what is evidence-based practice? louis castonguay the pennsylvania state university ca-spr montreal...

What is evidence-based practice?

What is evidence-based practice?

Louis Castonguay Louis Castonguay

The Pennsylvania State UniversityThe Pennsylvania State University

CA-SPR Montreal 2009CA-SPR Montreal 2009

11

The Early Participants in The Early Participants in the Debatethe Debate

The Early Participants in The Early Participants in the Debatethe Debate

Those who argue for Treatments That Those who argue for Treatments That Work (Division 12; Nathan & Work (Division 12; Nathan & Gorman, 1998; 2002; Chambless & Gorman, 1998; 2002; Chambless & Crits-Christoph, 2005) Crits-Christoph, 2005)

Those that argue for Relationships Those that argue for Relationships that work (Division 29; Norcross, that work (Division 29; Norcross, 2002; Norcross & Lambert, 2005)2002; Norcross & Lambert, 2005)

Those who argue for Participant Those who argue for Participant Factors that work (Bohart, 2005; Factors that work (Bohart, 2005; Wampold, 2001; 2005)Wampold, 2001; 2005)

Those who argue for Treatments That Those who argue for Treatments That Work (Division 12; Nathan & Work (Division 12; Nathan & Gorman, 1998; 2002; Chambless & Gorman, 1998; 2002; Chambless & Crits-Christoph, 2005) Crits-Christoph, 2005)

Those that argue for Relationships Those that argue for Relationships that work (Division 29; Norcross, that work (Division 29; Norcross, 2002; Norcross & Lambert, 2005)2002; Norcross & Lambert, 2005)

Those who argue for Participant Those who argue for Participant Factors that work (Bohart, 2005; Factors that work (Bohart, 2005; Wampold, 2001; 2005)Wampold, 2001; 2005)

22

Recognized False Recognized False DichotomiesDichotomies


“It is important to note that the effective practice of evidence-based psychotherapy involves more than the mastery of specific procedures outlined in EST manuals. Almost all ESTs rely on therapists’ having good nonspecific therapy skills” Chambless & Ollendick (2001)

-therapists’ competence-client’s ability to form an alliance-client’s initial functioning- interaction of client characteristics

and treatment approaches

“It is important to note that the effective practice of evidence-based psychotherapy involves more than the mastery of specific procedures outlined in EST manuals. Almost all ESTs rely on therapists’ having good nonspecific therapy skills” Chambless & Ollendick (2001)

-therapists’ competence-client’s ability to form an alliance-client’s initial functioning- interaction of client characteristics

and treatment approaches

33



“The therapeutic relationship acts in concert with discrete interventions, patient characteristics, and clinician qualities in determining treatment effectiveness. A comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations” (Norcross, 2002)

“The therapeutic relationship acts in concert with discrete interventions, patient characteristics, and clinician qualities in determining treatment effectiveness. A comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations” (Norcross, 2002)

44

An Alternative, Integrative An Alternative, Integrative PositionPosition

An Alternative, Integrative An Alternative, Integrative PositionPosition

Division 12 (APA) and North Division 12 (APA) and North American Society for American Society for Psychotherapy Research Joint Psychotherapy Research Joint Task Force on Identifying Task Force on Identifying Therapeutic Principles that Therapeutic Principles that Work.Work.

– Castonguay, L. G., & Beutler, L. E. Castonguay, L. G., & Beutler, L. E. (Eds)(2005). (Eds)(2005). Principles of Principles of Therapeutic Change that WorkTherapeutic Change that Work. . New York: Oxford University New York: Oxford University Press.Press.

Division 12 (APA) and North Division 12 (APA) and North American Society for American Society for Psychotherapy Research Joint Psychotherapy Research Joint Task Force on Identifying Task Force on Identifying Therapeutic Principles that Therapeutic Principles that Work.Work.

– Castonguay, L. G., & Beutler, L. E. Castonguay, L. G., & Beutler, L. E. (Eds)(2005). (Eds)(2005). Principles of Principles of Therapeutic Change that WorkTherapeutic Change that Work. . New York: Oxford University New York: Oxford University Press.Press.

55

Mission of Joint Task Mission of Joint Task ForceForce

Mission of Joint Task Mission of Joint Task ForceForce

To integrate participant, To integrate participant, relationship, and treatment relationship, and treatment factors and consolidate them into factors and consolidate them into working principles that are working principles that are grounded in research.grounded in research.

To integrate participant, To integrate participant, relationship, and treatment relationship, and treatment factors and consolidate them into factors and consolidate them into working principles that are working principles that are grounded in research.grounded in research.

66

Strategy of Strategy of Joint Task ForceJoint Task Force

Strategy of Strategy of Joint Task ForceJoint Task Force

To extract from previous Task To extract from previous Task Force Reports on Relationship Force Reports on Relationship Factors and Treatments that Factors and Treatments that work, common and specific work, common and specific principles of treatment that are principles of treatment that are “empirically-informed”.“empirically-informed”.

To extract from previous Task To extract from previous Task Force Reports on Relationship Force Reports on Relationship Factors and Treatments that Factors and Treatments that work, common and specific work, common and specific principles of treatment that are principles of treatment that are “empirically-informed”.“empirically-informed”.

77

Composition of Composition of Task ForceTask Force

Composition of Composition of Task ForceTask Force

24 Senior Scholars who were 24 Senior Scholars who were “assigned” in pairs to work with “assigned” in pairs to work with one another, based on having one another, based on having variable and contrasting variable and contrasting viewpoints.viewpoints.

21 Associated Scholars picked by 21 Associated Scholars picked by chapter authors to assist in the chapter authors to assist in the literature reviews and writing.literature reviews and writing.

24 Senior Scholars who were 24 Senior Scholars who were “assigned” in pairs to work with “assigned” in pairs to work with one another, based on having one another, based on having variable and contrasting variable and contrasting viewpoints.viewpoints.

21 Associated Scholars picked by 21 Associated Scholars picked by chapter authors to assist in the chapter authors to assist in the literature reviews and writing.literature reviews and writing.

88

Task Force StructureTask Force Structure

PDPD DysphDysph SubsSubs AnxAnx

Partici-Partici-

PantsPants

Relation-Relation-

ShipsShips

TechniquesTechniques

99

ProcedureProcedureProcedureProcedure

Review extant literature cited in Review extant literature cited in relevant chapters of Division 12 and relevant chapters of Division 12 and Division 29 task force reports and the Division 29 task force reports and the Handbook of Psychotherapy and Handbook of Psychotherapy and Behavior Change, Behavior Change, 1994 and 2004 1994 and 2004 editionseditions

Summarize results for studies relevant Summarize results for studies relevant to a specific disorderto a specific disorder

Extract principles that are supported Extract principles that are supported by a “preponderance of evidence”by a “preponderance of evidence”

Review extant literature cited in Review extant literature cited in relevant chapters of Division 12 and relevant chapters of Division 12 and Division 29 task force reports and the Division 29 task force reports and the Handbook of Psychotherapy and Handbook of Psychotherapy and Behavior Change, Behavior Change, 1994 and 2004 1994 and 2004 editionseditions

Summarize results for studies relevant Summarize results for studies relevant to a specific disorderto a specific disorder

Extract principles that are supported Extract principles that are supported by a “preponderance of evidence”by a “preponderance of evidence”

1010

Seeking ConsensusSeeking ConsensusSeeking ConsensusSeeking Consensus

Meeting of representatives of all Meeting of representatives of all chapters – June, 2003.chapters – June, 2003.

– Common Principles---those that cut Common Principles---those that cut across disorders, within a variable across disorders, within a variable domaindomain

– Unique Principles---The remaining Unique Principles---The remaining principles that are specific to one principles that are specific to one disorder, representing each domain disorder, representing each domain (participants, relationships, (participants, relationships, treatment techniques/models)treatment techniques/models)

Meeting of representatives of all Meeting of representatives of all chapters – June, 2003.chapters – June, 2003.

– Common Principles---those that cut Common Principles---those that cut across disorders, within a variable across disorders, within a variable domaindomain

– Unique Principles---The remaining Unique Principles---The remaining principles that are specific to one principles that are specific to one disorder, representing each domain disorder, representing each domain (participants, relationships, (participants, relationships, treatment techniques/models)treatment techniques/models)

1111

Summary of ResultsSummary of ResultsSummary of ResultsSummary of Results 26 “Common” and 35 “Unique” 26 “Common” and 35 “Unique”

PrinciplesPrinciples

– Participant PrinciplesParticipant Principles 16 on Observed and 12 on Inferred 16 on Observed and 12 on Inferred

QualitiesQualities 5 Common and 23 Unique5 Common and 23 Unique

– Relationship PrinciplesRelationship Principles 9 Common and 2 Unique Principles9 Common and 2 Unique Principles

– Treatment PrinciplesTreatment Principles 12 Common and 10 Unique12 Common and 10 Unique

26 “Common” and 35 “Unique” 26 “Common” and 35 “Unique” PrinciplesPrinciples

– Participant PrinciplesParticipant Principles 16 on Observed and 12 on Inferred 16 on Observed and 12 on Inferred

QualitiesQualities 5 Common and 23 Unique5 Common and 23 Unique

– Relationship PrinciplesRelationship Principles 9 Common and 2 Unique Principles9 Common and 2 Unique Principles

– Treatment PrinciplesTreatment Principles 12 Common and 10 Unique12 Common and 10 Unique

1212

ConclusionsConclusionsConclusionsConclusions

When properly applied, When properly applied, principles of change will allow principles of change will allow clinicians to operate research-clinicians to operate research-informed practices, to enhance informed practices, to enhance their ability to serve a wider their ability to serve a wider range of patients, and to use an range of patients, and to use an eclectic array of empirically eclectic array of empirically based clinical methods. based clinical methods.

