1、Improving CBT:Problems and Prospects G.Terence Wilson,Ph.D.Evidence-Based PracticeObstacles to Evidence-Based Treatment Two classes of obstacles:misconceptions about“evidence”and the applicability of research findings to clinical practice gaps in our current knowledge about treatments,mechanisms of
2、change,and reliable means of training competent practitioners (Shafran et al.,BRAT 2009)Problems with Clinical Judgement“Although this desire to tailor treatments to individual needs has face validity,it may be misguided.Reliance on clinical judgment is at odds with a body of research on clinical ve
3、rsus actuarial prediction indicating that,on the whole,actuarial methods are superior”(von Ranson&Robinson,2006)Problems with Clinical Judgement“In predicting behavior,highly trained clinical experts who assess all available information,and integrate it based on their own understanding of the detail
4、s of the individual case,do no better and usually worse than actuarial prediction”(Dawes,Faust,&Meehl,1989)Problems with Clinical Judgement Therapists may choose components of evidence-based treatment protocols based on“clinical experience,”subjective preference or ease of administration,hence omitt
5、ing or diluting what may be the most effective therapeutic elements(von Ranson&Robinson,2006;Waller,2009)Given free reign,even behavior therapists do not always use exposure in treating anxiety/phobic disorders(Becker et al.,2004;Schulte et al.,1995)Limitations of Clinical Judgement It is precisely
6、these limitations in decision making and case formulation,so well documented,that necessitate treatment guidelines(Dawes,1994;Wilson,1996)What Type of Clinical Judgement?Addressing patient non-response to treatment,and possibly revising the treatment formulation,requires clinical judgment Not subjec
7、tive clinical judgment based primarily on the therapists experience,but evidence-based judgment within the overall framework of CBT and in accordance with guidelines that are part of the treatment protocol e.g.,“taking stock”early(and possibly revamping the treatment plan)is a required feature of CB
8、T-E for eating disorders(Fairburn,2008)Competent manual-based therapy“.Two core skills are required:first,ensuring that patients remain engaged in the treatment and maintaining their motivation to change;and second,implementing and individualising the treatments strategies and procedures.Neither is
9、straightforward“(Fairburn,2010)Best Available Evidence?A scientifically-based approach to treatment must differentiate between types of evidence,and assign primary value to empirical research(i.e.,RCTs)APA scheme does not assign priority value to empirical research in clinical decision makingNICE Gu
10、idelines“.where sufficient evidence exists to allow general recommendation,the best practice must be to implement the treatment that enjoys the most empirical support rather than invoke subjective judgment”(Wilson&Shafran,2005-Lancet)Which Evidence-based Treatment?Selection criteria should include(a
11、mong others):Enduring effects Robust effects broadly applicable,generalized effects Brevity rapid response Cost-effectivenessTherapies or Therapists?It has been claimed that the evidence does not demonstrate the superiority of specific interventions,and that therapist effects may be more important t
12、han the therapyCBT treatment administered by competent therapists Typically few therapist effects in well-conducted RCTs showing superiority of one treatment over another Unsurprisingly,studies of weaker treatments without manuals have shown therapist effects(Crits-Christoph&Mintz,1991)Therapeutic r
13、elationship does not mediate outcomeEmpirically-supported treatments administered by competent therapists Therapists obtain better results as they become more competent in cognitive therapy(DeRubeis et al.,2005)Less experienced therapists using evidence-based treatment more effective than“expert”the
14、rapists using their preferred(non-CBT/DBT)approach(Linehan et al.,2006)Towards Developing More Effective TherapyTreatment Research PrioritiesIn evidence-based treatments,identify:1.Non-specific predictors of outcome(who is“treatment-resistant”?)2.Moderators of treatment effects(what works for whom u
15、nder what conditions?)3.Necessary and sufficient procedural components of effectiveness4.Mechanisms of change5.Treatment integrity6.Dissemination and implementation The Treatment Outcome Research Question“What treatment,by whom,is most effective for this individual with that specific problem,under w
16、hich set of circumstances”Gordon Paul(1967)ModeratorsImportance of Moderators Practitioners understandably want to know if a specific treatment is the most effective for an individual patient in particular?“personalized medicine”(Insel,2009)Importance of ModeratorsYet this is an unanswerable questio
17、n:“the best science can do is provide evidence for how well a given treatment works for a study population that shares with a given patient the same characteristics pertinent to the success of the treatment”(Kraemer,Kupfer,&Frank,2006,JAMA)BA versus CTDesign BA vs.CT vs.Meds in placebo-controlled RC
