceptions and interpretations

Negative perceptions of events is more likely to lead to depression or anxiety

Even though cognitions or thoughts cannot be directly observed (like behaviors), they can be changed

Cognitive Theories

Beck developed cognitive therapy after noticing that depressed patients had cognitions regarding: Loss Failure Abandonment Rejection

Negative thoughts play a role in the onset and maintenance of depression

Cognitive Theory

The Cognitive Triad1. Negative view of themselves (e.g., inadequate)2. Negative view of the world (e.g., unfair)3. Negative view of the future (e.g., I will always fail)

Negative Schemas Cognitive Distortions/Maladaptive Thoughts Ways of thinking that lead individuals to perceive

and interpret experiences in a negative manner Automatic: often occur very rapidly in certain

situations and may be outside of person’s awareness

Involve discrete predictions or interpretations of a given situation

Develop out of negative experiences

Cognitive Theory

Ellis’s A-B-C theory A-activating events B-irrational beliefs C-emotional consequences

When A occurs, an individual automatically engages in negative beliefs/thoughts about the event E.g., walk by “friend”, you say hi, they

do not respond……

Cognitive Theory

Examples of irrational beliefs: When things do not go the way I

would like, life is awful, terrible, horrible, or catastrophic

Unhappiness is caused by uncontrollable external events

I must have sincere love and approval from all significant people in my life

From Cognitive Theory to Intervention

Ellis’ A-B-C-D-E theory D-dispute irrational beliefs E-evaluate effects (reduction of

depression, anxiety)

D-dispute irrational beliefs Cognitive Reframing

Goal of Cognitive Therapy Must first increase awareness of types of

automatic negative thoughts one has Then learn to pursue thought until arriving at

context or prediction that is contributing to it. Then replace or reframe cognitive

distortions/maladaptive thoughts with more balanced and realistic thoughts and beliefs about oneself, the future, and the world around us.

negative & ↑ positive feelings and behaviors

Possible Components of CBTor Techniques used as part of

CBT

Cognitive Reframing Relaxation Training

1. Diaphragmatic Breathing2. Imagery 3. Progressive Muscle Relaxation4. Iatrogenic Relaxation

Modeling In vivo exposure Reinforced practice Social and Communication skills training Problem-solving training Anger-management training

Behavioral Strategies

Generally, behavior therapy emphasizes changing behavior by changing the antecedents or consequences, or learning new behavior-based skills


Relaxation Training Management of anxiety, pain, anger,

stress, emotional reactivity, depression, fatigue, etc.

1. Diaphragmatic Breathing

2. Guided Imagery - visualization

3. Progressive Muscle Relaxation4. Autogenic Relaxation5. Biofeedback


In Vivo Exposure Real-life exposure Practicing approaching and confronting

a feared situation or object (e.g., driving, germs)

Sessions should begin with easy situations and gradually work its way up to scarier and harder situations.

OCD, phobias Extreme versions: implosive therapy,

flooding


Modeling Involves demonstrating non-

fearful behavior in a feared situation and showing the child or adolescent a more appropriate response for dealing with a feared object or event

E.g., social situation, dogs


Participant Modeling Combines modeling and in vivo

exposure1. Model (e.g. therapist, friend, or peer)

demonstrates fearlessness and coping responses when confronting a feared situation or object

2. The model assists the child in practicing approaching and confronting the feared situation or object.

Sessions should begin with easy situations and gradually work its way up to scarier and harder situations.


Reinforced Practice Combines in vivo exposure with a

feared situation or object and rewards (e.g. praise, tokens, toys, hugs, etc.) for approaching and confronting a feared situation or object.

Child is rewarded for practicing approaching and confronting a feared situation or object.


Contingency management Changing behavior by controlling it’s

consequences PCIT

Shaping Reinforcing successive

approximations of a behavior e.g. sitting on toilet for toilet training

Token economy programs


Aversive Conditioning Reducing unwanted behaviors by

pairing it with a negative stimulus Electric shock Unpleasant tasting liquid

In children, usually only used with self-injurious behavior

Usually used as a last resort

Behavioral/Cognitive Strategies

Systematic Desensitization Child or adolescent imagines feared object

or situation while he/she is engaged in a response that is incompatible with anxiety (e.g. relaxation or play).

Based on the theory of reciprocal inhibition—one cannot be anxious and relaxed at the same time (Wolpe, 1958)

Unlike participant modeling and reinforced practice, the feared object or situation is presented in imagination rather than real life.


Anger Coping Therapy Designed to address deficiencies in thinking and

problem-solving exhibited by aggressive children

Children learn to Establish group rules and generate reinforcers Use self-statements to inhibit impulsive behaviors Identify problems and take other perspectives Generate alternate solutions and be aware of

consequences of their actions Model videotapes and become more aware of physical

symptoms involved in anger Make their own video of problem-solving and self-

inhibiting statements Role-playing to solve current anger problems


Problem Solving Skills Training Teaches children skills to solve

problems better Developing alternative solutions,

anticipating consequences, and taking others’ perspectives

Parents taught to manage their children’s behavior using time-out, positive reinforcement, negotiating, and other strategies.

Teaching methods included role-playing, corrective feedback, practice, modeling, and token economy.


Social Skills Training Used with patients with depression,

anxiety, social phobia, schizophrenia Focuses on verbal and nonverbal

behaviors Uses behavioral techniques such as

modeling, role play, rehearsal Patient begins to be positively

reinforced for social skills


Social Skills Training may focus on: Maintaining eye contact Smiling at appropriate times Matching tone of voice to content Accurately perceiving the emotions of others Interpreting nonverbal behaviors Making requests of others Standing up for their rights Maintaining a conversation Timing responses appropriately

Progressive Muscle Relaxation

In-Class Exercise

Systematic tensing and relaxation of major muscle groups of whole body

With practice, goal is to learn to become deeply relaxed fairly rapidly

Impossible to be tense and relaxed at same time, can implement skill when noticing that you are starting to become tense and anxious

HAPPY HALLOWEE

N

Date post:	21-Jun-2015
Category:	Documents
Upload:	marina761
View:	1,041 times
Download:	0 times

Evaluating Psychological Interventions Empirically Supported ...

Documents