CHANGE PROCESS RESEARCH: REFLECTING ABOUT THE STATE OF THE ART João Salgado University Institute of Maia, Portugal Contact: jsalgado@ismai.pt Keynote address Jyväskylä - 12.2.2015 Aims To briefly present my personal perspective upon the state of the art in the area of process- outcome research What do we know about the change processes? More specifically, what does research has to tell us about that? What is my reaction to that state of affairs? To suggest an ambitious agenda to the field of change process research 2 1
15/02/18 Rationalism A personal note: An inner division Empiricism The School of Athens Raphael (1509-1511. Vatican City) 3 Knowledge is constrained by a specific observational stance or paradigm. Creative science involves recombination of elements in new gestalts TEN SIO N Knowledge can be obtained by observation. Analytical effort decomposing phenomena in simpler units (atomization) 4 2
We need more empirical support for our practices Randomized Clinical Trials More sophisticated measurements We need better and more comprehensive theories. Qualitative Understanding 5 But what happens when we look at psychotherapy research? Dominant voice: Outcome quantitative studies RCTs as the golden rule; outcome studies; a great distance between theory and empirical observations Dominated voice: Change process studies Qualitative studies; case studies; idiographic studies 6 3
The paradigmatic case of depression Empirically- supported treatments (APA Division 12) Behavior Therapy/Behavioral Activation (strong research support) Cognitive Therapy (strong research support) Cognitive Behavioral Analysis System of Psychotherapy (strong research support) Interpersonal Therapy (strong research support) Problem- Solving Therapy (strong research support) Self- Management/Self- Control Therapy (strong research support) Acceptance and Commitment Therapy (modest research support) Behavioral Couple Therapy (modest research support) Emotion- Focused Therapy (Process- Experiential) (modest research support) Rational Emotive Behavioral Therapy (modest research support) Reminiscence/Life Review Therapy (modest research support) Self- System Therapy (modest research support) Short- Term Psychodynamic Therapy (modest research support) 7 The end of history in the treatment of depression? Have we reached the "End of History in the treatment of Depression? "We have enough treatments" Diversity is an illusion and "branding" ("models are superimposed"): differences are elusive 8 4
We still need to address several issues Very high rates of relapse and non- response to treatment of MDD The need to validate and consolidate promising treatment protocols (e.g. Narrative Therapy) Creating larger support for therapies (eg, EFT) The need to reduce the risk of false variety of treatments And 9 Kazdin s provocation Meta- analyses and narrative reviews of well- controlled studies have indicated that many forms of psychotherapy for children, adolescents, and adults lead to therapeutic change (e.g., Kazdin & Weisz, 2003; Lambert, 2004; Nathan & Gorman, 2007). Multiple questions remain, including the extent and indeed whether many treatments make a palpable difference in the lives of those treated, whether some treatments are more effective than others, and how we can harness the many factors that influence outcome. Arguably the most pressing question is how therapy leads to change. Currently, we do not know the reasons, although many ideas have been proposed. (p. 1) 10 5
We need to understand how psychotherapy works We need change process research Some usual terms Process research: what happens in therapy Process- outcome research: what happens in therapy and how is this related to outcome (post- session; post- treatment) Change process research: Term coined by L. S. Greenberg (1986) identifying, describing, explaining, and predicting the effects of the processes that bring about therapeutic change (Greenberg, 1986, p. 4) Not only if there is a causal connection between intervention and outcome, but also the nature of its connection One treatment may be effective based on a misattribution of effectiveness to the wrong components. 12 6
Process- outcome research A very brief overview 13 Some terminological distinctions (Doss, 2004; Crits- Christoph et al., 2013) Mechanisms of change: Changes occurring wthin the client along the process Intermediate outcomes? Short- term outcomes or mechanisms of change? E.g. Insight Processes of change: Psychotherapy related events E.g. client- therapist interaction; homework 14 7
Why not a full review? Orlinsky et al. (2004) review found more than 2000 process- outcome studies! Nowadays, the situation would be tremendously more complex Recent reviews of process- outcome are much more focused on specific topics The most pressing questions are related with change processes and mechanisms in different kinds of psychotherapy: What are the processes and mechanisms of change created by THIS therapy with THIS clinical condition (for THIS group of patients)? 15 The golden rule for process- outcome research (nowadays) Testing mediation models lodged in experimental designs (Kazdin, 2009): To determine if there is a certain process- variable mediates the effect of therapy 16 8
An utopia? Until recently, there was NO study complying with all the necessary rules This type of design is difficult to achieve Negative findings usually are not published There are some (few) studies now (mainly studies on the therapeutic alliance) Other problems: Most of these studies are not experimental 17 Usual problems in process- outcome research Moreover, recent in- depth reviews conclude that the vast majority of studies does not solve adequately key design problems (Crits- Christoph et al. 2013): 1. Dependability of the process measure: refers to the adequacy of generalizing over sampling units (e.g., sessions, patients, therapists) to the universe of such units from which the samples were selected. inadequate sampling of sessions might provide misleading results 18 9