18、TResults BA at least as effective as meds;both significantly outperformed CT with severely depressed patientsDimidjian et al.(JCCP,2006)Implications for Clinical Practice“more difficult patients may benefit from sustained focus on more limited goals.Using fewer intervention strategies and targeting
19、fewer areas of change could accomplish this”Coffman et al.(2007)Identifying necessary and sufficient procedural components of treatments e.g.,treatment of depression Jacobson et al.(1996)dismantling study early response findings(Ilardi&Craighead,1994)Becks CT:A Component Analysis Implications:major
20、challenge to the cognitive theory of CT development of BA into a therapy in its own right a functional analytic treatment grounded in contextualism(Martell,Addis,&Jacobson,2001)BA is“clearly easier to teach and easier to learn than cognitive therapy”(Hollon,2001)Early Response to CBT Manual-based CB
21、T produces much of its success within the first 4 8 sessions of treatment(Ilardi&Craighead,1994;Wilson,1999)This robust finding has important theoretical,methodological,and practical implications Innovation Evidence:manual-based treatments have encouraged testing of therapies,spurred theoretical deb
22、ate,and facilitated practical innovationsIdentifying mechanisms of change Active therapeutic components can be intensified and refined;inactive or redundant ingredients eliminated Results in more effective and efficient treatment May allow more efficient(and effective?)treatment of comorbid disorder
23、s (Craske et al.,2007;Kazdin&Weisz,1998;Kraemer et al.,2002)Mechanism-based Treatment?Single targeted treatment yields more positive influences on co-occurring disorders than multiple targeted treatments Effects on co-occurring disorders may be mediated by success in lessening fears of bodily sensat
24、ions Craske et al.(2007)Improving CBT?Combine with other treatments need to identify mechanisms of change in order to usefully“integrate”different treatments failed(to date)but endlessly popular goal of“integrating”different psychological therapies inconsistent effects of combining CBT with antidepr
25、essant meds D-cycloserine and exposure treatmentTreatment Integrity Treatment integrity has 2 components:a)adherence to the protocol;and b)therapist competence systematic evaluations of this critically important aspect of treatment studies have been“extremely rare”(Perepletchikova et al.,2007)Compli
26、cates if not makes impossible interpretation of research studies Hinders dissemination of effective treatmentsGeneralizability of Research Findings Clinical trials can be representative of the usual clinical population Mounting evidence that the results of RCTs can,and do,generalize to routine clini
27、cal practice in different settings Research on generalizability remains a priority Dissemination and ImplementationDissemination Clear evidence that patients are not receiving empirically-supported treatments in routine clinical care Even when patients do receive these treatments there is evidence t
28、hat they are often not well-delivered Barriers to Dissemination and Implementation Clinicians are increasingly eager to learn we have failed them to date Need to identify and assess competency levels required for therapists to implement empirically-supported treatments effectively Need to improve tr
29、aining methods and supervisionDoes CBT Pose Particular Problems for Dissemination?Yes Technical expertise required Complex treatment strategies/packages Need to combine technical expertise with relationship skills blending focus(structure of manual)with flexibilityCan Less be More?Less complex treat
30、ments may be more easily disseminated Reduced training requirements for less complex treatment BA for depression(Dimidjian et al.,2006)PE for PTSD(Foa et al.,2005)CBTgsh for Binge Eating Disorder(Wilson et al.,2010)Barriers to Dissemination Problem:“Too many multi-component manuals designed to treat
31、 ever-expanding array of topographically defined syndromes”“such a brute force empirical approach makes it increasingly difficult to teach what is known or to focus on what is essential”Hayes et al.(BRAT,2006)Transdiagnostic CBT Transdiagnostic treatments may maximize the benefits of both fidelity a
32、nd adaptation by treating similar disorders using interventions that may target underlying processes they offer greater flexibility in the pacing and content of treatment while still providing structure (Craske et al.,2009;Fairburn,2008;McHugh et al.,2009)Partnering with Practitioners“Clinicians do
33、not want to be disseminated on.”(Westen et al.,2005)Can we adopt a“collaborative,cyclical and iterative process”between researchers and practitioners?(Becker et al.,BRAT 2009)Partnering with Practitioners Can we allow/encourage local adaptation of research-based treatments and thereby improve adoption without losing effectiveness?“where are the bounds of flexibility before effectiveness is compromised?”(Proctor et al.,2009)