When properly applied, When properly applied, principles of change will allow principles of change will allow clinicians to operate research-clinicians to operate research-informed practices, to enhance informed practices, to enhance their ability to serve a wider their ability to serve a wider range of patients, and to use an range of patients, and to use an eclectic array of empirically eclectic array of empirically based clinical methods. based clinical methods.

1313

Therapeutic principles of Therapeutic principles of change in the treatment of change in the treatment of

depression.depression.

Therapeutic principles of Therapeutic principles of change in the treatment of change in the treatment of

depression.depression.

14141414

PRINCIPLES REGARDING PRINCIPLES REGARDING PATIENT PROGNOSIS PATIENT PROGNOSIS

REGARDLESS OF TREATMENT REGARDLESS OF TREATMENT TYPE*…TYPE*…


REGARDLESS OF TREATMENT REGARDLESS OF TREATMENT TYPE*…TYPE*…

1. Patients representing underserved ethnic or racial group achieve fewer benefits than Anglo-American groups, from conventional psychotherapy.

2. If patients and therapists come from the same or similar racial/ethnic backgrounds, drop out rates are positively affected and improvement is enhanced.

3. If psychotherapists are open, informed, and tolerant of various religious views, treatment effects are likely to be enhanced.

4. Co-morbid personality disorders, are negative prognostic indicators in the psychological treatment of depressed patients.

1. Patients representing underserved ethnic or racial group achieve fewer benefits than Anglo-American groups, from conventional psychotherapy.

2. If patients and therapists come from the same or similar racial/ethnic backgrounds, drop out rates are positively affected and improvement is enhanced.

3. If psychotherapists are open, informed, and tolerant of various religious views, treatment effects are likely to be enhanced.

4. Co-morbid personality disorders, are negative prognostic indicators in the psychological treatment of depressed patients.

*Beutler et al (2005) 1515


REGARDLESS OF TREATMENT REGARDLESS OF TREATMENT TYPE* continuedTYPE* continued


REGARDLESS OF TREATMENT REGARDLESS OF TREATMENT TYPE* continuedTYPE* continued

5. Age is a negative predictor of a patient’s response to general psychotherapy.

6. Patients who enter treatment with high levels of functional impairment, tend to do poorly relative to other patients.

7. A secure attachment pattern in both patient and therapist appears to facilitate the treatment process.

8. The most effective treatments are likely to be those that do not induce patient resistance.

*Beutler et al (2005)

5. Age is a negative predictor of a patient’s response to general psychotherapy.

6. Patients who enter treatment with high levels of functional impairment, tend to do poorly relative to other patients.

7. A secure attachment pattern in both patient and therapist appears to facilitate the treatment process.

8. The most effective treatments are likely to be those that do not induce patient resistance.


1616

PRINCIPLES RELATING TO PRINCIPLES RELATING TO MATCHING THERAPY TO A MATCHING THERAPY TO A

PARTICULAR CHARACTERISTIC PARTICULAR CHARACTERISTIC

OF THE CLIENT*…OF THE CLIENT*…

PRINCIPLES RELATING TO PRINCIPLES RELATING TO MATCHING THERAPY TO A MATCHING THERAPY TO A

PARTICULAR CHARACTERISTIC PARTICULAR CHARACTERISTIC

OF THE CLIENT*…OF THE CLIENT*…

1.Benefit may be enhanced when the interventions selected are responsive to and consistent with the patient’s level of problem assimilation.

2. If patients have a preference for religiously oriented psychotherapy, treatment benefit is enhanced if therapists accommodate this preference.

3. In dealing with the resistant patient, the therapist’s use of directive therapeutic interventions should be planned to inversely correspond with the patient’s manifest level of resistant traits and states.


1.Benefit may be enhanced when the interventions selected are responsive to and consistent with the patient’s level of problem assimilation.

2. If patients have a preference for religiously oriented psychotherapy, treatment benefit is enhanced if therapists accommodate this preference.

3. In dealing with the resistant patient, the therapist’s use of directive therapeutic interventions should be planned to inversely correspond with the patient’s manifest level of resistant traits and states.


