Controversies in Intervention

1
Controversies in Intervention

• Efficacy vs. effectiveness studies
• Empirically validated treatments (EVTs)
• Criteria for what is considered validated
• Lists of empirically validated treatments
• Practice standards in psychiatry

2
Controversies, contd

• Dodo Bird verdict
• New and novel (and controversial!) treatments

3
Efficacy vs. Effectiveness

• Martin Seligman
• Efficacy traditional controlled outcome
  studies, e.g., RCTs (Randomized Controlled
  Trials)
• Effectiveness real world studies of therapy
  as performed outside research studies
  (techniques, populations)

4
Advantages of Each Type of Study

• Efficacy good control over confounding
  variables, reliable inference of causation
• Effectiveness good generalization to real-life
  patient populations (e.g., multiple problems) and
  real-life treatment methods (e.g., eclectic)

5
Consumer Reports Survey

• 180,000 subscribers polled
• 7,000 responders (lt 4), of whom 2,900 had had
  formal treatment from professional (lt 2) 1,300
  had self-help group 1,000 saw family doctor
• Outcome variables self-rated satisfaction,
  self-rated improvement

6
Consumer Reports Results

• Equally satisfied no matter who they saw (MH
  professional, family doctor, etc.)
• More reported improvement if saw MH professional
  gt 6 months
• More reported therapy (duration) predicted more
  reported improvement
• Self-help groups rated especially satisfying

7
Problems with CR Study

• Unrepresentative sample (CR subscribers)
• Very low response rate (lt 4 or lt 2)
• Only self-report therapist, therapy, outcomes
• No proper control group (just some people who
  said theyd had no therapywhy would they write
  in?)

8
Empirically Validated/Supported Treatments

• Four level definition of adequate support
• Well-established as efficacious (see next slide)
• Probably efficacious (see later slide)
• Possibly efficacious
• Anything else

9
Well-Established Definition

• 2 independent, sufficiently rigorous outcome
  studies (e.g., Randomized Controlled Trials,
  multiple considerable series of single-case
  ABAB designs)
• Consistently showing significant improvement
  (greater than control)
• Reasonably well described treatment (e.g.,
  manual)
• Reasonably well described patient population

10
Probably Efficacious Definition

• Only one lab generates 2 sufficiently rigorous
  outcome studies, or just one rigorous study
  exists, or multiple independent but less rigorous
  studies exist
• Inconsistent results, overall favoring treatment
• Well-described treatment (e.g., manual)
• Well-described patient population (e.g.,
  diagnosis)

11
Quasi-Continuum of Validation

• Types of studies graded by rigor
• Type 1 RCT (e.g., blind placebo-controlled
  randomized trial)
• Type 2 RCT (e.g., non-placebo control such as
  wait list)
• Open trials (not blinded, no placebo)
• Quasi-experimental case studies (e.g., ABAB)
• Box scores of counted favorable results (e.g.,
  9/13 studies show significant effect for
  treatment, compared to control)
• Consistency of results

12
Lists of Validated Therapies

• Chambless Task Force on Training In and
  Dissemination of Empirically Validated
  Psychological Treatments (1995)
• 4 grades of support
• 22 well established treatments for 21 syndromes
• 7 probably efficacious treatments

13
EVT Lists, contd

• Nathan task force Treatments That Work
• Established by Seligman/Division 12
• Published book 1998
• 64 treatments for 28 syndromes, of varying
  degrees of validation
• 44 with 2 high-quality RCTs
• Of these, 13 are psychosocial treatments rest
  are pharmacologic/ECT

14
EVT Lists, contd

• Nathan Gorman, 2nd ed. of book (2003)
• 142 treatments listed for 29 syndromes, with
  varying degrees of support
• 69 with 2 high-quality RCTs for 22 syndromes
• Of these, 23 are psychosocial treatments
• Others are somatic (pharmacological, ECT, light
  therapy, chemical aversion therapy for
  alcoholism, etc.)

15
EVT Reviews, contd

• Roth Fonaghy What Works for Whom? book
• Cochrane reviews in specific areas (e.g.,
  Critical Incident Stress Debriefing)

16
Practice Guidelines

• ApA (American Psychiatric Association) Practice
  Guidelines (1993, 94, 95) list first-choice and
  second-line treatments for
• major depression in adults
• bipolar disorder
• substance use disorders
• schizophrenia

17
Dodo Bird Verdict

• Everyone has won and all must have prizes
• Favored by psychodynamic client-centered therapy
  advocates disfavored by behavioral, cognitive
  advocates
• Original Smith, Glass Miller meta-analysis
  found no significant differences between
  treatments
• Nonspecific factors issue (Rogers)
• Allegiance effect issue (Luborsky)

18
Dodo Bird, contd

• Hotly contested (especially by behavior
  therapists) criticisms
• Garbage In, Garbage Out (insufficient screening
  of included studies)
• Apples and oranges comparisons
• Still being actively debated
• Majority opinion some disordersfew differences
  in efficacy (e.g., major depression)
  othersimportant differences (e.g., OCD)

19
Novel Controversial Treatments

• Eye Movement Desensitization and Reprocessing
  (EMDR)
• Critical Incident Stress Debriefing (CISD)
• Recovered Memory Therapy

20
EMDR (Shapiro)

• Theory
• Technique
• Controversy about marketing
• Controversy about effectiveness
• Found effective in a few RCTs
• Eye movements appear to have nothing to do with
  its effectiveness

21
CISD

• Theory
• Technique (by subscription, vs. en masse after
  disaster)
• Cochrane report review conclusion On average,
  CISD is harmful to patients
• Some suggestion this may be true (or especially
  true) of coercive application

22
RMT (and Related MPD) Therapies

• Theory of repression/dissociation of trauma
  memories
• Memory as video recorder
• Single- vs. multi-incident repression/
  dissociation
• Multiple, ongoing abuse repression/dissociation
• Betrayal trauma (Freyd)
• Body memories

23
RMT (and MPD) Treatment Practices

• Insight-oriented, several sessions/week,
  years-long
• Hypnosis, sodium amytal often used
• Memory work guided imagery, safe place,
  journaling, abreactions (catharsis, with/without
  restraints)
• Concomitant pharmacotherapy (antidepressants,
  benzodiazepines, antipsychotics, heart
  medications)
• Identification/mapping of alter personalities,
  integration (various methods) for MPD

24
RMT (MPD) Treatment Effectiveness

• Zero controlled studies of this treatment
• One published uncontrolled study after 4 years,
  zero recovery (for MPD patients)
• May be harmful
• Anecdotal evidence
• Professional society warnings
• Lawsuits
• Licensure actions