Design problems (2) 2. Correlational design vs causal inference is there any control of 3 rd variables? And time precedence (i.e., does the process variable occur before the outcome variable?) 19 Design problems (3) 3. Therapist and patient responsiveness: Increasing a specific technique because the client needs it more, but not improving enough to be a good outcome case might create a zero or negative correlation between outcome and this specific technique Frequency vs. Quality and quality is less affected by responsiveness 20 10
Design problems (4) 4.Dyadic (at least) interaction implies multilevel analysis, with clients being nested in therapists. Multilevel modelling statistics as possible solutions (e.g. HLM) 21 Design problems (5) 5. Does the design allows for the assessment of whether the effects are specific to a particular form of psychotherapy: E.g. Cognitive therapy reduces depressogenic thoughts? And this is related with outcome? And other forms of therapy do not reduce depressogenic thoughts? 22 11
Main findings of one in- depth review of Behavioural, Cognitive, Psychodynamic and Experiential Process- outcome research The strongest conclusion that can be made from the large body of process- outcome studies is that the alliance is an important aspect of outcome across a range of psychotherapies. In anxiety disorders, exposure- based behavioural therapy seems to be an essential ingredient (good support) Some concrete cognitive techniques (e.. Reviewing homework) seems to be associated with good outcome in the treatment of depression (some support, needs further research) Gains in self- understanding lead to improvements in symptoms in psychodynamic therapy (some support, needs further research) (Crits- Christoph et al. 2013) 23 The case of Major Depression and CBT Change process: Webb et al. (2010): Correlation between scales of adherence and expertise with outcome: approximately zero! Crits- Christoph et al. (2013): Detailed review of some studies found a positive relationship between competence and outcome Change mechanisms: Garrat, Ingram, Rand & Sawalani (2007): review of 31 studies General support for a positive association between cognitive change and symptom change Crits- Cristoph et al (2013): new studies further support that CT and pharmacotherapy deactivate depresogenic thoughts However, only one study identifies cognitive change as distinctive of the CT (Quilty et al., 2008) 24 12
Cognitive Therapy Good outcome Cognitive therapy Cognitive change Competence or adherence to CT Mixed results- maybe Other therapies Cognitive change A somewhat surprising conclusion Is is somewhat surprising that, despite the widespread influence of Cognitive Therapy (CT) for Major Depression Disorder (MDD) and the relatively large number of outcome studies that have been conducted to date on this treatment, that more and better studies of techniques used in CT for MDD in relation to outcome have not been conducted. Much more research is needed to determine whether the specific techniques of CT are responsible for symptom change in the treatment of MDD And for what? To determine mediators (Crits- Cristoph et al., 2013, p. 317) 13
An important note about mediation a mediator may not and usually is not intended to explain precisely how the change comes about. Also, the mediator could be a proxy for one or more other variables or be a general construct that is not necessarily intended to explain the mechanisms of change. A mediator may be a guide that points to possible mechanisms but is not necessarily a mechanism. (Kazdin, 2009, p. 5) But then how to find mechanisms? 28 14
A critical reflection upon this state of affairs Partially, the problem lies in the research strategy Atomistic:it divides phenomena in simpler units Mechanistic: it assesses how each unit is associated with other units Linear causation: it infers causation based on the relation between units/variables 29 A critical reflection upon this state of affairs (2) However, this might be a violation of some of the governing principles of the phenomena itself. The (dialogical/responsive) human mind: Has a complex multi- layered organization governing the interaction between elements Might have some free will and agency simpler elements (such as single thoughts or emotions) are probably governed by higher- order processes Implies meaning- making processes of semiosis that surpass mechanic accounts. 30 15
Jarl Whalstrom s analogy Psychotherapy and the wine We need to know the basic processes underlying clinical problems and change We need to have a science of the human mind Psychotherapy as an art to be informed by science and understanding Wine - - - Biochemistry Psychotherapy - - - Psychology 31 A possible challenge for psychotherapy research (trying to integrate my inner division) Psychotherapy research (and maybe, psychological research) needs to be lodge in a strong comprehensive model of the human mind Some available promising models: cultural, semiotic approach from J. Valsiner; dialogical approaches Bottom- up research needs to be compensated with top- down research, theoretically- driven Theories need to address general psychological processes and break down old barriers and old schools, encompassing affective/ emotional, cognitive, behavioural, and relational dimensions of the human mind We need different communities of researchers doing different things (quantitative, quantitative; sample- based research, case analysis; ); but this can be integrated in a wider framework 32 16
Remembering Gregory Bateson Meaning is constrained by a specific frame/context. There is no meaning without a context The atomistic framework/context traps us in old riddles This is (or may be) an opportunity to create an adequate context of dialogue between opposing forces within an integrative field, based on a comprehensive model of the human mind 33 Kiitos! 34 17