1717

PRINCIPLES RELATING TO MATCHING PRINCIPLES RELATING TO MATCHING THERAPY TO A PARTICULAR THERAPY TO A PARTICULAR

CHARACTERISTIC OF THE CLIENT* CHARACTERISTIC OF THE CLIENT* continuedcontinued

PRINCIPLES RELATING TO MATCHING PRINCIPLES RELATING TO MATCHING THERAPY TO A PARTICULAR THERAPY TO A PARTICULAR

CHARACTERISTIC OF THE CLIENT* CHARACTERISTIC OF THE CLIENT* continuedcontinued

4.4. Patients with high levels of initial impairment respond Patients with high levels of initial impairment respond better when offered long term, intensive treatment, than better when offered long term, intensive treatment, than when they receive non-intensive and brief treatments, when they receive non-intensive and brief treatments, regardless of the particular model and type of treatment regardless of the particular model and type of treatment assigned. Patients with low impairment, seem to do assigned. Patients with low impairment, seem to do equally well in high and low intensive treatmentsequally well in high and low intensive treatments

5.5. Patients whose personalities are characterized by Patients whose personalities are characterized by impulsivity, social gregariousness, and external blame impulsivity, social gregariousness, and external blame for problems, benefit more from direct behavioral for problems, benefit more from direct behavioral change and symptom reduction efforts, including change and symptom reduction efforts, including building new skills, and managing impulses, than they building new skills, and managing impulses, than they do from procedures that are designed to facilitate insight do from procedures that are designed to facilitate insight and self-awareness.and self-awareness.

6.6. Patients whose personalities are characterized by low Patients whose personalities are characterized by low levels of impulsivity, indecisiveness, self-inspection, levels of impulsivity, indecisiveness, self-inspection, and over control, tend to benefit more from procedures and over control, tend to benefit more from procedures that foster self-understanding, insight, interpersonal that foster self-understanding, insight, interpersonal attachments, and self-esteem, than they do from attachments, and self-esteem, than they do from procedures the aim at directly altering symptoms and procedures the aim at directly altering symptoms and building new social skillsbuilding new social skills

*Beutler et al (2005)*Beutler et al (2005)

4.4. Patients with high levels of initial impairment respond Patients with high levels of initial impairment respond better when offered long term, intensive treatment, than better when offered long term, intensive treatment, than when they receive non-intensive and brief treatments, when they receive non-intensive and brief treatments, regardless of the particular model and type of treatment regardless of the particular model and type of treatment assigned. Patients with low impairment, seem to do assigned. Patients with low impairment, seem to do equally well in high and low intensive treatmentsequally well in high and low intensive treatments

5.5. Patients whose personalities are characterized by Patients whose personalities are characterized by impulsivity, social gregariousness, and external blame impulsivity, social gregariousness, and external blame for problems, benefit more from direct behavioral for problems, benefit more from direct behavioral change and symptom reduction efforts, including change and symptom reduction efforts, including building new skills, and managing impulses, than they building new skills, and managing impulses, than they do from procedures that are designed to facilitate insight do from procedures that are designed to facilitate insight and self-awareness.and self-awareness.

6.6. Patients whose personalities are characterized by low Patients whose personalities are characterized by low levels of impulsivity, indecisiveness, self-inspection, levels of impulsivity, indecisiveness, self-inspection, and over control, tend to benefit more from procedures and over control, tend to benefit more from procedures that foster self-understanding, insight, interpersonal that foster self-understanding, insight, interpersonal attachments, and self-esteem, than they do from attachments, and self-esteem, than they do from procedures the aim at directly altering symptoms and procedures the aim at directly altering symptoms and building new social skillsbuilding new social skills

*Beutler et al (2005)*Beutler et al (2005)1818

PRINCIPLES RELATED TO PRINCIPLES RELATED TO THERAPEUTIC THERAPEUTIC

RELATIONSHIP*…RELATIONSHIP*…

PRINCIPLES RELATED TO PRINCIPLES RELATED TO THERAPEUTIC THERAPEUTIC

RELATIONSHIP*…RELATIONSHIP*…

1.When working with clients with dysphoric disorders, therapists should strive to develop and maintain a positive working alliance with their clients.

2. When conducting group therapy with depressed individuals, therapists should foster a strong level of cohesiveness within the group.

3. Therapists working with depressed individuals should attempt to facilitate their engagement during and between sessions.

4. When working with depressed individuals, therapists should relate to their clients in an empathic way.

5. When adopted by therapists, an attitude of caring, warmth, and acceptance is likely to be helpful in facilitating therapeutic change in depressed clients.

• *Castonguay et al (2005)

1.When working with clients with dysphoric disorders, therapists should strive to develop and maintain a positive working alliance with their clients.

2. When conducting group therapy with depressed individuals, therapists should foster a strong level of cohesiveness within the group.

3. Therapists working with depressed individuals should attempt to facilitate their engagement during and between sessions.

4. When working with depressed individuals, therapists should relate to their clients in an empathic way.

5. When adopted by therapists, an attitude of caring, warmth, and acceptance is likely to be helpful in facilitating therapeutic change in depressed clients.

• *Castonguay et al (2005) 1919

PRINCIPLES RELATED TO PRINCIPLES RELATED TO THERAPEUTIC RELATIONSHIP* THERAPEUTIC RELATIONSHIP*

continuedcontinued

PRINCIPLES RELATED TO PRINCIPLES RELATED TO THERAPEUTIC RELATIONSHIP* THERAPEUTIC RELATIONSHIP*

continuedcontinued6. When working with individuals suffering from depressive

symptoms, therapists are likely to facilitate change when adopting an attitude of congruence or authenticity.

7. Therapists working with depressed individuals may find it helpful to adopt an empathic and nondefensive (or nonrigid) attitude when attempting to repair alliance ruptures.

8. When working with depressed clients, therapists' use of self-disclosure is likely to be helpful. This may be especially the case for reassuring and supportive self-disclosures, as opposed to challenging self-disclosures.

9. When working with depressed clients, therapists should avoid high levels of relational interpretations.

10. When making relational interpretations, therapists should strive to accurately address client's central interpersonal themes, as a high level of accuracy (or quality) with regard to these interpretations is likely to be beneficial for the client.

*Castonguay et al (2005)

6. When working with individuals suffering from depressive symptoms, therapists are likely to facilitate change when adopting an attitude of congruence or authenticity.

7. Therapists working with depressed individuals may find it helpful to adopt an empathic and nondefensive (or nonrigid) attitude when attempting to repair alliance ruptures.

8. When working with depressed clients, therapists' use of self-disclosure is likely to be helpful. This may be especially the case for reassuring and supportive self-disclosures, as opposed to challenging self-disclosures.

9. When working with depressed clients, therapists should avoid high levels of relational interpretations.

10. When making relational interpretations, therapists should strive to accurately address client's central interpersonal themes, as a high level of accuracy (or quality) with regard to these interpretations is likely to be beneficial for the client.

*Castonguay et al (2005)2020

PRINCIPLES RELATED TO PRINCIPLES RELATED TO THERAPEUTIC THERAPEUTIC TECHNIQUES*TECHNIQUES*

PRINCIPLES RELATED TO PRINCIPLES RELATED TO THERAPEUTIC THERAPEUTIC TECHNIQUES*TECHNIQUES*

1. Challenge cognitive appraisals and behavior with new experience.

2. Increase and diversify the patient's access to contingent positive reinforcement for depressive and avoidant behaviors.

3. Improve the patient's interpersonal social functioning.

4. Improve marital, family, and social environment to reduce the establishment, maintenance, or recurrence of depressive behaviors.

5. Improve awareness, acceptance, and regulation of emotion and promote change in maladaptive emotional responses.

1. Challenge cognitive appraisals and behavior with new experience.

2. Increase and diversify the patient's access to contingent positive reinforcement for depressive and avoidant behaviors.

3. Improve the patient's interpersonal social functioning.

4. Improve marital, family, and social environment to reduce the establishment, maintenance, or recurrence of depressive behaviors.

5. Improve awareness, acceptance, and regulation of emotion and promote change in maladaptive emotional responses.

2121

TENTATIVE PRINCIPLES TENTATIVE PRINCIPLES REGARDING PARTICIPANT REGARDING PARTICIPANT

FACTORS*FACTORS*

TENTATIVE PRINCIPLES TENTATIVE PRINCIPLES REGARDING PARTICIPANT REGARDING PARTICIPANT

FACTORS*FACTORS* 1. Research on gender effects is insufficient for

a clear judgment of effects on treatment of depressed patients to be made.

2. Principles related to preference and expectance are not sufficiently well defined to be applied to the clinical treatment of depressed patients.

3. Insufficient research has been conducted on SES to determine if it is a contributor to treatment outcome for depressed patients.

4. Patient stage of change is a promising (but not proven) variable for fitting patient and treatment and for predicting the level of intervention in which to engage the patient.


1. Research on gender effects is insufficient for a clear judgment of effects on treatment of depressed patients to be made.

2. Principles related to preference and expectance are not sufficiently well defined to be applied to the clinical treatment of depressed patients.

3. Insufficient research has been conducted on SES to determine if it is a contributor to treatment outcome for depressed patients.

4. Patient stage of change is a promising (but not proven) variable for fitting patient and treatment and for predicting the level of intervention in which to engage the patient.


2222

TENTATIVE PRINCIPLES TENTATIVE PRINCIPLES RELATED TO THERAPEUTIC RELATED TO THERAPEUTIC

RELATIONSHIP*RELATIONSHIP*

TENTATIVE PRINCIPLES TENTATIVE PRINCIPLES RELATED TO THERAPEUTIC RELATED TO THERAPEUTIC

RELATIONSHIP*RELATIONSHIP*

1. Repairing alliance ruptures that emerge during treatment is likely to be helpful when working with depressed clients.

2. Depressed clients are likely to benefit from receiving feedback from their therapists.

3. When working with depressed clients, therapists are likely to be more effective when they adequately manage their countertransference reactions toward their clients.


1. Repairing alliance ruptures that emerge during treatment is likely to be helpful when working with depressed clients.

2. Depressed clients are likely to benefit from receiving feedback from their therapists.

3. When working with depressed clients, therapists are likely to be more effective when they adequately manage their countertransference reactions toward their clients.


2323

24

Current Developments in Current Developments in Psychotherapy Psychotherapy

IntegrationIntegration

Current Developments in Current Developments in Psychotherapy Psychotherapy

IntegrationIntegration

1)1) Theoretical IntegrationTheoretical Integration

2)2) EclecticismEclecticism

3)3) Common FactorsCommon Factors

4)4) Integrative Approaches for Integrative Approaches for Specific Clinical ProblemsSpecific Clinical Problems

5)5) Improvement of Major Systems Improvement of Major Systems of Psychotherapyof Psychotherapy

1)1) Theoretical IntegrationTheoretical Integration

2)2) EclecticismEclecticism

3)3) Common FactorsCommon Factors

4)4) Integrative Approaches for Integrative Approaches for Specific Clinical ProblemsSpecific Clinical Problems

5)5) Improvement of Major Systems Improvement of Major Systems of Psychotherapyof Psychotherapy

Sequence of Events for Sequence of Events for

Dropouts (Piper et al., 1999Dropouts (Piper et al., 1999))Sequence of Events for Sequence of Events for

Dropouts (Piper et al., 1999Dropouts (Piper et al., 1999))

The patient voiced thoughts about dropping out

The patient expressed frustration The therapist focused on the transference The patient resisted focus on the

transference The therapist persisted A power struggle developed The patient continued to resist The patient reluctantly agreed to return The patient never returned

The patient voiced thoughts about dropping out

The patient expressed frustration The therapist focused on the transference The patient resisted focus on the

transference The therapist persisted A power struggle developed The patient continued to resist The patient reluctantly agreed to return The patient never returned

2525

Technique and relationship in Technique and relationship in Psychodynamic therapy (Schut Psychodynamic therapy (Schut

et al. 2006) et al. 2006)

Technique and relationship in Technique and relationship in Psychodynamic therapy (Schut Psychodynamic therapy (Schut

et al. 2006) et al. 2006)

Interpretation Disaffiliative processes Interpretation and disaffiliative

processes

Interpretation Disaffiliative processes Interpretation and disaffiliative

processes

2626

Integrative Cognitive Therapy Integrative Cognitive Therapy (Castonguay et al., 2004)(Castonguay et al., 2004)

Integrative Cognitive Therapy Integrative Cognitive Therapy (Castonguay et al., 2004)(Castonguay et al., 2004)

CT manual (Beck et al., 1979)

Identification of alliance ruptures– Empathy scale (Burns, 1990)– Markers of ruptures (Safran & Segal,

1990)

Strategies to repair alliance ruptures (Burns. 1990; Safran & Segal, 1990)– Invitation to explore ruptures– Empathic response– Disarming

CT manual (Beck et al., 1979)

Identification of alliance ruptures– Empathy scale (Burns, 1990)– Markers of ruptures (Safran & Segal,

1990)

Strategies to repair alliance ruptures (Burns. 1990; Safran & Segal, 1990)– Invitation to explore ruptures– Empathic response– Disarming

2727

Table 1. Symptomatic Measures at Pre- and Post-test

ICT WL CT-NIMH

n M SD n M SD n M SD

BDI

Pre-test 11 27.36 4.34 10 27.50 5.28 37 26.8 8.4

Post-test 11 4.82 3.66 10 17.50 8.80 37 10.81 11.94

HDRS

Pre-test 11 15.00 4.40 10 18.00 2.66 37 19.2 3.6

Post-test 11 4.05 2.53 10 11.70 5.89 37 7.81 6.80

GAF

Pre-test 11 53.09 7.01 10 54.20 5.73 37 52.8 7.2

Post-test 11 78.36 8.91 10 67.20 15.11 37 69.19 12.04

Note: ICT: Integrative Cognitive Therapy; WL= Waiting List condition; CT-NIMH: Cognitive

Therapy Condition of the NIMH Collaborative Study; ICT post WL: Group of participants who

received ICT after completing WL and meeting study’s inclusion criteria before beginning

treatment.

2929

30

CBT for GADCBT for GAD

More efficacious than no treatment, More efficacious than no treatment, analytic psychotherapy, pill placebo, analytic psychotherapy, pill placebo, nondirective therapy, and placebo nondirective therapy, and placebo therapytherapy (Borkovec & Ruscio, 2001) (Borkovec & Ruscio, 2001)

Smallest percentage of high endstate Smallest percentage of high endstate functioning compared to other anxiety functioning compared to other anxiety disordersdisorders (Brown, Barlow & Liebowitz, (Brown, Barlow & Liebowitz, 1994)1994)

Alternatives?Alternatives?

CBT for GADCBT for GAD

More efficacious than no treatment, More efficacious than no treatment, analytic psychotherapy, pill placebo, analytic psychotherapy, pill placebo, nondirective therapy, and placebo nondirective therapy, and placebo therapytherapy (Borkovec & Ruscio, 2001) (Borkovec & Ruscio, 2001)

Smallest percentage of high endstate Smallest percentage of high endstate functioning compared to other anxiety functioning compared to other anxiety disordersdisorders (Brown, Barlow & Liebowitz, (Brown, Barlow & Liebowitz, 1994)1994)

Alternatives?Alternatives?

Rationale for adding Rationale for adding I/EP to CBTI/EP to CBT

Rationale for adding Rationale for adding I/EP to CBTI/EP to CBT

Applied and basic research has Applied and basic research has suggested that a focus on dimensions of suggested that a focus on dimensions of functioning that are not typically or functioning that are not typically or appropriately addressed by CBT may appropriately addressed by CBT may improve treatment efficacy with GAD:improve treatment efficacy with GAD:

Interpersonal IssuesInterpersonal Issuesa)a) Interpersonal ProblemsInterpersonal Problems

b)b) Developmental ProblemsDevelopmental Problems

c)c) Problems in the therapeutic Problems in the therapeutic relationshiprelationship

Emotional IssuesEmotional Issues

Applied and basic research has Applied and basic research has suggested that a focus on dimensions of suggested that a focus on dimensions of functioning that are not typically or functioning that are not typically or appropriately addressed by CBT may appropriately addressed by CBT may improve treatment efficacy with GAD:improve treatment efficacy with GAD:

Interpersonal IssuesInterpersonal Issuesa)a) Interpersonal ProblemsInterpersonal Problems

b)b) Developmental ProblemsDevelopmental Problems

c)c) Problems in the therapeutic Problems in the therapeutic relationshiprelationship

Emotional IssuesEmotional Issues

3131

32

Current GAD CBT Current GAD CBT protocols fail to address protocols fail to address emotion avoidance and emotion avoidance and interpersonal problemsinterpersonal problems

Current GAD CBT Current GAD CBT protocols fail to address protocols fail to address emotion avoidance and emotion avoidance and interpersonal problemsinterpersonal problems

Reflective listening significantly superior to CBT on depth of emotional processing (Borkovec & Costello, 1993)

CBT failed to make a significant change in 6 of 8 IIP-C scales (Borkovec, Newman, Lytle, & Pincus, 2002)

Interpersonal problems not successfully treated by CBT at post-assessment were predictive of failure to maintain follow-up gains (Borkovec et al., 2002)

Reflective listening significantly superior to CBT on depth of emotional processing (Borkovec & Costello, 1993)

CBT failed to make a significant change in 6 of 8 IIP-C scales (Borkovec, Newman, Lytle, & Pincus, 2002)

Interpersonal problems not successfully treated by CBT at post-assessment were predictive of failure to maintain follow-up gains (Borkovec et al., 2002)

33

PI>CBT process featuresPI>CBT process featuresBlagys & Hilsenroth (2000)Blagys & Hilsenroth (2000)PI>CBT process featuresPI>CBT process features

Blagys & Hilsenroth (2000)Blagys & Hilsenroth (2000)

Focus on affect and expression of emotions

Exploration of avoidance or hindering of treatment progress

Identification of patterns (actions, thoughts, feelings, relationship)

Emphasis on past experience Focus on interpersonal experience Emphasis on therapeutic relationship Exploration of wishes, dreams or

fantasies

Focus on affect and expression of emotions

Exploration of avoidance or hindering of treatment progress

Identification of patterns (actions, thoughts, feelings, relationship)

Emphasis on past experience Focus on interpersonal experience Emphasis on therapeutic relationship Exploration of wishes, dreams or

fantasies

34

Jones & Pulos (1993) Jones & Pulos (1993) Psychodynamic Techniques Psychodynamic Techniques

Factors Factors

Jones & Pulos (1993) Jones & Pulos (1993) Psychodynamic Techniques Psychodynamic Techniques

Factors Factors T emphasizes P feelings to help him/her experience

them more deeply T is neutral T interprets warded-off unconscious wishes, feelings,

or ideas T points out P’s use of defensive maneuvers P feelings or perceptions are linked to situations or

behaviors of the past T draws attention to feelings regarded by P as

unacceptable Memories or reconstruction of infancy and childhood

are topics of discussion T draws connections between therapeutic relationship

and other relationships P’s behavior during the hour is reformulated by T in a

way not explicitly recognized T identifies a recurrent theme in P experience or

conduct

T emphasizes P feelings to help him/her experience them more deeply

T is neutral T interprets warded-off unconscious wishes, feelings,

or ideas T points out P’s use of defensive maneuvers P feelings or perceptions are linked to situations or

behaviors of the past T draws attention to feelings regarded by P as

unacceptable Memories or reconstruction of infancy and childhood

are topics of discussion T draws connections between therapeutic relationship

and other relationships P’s behavior during the hour is reformulated by T in a

way not explicitly recognized T identifies a recurrent theme in P experience or

conduct

35

Integrative Treatment for GADIntegrative Treatment for GAD

GAD IV: CBT + I/EPGAD IV: CBT + I/EP

GAD V: CBT + I/EP VS CBT + SLGAD V: CBT + I/EP VS CBT + SL

Integrative Treatment for GADIntegrative Treatment for GAD

GAD IV: CBT + I/EPGAD IV: CBT + I/EP

GAD V: CBT + I/EP VS CBT + SLGAD V: CBT + I/EP VS CBT + SL

36

GAD IVGAD IVNewman, Castonguay, Borkovec, Newman, Castonguay, Borkovec,

Fisher, Nordberg, 2007Fisher, Nordberg, 2007

GAD IVGAD IVNewman, Castonguay, Borkovec, Newman, Castonguay, Borkovec,

Fisher, Nordberg, 2007Fisher, Nordberg, 2007

37

Therapy Therapy ConditionCondition

Post-Post-TherapyTherapy

Follow-upFollow-up

Extant Extant GAD GAD Outcome Outcome StudiesStudies

(N = 11)(N = 11)

2.482.48 2.442.44

GAD IIIGAD III CTCT 2.942.94 2.482.48SCDSCD 2.382.38 2.432.43CBTCBT 2.802.80 2.432.43

GADIVGADIV

CBT/IEPCBT/IEP 3.153.15 3.563.56

Average Within-Group Effect Sizes at Average Within-Group Effect Sizes at Post-Therapy and Follow-up for Post-Therapy and Follow-up for

Commonly Used Measures of Anxiety Commonly Used Measures of Anxiety (Assessor Severity Rating, Hamilton (Assessor Severity Rating, Hamilton Anxiety, Stai-Trait) and Depression Anxiety, Stai-Trait) and Depression

(Hamilton Depression and Beck (Hamilton Depression and Beck Depression Inventory)Depression Inventory)

38

GAD VGAD VNewman, Castonguay, Newman, Castonguay,

Fisher, & Borkovec, 2008Fisher, & Borkovec, 2008

GAD VGAD VNewman, Castonguay, Newman, Castonguay,

Fisher, & Borkovec, 2008Fisher, & Borkovec, 2008

39


Results highlight the importance of long-term follow-up assessments

Our data replicate studies showing different Attachment profiles in GAD

Suggests that one theory to describe GAD functioning and one treatment for all people with GAD may not be optimal

Future studies should examine whether assignment to therapy based on pre-treatment attachment profile leads to better outcome

40


People with Enmeshment attachment Profile:

Tend to be overemotional and disregarding of cognitions

Tend to be interpersonally unable to extract self from others

People with a Dismissing/Derogating attachment profile :

Tend to be emotionally avoidant and overly cognitive

Tend to be interpersonally overly autonomous and believe can’t depend on anyone but themselves

New directions to New directions to improve the fieldimprove the fieldNew directions to New directions to improve the fieldimprove the field

Integrating practice and research Integrating theoretical perspectives Integrating research domains

Integrating practice and research Integrating theoretical perspectives Integrating research domains

4141

Integrating research Integrating research domainsdomains

Integrating research Integrating research domainsdomains

Bringing psychopathology and psychotherapy research together (Castonguay & Oltmanns, in preparation)

Deriving clinical guidelines (assessment foci and principles of change) from basic research

Improving case formulations and treatment plans based on empirical information that cut across theoretical orientations

Bringing psychopathology and psychotherapy research together (Castonguay & Oltmanns, in preparation)

Deriving clinical guidelines (assessment foci and principles of change) from basic research

Improving case formulations and treatment plans based on empirical information that cut across theoretical orientations

4242

what is evidence-based practice? louis castonguay the pennsylvania state university ca-spr montreal...

Documents

common principles

therapeutic principles

principles of change

remaining principles

working principles

strategy of joint task

treatment factors

previous task force