Caveats. Advancing psychotherapy via clinical and non-clinical science. ICEEFT San Diego October 2017

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1 Advancing psychotherapy via clinical and non-clinical science ICEEFT San Diego October 2017 Louis G. Castonguay The Pennsylvania State University Caveats North American perspective Theoretical and epistemological assumptions CBT and RCT Building on convergences and complementary across theories, domains, expertise Improving effectiveness without always requiring drastic change in practice Improving practice by integrating two types of research: evidence based and practice oriented 2 HOW RESEARCH CAN BE USE TO EXPAND OUR CLINICAL REPERTOIRE Empirically Supported Treatments (EST) and Potentially Harmful Treatments (PHT): First lines of attack (FLA) and warning signals (WS) for some clients - Depression: Good news and bad news Empirically based guidelines: Modifying, expending, and adding to FLA and WS - Principles of change - Psychopathology findings - Process research and outcome research Practice-oriented research: Complementing evidence based practice

2 Principles of Change: Building on Theoretical connections APA & NASPR Task Force (Castonguay & Beutler 2005) Domains: -Client characteristics -Relationship variables -Techniques variable Problems: -Depression -Anxiety -Personality Disorders -Substance Use Disorders Principles Related to Participant Factors in Treating Anxiety Disorders Newman et coll. (2005) 1. Psychotherapy for anxiety is less likely to be successful if the client experiences high level of functional impairment (e.g., severity, distress, axis I comorbidity, interpersonal problems, social support perceived as critical) 2. Psychotherapy for anxiety is less likely to be successful if the client has negative perceived parenting. Principles Related to Relationship Variables in Treating Depression. Castonguay et coll. (2005) 1. When working with depressed clients, therapist s use of self disclosure is likely to be helpful. This may be particularly the case for reassuring and supportive selfdisclosure, as opposed to challenging self-disclosures. 2. When working with depressed clients, therapists should strive to develop and maintain a positive working alliance with their clients.

3 Alliance: What do we know? Castonguay, Constantino, & Grosse Holtforth (2006) - It predicts outcome across several orientations - It is predicted by client s characteristics and behaviors - It correlates with therapist s characteristics and behaviors - It predictive when measured early in therapy - It is at least as predictive when measured by the client than when measured by the therapist Principles Related to Technique in Depression Follette & Greenberg (2005) 1. Challenge cognitive appraisals and behavior with new experience. 2. Increase and diversify the patient's access to reinforcements to increase behavioral activation and decrease 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. Principles Related to Deterioration Castonguay et al., (2010) Prevent and repair toxic relational and technical processes Help trainee become aware of instances where inflexible adherence to techniques threatens the alliance. He/she should be trained to use potentially helpful interventions in a clinically flexible and sensible way Treatment choice, implementation, and expectation should be adjusted to client Help trainee be aware that clients with high levels of reactance are not likely to benefit from directive forms of therapy, and that clients with low levels of reactance are not likely to benefit from non-directive treatments

4 Principles Related to Deterioration Castonguay et al., (2010) Some therapists may be better than others Help trainee increase self-awareness of their hostility toward him/herself and potentially steer toward own personal psychotherapy HOW EVIDENCE BASED RESEARCH CAN EXPAND OUR CLINICAL REPERTOIRE Empirically based guidelines: Modifying, expending, and adding to FLA and WS - Principles of change - Psychopathology findings - Process research and outcome research Practice-oriented research: Complementing evidence based practice Psychopathology: Building on Connections of Research Domains - Psychopathology research can tell us what to change, psychotherapy research can tell us how to change it (Arkowitz, 1990) - Clinical implications of research on symptoms, clinical features, epidemiology, course, comorbidity, and etiology

5 Integrating Research Domains Psychopathology of Depression Symptomatology: Psychomotor change (Buchwald & Rudick-Davis, 1993) Clinical features: Anger and lack of cooperation (Joiner, 2002) Epidemiology: Prevalence (Seligman, 1989) Gender (Nolen-Hoeksema, 1987) Principles Related to Technique in Depression Follette & Greenberg (2005) 1. Challenge cognitive appraisals and behavior with new experience. 2. Increase and diversify the patient's access to reinforcements to increase behavioral activation and decrease avoidant behaviors. 1. Improve the patient's interpersonal social functioning. 2. Improve marital, family, and social environment to reduce the establishment, maintenance, or recurrence of depressive behaviors. 3. Improve awareness, acceptance, and regulation of emotion and promote change in maladaptive emotional responses. Integrating Research Domains Psychopathology of Depression Etiology: Cognitive inhibitions (Joormann et al., 2007) Reappraisal of negative events Emotional disclosure Distraction Parental neglect/abuse and insecure attachment Therapeutic relationship as corrective experience Exploration of early relationship events Stress and stress regulation strategies Interpersonal styles

6 Integrating Research Domains Psychopathology of BP Risk factors: Medication adherence Depression symptoms Negative life events, perceived low social support, EE Negative cognitive styles Manic symptoms Goal dysregulation Schedule disruption Integrating Research Domains Psychopathology of BP Principles of change: Improve awareness of symptoms Increase motivation for medication adherenc Increase treatment engagement Reduce risk factors for episodes Promote regulation of sleep and activities Address overly ambitious goals Address maladative thoughts Address interpersonal stress and social isolation Integrating Research Domains Psychopathology: From Science to Clinical Practice (Castonguay & Oltmanns, 2013)

7 Integrating Research Domains Pairs of scholars from psychopathology and psychotherapy research Deriving clinical guidelines based on empirical information that can be relevant to most if not all orientations, in terms of assessment, case formulation, and treatment planification These two lines of research suggest EBP does not have to imply radical change EBP should include RCT EBP should not be restricted to RCT Other lines of research Psychotherapy: Bringing Psychotherapy Research to Life: Understanding Change through the work of leading clinical researchers (Castonguay, Muran, Angus, Hayes, Ladany, & Anderson, 2010) Visions in Psychotherapy Research and Practice (Strauss, Barber, & Castonguay, 2015) Basic Research: Constantino & Castonguay (2003)

8 HOW EVIDENCE BASED RESEARCH CAN EXPAND OUR CLINICAL REPERTOIRE Empirically based guidelines: Modifying, expending, and adding to FLA and WS - Principles of change - Psychopathology findings - Process research and outcome research -Unique variables - Common factors - Faux unique variables Practice-oriented research: Complementing evidence based practice Findings supporting CBT model Homework (Burns & Nolen-Hoeksema, 1991) Specific CT techniques (DeRubeis & Feeley, 1990), including homework & self monitoring Cognitive changes (Garratt et al., 2007, Ingram, 2007), e.g., prior to sudden gains (Tang & DeRubeis, 1999) Compensatory skills (Barber & DeRubeis, 2001; Strunk et al., 2007) Exposure (Foa et al., 2006) Inconsistent findings with CBT model Lack of correlation with outcome Adherence and competence Webb, DeRubeis, Baber, 2010 Negative correlation with outcome Hayes, Castonguay & Goldfried, 1996 Castonguay, et al., 1996 Boswell, Castonguay & Wiserman, 2010

9 Rigid Adherence in Cognitive Therapy Castonguay et al. (1996) Therapist used prescribed interventions! Client was reluctant to accept or engage in procedures! Therapist increased focus on rationale or procedures! Further client disagreement or non-responsiveness Rigid Adherence in Psychodynamic Therapy Piper et al. (1999) The patient voiced thoughts about dropping out and expressed frustration! The therapist focused on the transference! The patient resisted focus on the transference! The therapist persisted! The patient continued to resist! The patient reluctantly agreed to return! The patient never returned Technique and Relationship in Psychodynamic Therapy Schut, Castonguay, et al. (2006) - Interpretation - Disaffiliative processes - Interpretation and disaffiliative processes

10 These results do not indicate that techniques are detrimental They do suggest that we build and expand upon our conceptual models of change Interaction of participant, relationship, and technical variables Common factors Faux unique variables Basic Findings 28 Common Factors Relationship variables (Norcross, 2012) Common Factors are not Non-specific variables (Castonguay, 1993) They can be specified They are not restricted to relationship variables Goldfried s 5 principles of change 29 The Penn State Conferences on the process of change in psychotherapy: Building on Theoretical connections Insight or the acquisition of a new perspective of self (Castonguay & Hill, 2005) Corrective experiences (Castonguay & Hill, 2012)

11 The Penn State Conferences on the process of change in psychotherapy Conceptual clarification New quantitative and qualitative studies Consensus Insight or the Acquisition of New Perspective of Self Insight in Psychotherapy (Castonguay & Hill, 2005) What is insight? What leads to insight? What are the consequences of insight? What other issues need to be considered in thinking about insight? Insight or the Acquisition of New Perspective of Self Future research directions (Hill et al., 2005) Does insight need to be true or historically accurate? Are insights better if they are client-generated, therapist-generated, or co-constructed? Do more complex, emotionally intense, central insights lead to stronger, and longer lasting changes?

12 Quite often we do not succeed in bringing the patient to recollect what has been repressed. Instead of that, if the analysis is carried out correctly, we produce in him an assured conviction of the truth of the construction which achieves the same result as a recaptured memory (Freud, 1937) 34 False Unique Variables Psychodynamic > CBT (Blagys & Hilsenroth, 2000) Emphasis on past experience Focus on interpersonal experience Emphasis on therapeutic relationship Predictive of outcome in CBT Focus on attachment patterns (Hayes, Castonguay, & Goldfried, 1996) Connections between therapeutic relationship and other relationships (Jones & Pulos, 1993) False Unique Variables Psychodynamic > CBT (Blagys & Hilsenroth, 2000) Focus on affect and expression of emotions Predictive of outcome in CBT Emotional experience (Castonguay et al., 1996, 1997; Watson & Bedard, 2006) Process & techniques related to emotional exploration and experience (Ablon & Jones 1998; Jones & Pulos, 1993)

13 Process studies suggest Current theories are not flawed but not sufficient (There is more to cognitive behavior therapy than a mechanistic approach focus on current life and problem solving skills) Thinking outside traditional paradigms might be helpful to understand and improve therapy Big 4 are here to stay, but we can built on common factors, faux unique, and basic research HOW EVIDENCE BASED RESEARCH CAN EXPAND OUR CLINICAL REPERTOIRE Empirically based guidelines: Modifying, expending, and adding to FLA and WS - Principles of change - Psychopathology findings - Process research and outcome research Current Developments in Psychotherapy Integration Castonguay et al., 2015; Theoretical Integration 2. Eclecticism 3. Common Factors 4. Improvement of Major Systems of Psychotherapy

14 40 Contributing factors to the Integration Movement 1) Shock with Empirical Reality: Therapists have realized that their own approach is not as effective as they once thought it was. Therapists have also realized that their particular approach was not necessarily more effective than other therapeutic methods. Therapists have discovered that the way they conduct therapy is not always different from the way therapists of other orientations conduct their treatments. 2) Conceptual Limitations Therapists have become aware of limitations of their preferred theory, as it attempts to describe the process of therapy and explain human functioning. 3) Clinical Limitations Therapists have recognized that not one approach can provide an adequate treatment for all of the clinical problems they confront in their practice.

15 Theoretical Integration Prochaska s transtheoretical model Stiles assimilation model Grawe s consistency Theory Eclecticism Beutler systematic eclectic therapy Empirical Support: Alliance Empathy Positive regard Common Factors

16 Common Factors Table 1. Common Factors in Psychotherapy Framework Basic Processes Dimensions Participants (client & therapist) Therapeutic setting Assessment procedures Therapeutic contract Treatment Stages Interpersonal Influence: - Persuasion - Operant conditioning - Modeling Therapeutic Relationship: - Therapist interpersonal skills - Therapeutic alliance and transference Engagement: - Emotional - Cognitive - Behavioral Communication: - Forms (verbal & nonverbal) - Rules (e.g., specificity, coherence) - Content (e.g., anxiety) Methods of Intervention: - Techniques and procedures - Principles General strategies of change of intervention Common Factors Improvement of Major Systems of Psychotherapy Integrative Cognitive Therapy For Depression (Castonguay et al., 2004) CT manual (Beck et al., 1979) Strategies to repair alliance ruptures (Burns. 1990; Safran et al., 1990) - Invitation to explore ruptures - Empathic response - Disarming

17 Integrative Cognitive Therapy For Depression: Preliminary support Castonguay et al. (2004) ICT > Wait list Effect size (BDI): 1.91 Constantino et al. (2008) ICT > CT Effect size (BDI): 0.50 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 Post-test HDRS Pre-test Post-test GAF Pre-test Post-test 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.

18 Other assimilative efforts CBT + Expectations CBT + Motivational interview CBT + Chaos system Psychodynamic therapy + homework But this is not a panacea.. Integrative Therapy for GAD Newman, Castonguay, & Borkovec Based on process and basic research Emotion Interpersonal issues Anchored in integrative models Safran & Segal (1990) Goldfried (1980) Interpersonal/Emotional Processing Therapy 1. Exploration of past and current interpersonal relationships and experiments between sessions. 2. Use of experiential techniques to facilitate deepening of emotion and conflict resolution related to interpersonal markers. 3. Use of the therapeutic relationship to explore and challenge client s interpersonal schemas and patterns of interpersonal functioning. 4. Social skills training and role playing specifically aimed at changing client s contribution to maladaptive interpersonal patterns.

19 CBT Model of GAD High Anxiety and Ruminative Worry Images Thoughts Body Sensations Behaviors Images Thoughts Body Sensations Behaviors Anxiety producing thought Muscles Tense Imagine a terrible outcome Heart beats faster Throat becomes dry Worry CBT Goals 1. Modify/reduce cognitive, imaginal, and physiological responses to perceived threat. 1. Focus on specific situational internal (intrapersonal) issues to help the client develop better coping skills that will facilitate the reduction of anxious experience.

20 Techniques CBT 1. Self-monitoring and early cue detection. 2. Relaxation methods a.diaphragmatic breathing b.progressive muscle relaxation c.applied relaxation d.pleasant Imagery 3.Self-control desensitization 4.Cognitive Therapy Rationale for adding I/EP to CBT Applied and basic research has suggested that a focus on dimensions of functioning that are not typically or appropriately addressed by CBT may improve treatment efficacy with GAD: Interpersonal Issues a) Interpersonal Problems b) Developmental Problems c) Problems in the therapeutic relationship Emotional Issues Interpersonal/Emotional Processing Therapy Goals 1. Facilitate client identification of interpersonal needs, fears, and schemas. 2. Help the client develop behavior that will better satisfy his/her interpersonal needs. 3. Encourage the client to eliminate 4 types of avoidance: a. Avoidance of emotional experience, expression, and vulnerability. b. Avoidance of awareness as to how they contribute to their interpersonal problems. c. Avoidance of behavioral change d. Avoidance of processing therapeutic relationship difficulties.

21 Interpersonal/Emotional Processing Therapy continued Techniques 1. Exploration of past and current interpersonal relationships and experiments between sessions. 2. Use of experiential techniques to facilitate deepening of emotion and conflict resolution related to interpersonal markers. 3. Use of the therapeutic relationship to explore and challenge client s interpersonal schemas and patterns of interpersonal functioning. 4.Social skills training and role playing specifically aimed at changing client s contribution to maladaptive interpersonal patterns. GAD IV Newman et al. (2008) GAD Studies (N = 11) Therapy Condition Post-Therapy Follow-up CBT GADIV CBT/IEP GAD V Newman et al. (2009) - CBT + I/EP vs CBT + SL - No significant difference on primary outcome

22 GAD V Newman et al. (2009) - High in dismissing attachment -Benefitted more in CBT + I/EP - 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 GAD V Youn et al. (2017) - Therapist effects -Impact of 1 out of three therapists prevented to detect improvement of CBT via the integration of I/ EP -Two effective therapists foster and/or did not interfere with process of change -The less effective therapist did not foster client s full engagement in mechanisms of change targeted by the two treatments. He failed to do so by committing two types of mistakes: - Errors of commission and errors of omission - What do we know Therapist Effects Castonguay & Hill (2017) -Ability to establish a therapeutic alliance -Facilitative interpersonal skills -Self-doubt -Deliberate practice

23 Therapist Effects Castonguay & Hill (2017) - What else could explain therapist effects -Personality characteristics (attachment style; creativity, openness, and flexibility -Technical skills -Relational skills (e.g., management of CT) -Conceptual skills (e.g., case formulation) -Cultural awareness -Responsiveness to client needs Therapist Effects Castonguay & Hill (2017) - What else could explain therapist effects (continued) -Attentiveness to inner experiences/emotional reactions -Presence -Automatization of basic skills, superior abilities in complex skills (e.g., appropriate reactions to difficult situations), use of feedback -Humor -Fostering engagement Possible ways that research can help us help others EST and PHT: Providing First lines of attack (FLA) and warning signals (WS) for some clients Empirically based guidelines: Modifying, expending, and adding to FLA and WS - Principles of change - Psychopathology findings - Process research and outcome research Practice-oriented research: Complementing evidence based practice

24 HOW CAN WE CREATE RESEARCH TO EXPAND OUR EMPIRICAL BASE FOR CLINICAL PRACTICE Practice- Oriented Research: Clinician and researcher partnerships, with the goals: 1) providing an antidote to empirical imperialism 2) creating new landscapes of practice and knowledge Some Obstacles to Partnership Traumatic experiences Lack of perceived relevance of research Lack of models in grad school Time Opportunities of collaboration beyond empirical imperialism Lies of graduate applicants Illustrations of Partnership Practice-oriented research (Castonguay, Barkham, Lutz, & McAleavey, 2013) - Patient Focus Research - Practice Based Evidence - Practice Research Network

25 Practice Oriented research: Convergences Studies are conducted in naturalistic settings Adoption of a standardized measurement system as part of routine practice Unifying goals of practice-oriented research - provide practitioners with the opportunity to be active participants - use data, as it is being collected, to inform their interventions during therapy - examine questions that they perceive as relevant to their practice - allow practitioners to contribute to the accumulation of rigorous knowledge Practice Oriented research: Why should we? Compensates some limitations of evidence based research Increases our confidence in knowledge Broaden our understanding and practice Provides voice to clinicians in setting research agenda Reflects and contribute to integration movement Patient focused research Goals - Examining patterns of change - Providing tools to support clinical decision making Example: Feedback - Deterioration - Clinicians ability to predict failure - Feedback and clinical tools to improve outcome and reduce failure 75

26 Usually the therapeutic effect at the moment is nothing; the resulting horror of analysis, however, is ineradicable (Freud, 1913) 76 Practice Evidence Research Investigation of provision of care based on the adoption and ownership of a bona fide measurement system and its implementation as standard procedure within routine practice Single service or professional center level Multiple services level Meta-analyzes of practice-based and effectiveness studies Practice-based studies of comparative treatment outcome Practice Evidence Research Practitioner level: Therapist effect (Wampold, 2001) Specific impact (Kraus, Castonguay, Boswell, & Nordberg, 2010) The rich The poor The rest of us What are the variables responsible? Penn State Conference on the process of change

27 Practice Research Networks group of practicing clinicians that cooperates to collect data and conduct research (Zarin, Pincus, West, & McIntyre, 1997) Clinicians and scientists working together in collaborative research Clinically meaningful questions in a naturalistic setting External validity Scientifically rigorous methodology employed for internal validity (Borkovec, 2002) Practice Research Networks collaboration aims to foster a sense of equality, shared ownership, and mutual respect between researchers and clinicians, and promoting diversity of scholarship (i.e., different ways of understanding and investigating complex phenomena). It also capitalizes on the complementary expertise, knowledge, and experiences of each stakeholder to provide unique opportunities for two-way learning in order to conduct studies that are both clinically relevant and scientifically rigorous (Castonguay et al., 2013) Practice Research Network: Examples Attachment and alliance in CBT (Zack et al., 2015) - No drastic change required for CBT - Techniques are not sufficient to maximize evidence based practice - Importance of being attuned to individualized needs of clients

28 Practice Research Network: Examples PPA PRN Phase I (Borkovec, Echemendia, Ragusea, & Ruiz, 2001) Goals: - Create a state-wide infrastructure - Obtain experience in the use of a core battery and in the conduct of collaborative research in the applied setting Phase II (Castonguay et al., 2010 a, b) Goals: - Examine what do clients find helpful (and unhelpful) during a session? - Investigate whether knowledge of client s perception of helpful (and hindering) events can improve the effectiveness of therapy. Questions What events are found by clients to be most helpful and hindering during sessions conducted within the context of regular private practice? What events are found by therapists to be most helpful and hindering during the same sessions? What are some of the content of discussions addressed within these helpful and hindering events? Method Design Within each of three age groups (child, adolescent, adult), clients were randomly assigned to experimental or control conditions Experimental condition: HAT filled out by both client and therapist after every session Control condition: HAT filled out by therapist only This presentation focus primarily on adolescents and adults clients (12 years old and older)

29 Method Participants 13 experienced therapists in private practice, all but one full-time clinicians 121 clients Clients per therapist, Mean of 9.31 (sd=7.33) ranging from 2 to 24. Number of sessions: Mean of 7.98 (sd=8.17), ranging from 1 to 36 Method Instruments A. Helpful Aspects Therapy Questionnaire (HAT, Llewelyn, 1985) 1. Did anything particularly helpful happen during this session? Circle: Yes / No (If yes, please describe it briefly below and circle its helpfulness) Slightly Moderately Greatly Extremely Helpful Helpful Helpful Helpful 2. Did anything happen during this session which might have been hindering? Circle: Yes / No (If yes, please describe it briefly below and circle its hindering) Slightly Moderately Greatly Extremely Hindering Hindering Hindering Hindering Method Procedures All new clients completed the TOP before first session. HAT cards were filled out after every session. Therapists read the HAT filled out by the client before the next session. All new clients were asked to fill out the TOP after the last session of their treatment.

30 A) IMPACT Client report 1) Self-awareness B) IMPACT Therapist report 1) Self-awareness 2) Alliance Strengthening Results A) Content Client report 1) Helpful events: Therapy 2) Hindering events: Therapy A) Content Therapy report 1) Helpful events: Therapy 2) