Freud’s consulting room, Hampstead * Reflecting on alternative models of therapy Is therapy about care of patients in distress or about cure of disease? * Care * Implies an ill – healthy continuum * Concept of psychological hardiness useful * Chronic - could be long term support * Outcomes subjective and hard to measure * Eg. patient satisfaction * Cure * Implies medically based ill - healthy dichotomy * Discrete and identifiable disorders * Acute – short term cure in response to crisis * Positivism and measurable outcomes * Eg. using RCTs Less dichotomous in reality but an important debate for research into outcome * Questions * To what extent do discrete disorders exist? * and are they socio-culturally independent? * Are people who are distressed likely to be multiply affected (Co-morbidity) * Eg depression, and anxiety, and substance abuse? * Can disturbances be cyclical? Environmentally triggered? * Can therapy simply bring about cure or does it work through improving self management and self awareness? Dilbert 1 Dilbert 2 Dilbert 3 Do psychological therapies work? * This is a basic generation 1 question arising from Eysenck 1952 and led to a generation of justificatory research * Is it a reasonable question? * Do we ask if friendship, theatre, music, religion ‘work’? * Should we equate psychological therapies to physical therapies such as those involving drugs? * Is psychotherapy a social practice or a medical intervention? * Measurable outcomes or customer satisfaction? Fenichel 1930 * Review of outcome in Berlin Psychoanalytic Institute * 1955 consultations - 721 cases opened * 363 completed, 241 left prematurely, 117 still in treatment * 11 judged cured, 89 v. much improved, 116 improved, 47 not cured etc. * Depending on how view drop-outs…. 59 – 91% improvement Problems with early research * Use of pre / post treatment comparisons only * No comparison / control conditions * So no control for passage of time or measure of spontaneous remission * Ethical problems of random allocation, eg. Rogers and Dymond, 1954 * Need a control condition, either: * * No-treatment * Waiting list * placebo Generation 1 research * Arbuckle and Boy (1961) * 3x12 person matched samples, random allocation - client-centred therapy effective * Sloane et al (1975) * 3x30 matched samples: wait list / insight therapy / behaviour therapy, 16 wks / sessions * Therapists matched for experience * Pre / post / 12 months post use of SSIAM & target symptom rating * Both therapies improved equally, more than wait list which also improved * A good small scale study Does the literature add up? * What is an appropriate outcome measure? * Insight? Support through a process? Behaviour change? Loss of symptoms? * Will vary with condition treated, eg. eating disorder * Research design, choice of outcome measure, formulation and focus of therapy all related to theoretical orientation so difficult to compare therapies Research reviews * Eysenck, ’61, ’66…….. 0% effective * Rackman, 1971…….… 4% effective * Luborsky et al 1978….. 78% effective * So…contaminated by therapist allegiance * Use judgement to select studies for consideration, may reject on basis of design and outcome measures * Eg. behaviourists reject Sloane et al 1975 as outcome measures too medical / not behavioural Statistical issues * Significance is a function of size of effect & sample size, smalls differences may be significant with large sample and vice versa * With clinical research difficult to get large samples or to increase 2 condition contrast * Alternative - measure effect size Statistical issues 2 * Effect size of 1.0 means that therapy group is 1sd better than mean of control group – 84% of therapy group better than average control group member * Meta analysis – use effect size to quantify and aggregate a statistical review * But….garbage in = garbage out, as Eysenck argues. Meta analytic reviews * Smith et al 1980 * 474 studies, 18 types of therapy * Effect size of 0.85 – 80% of treated sample score above mean of control sample * Many similar studies, broadly similar results * Efficacy of therapy demonstrated in broad terms – mean effect size of 0.74 (approaching large) quoted by Lambert & Bergin (94) Comparative effectiveness * Overlap with earlier research * Dispute over a priori assumptions * Luborsky’s review – the Dodo verdict, the outcome equivalence paradox * Potential for meta analysis to resolve? * Not realised, many reviews, no consistent winners and losers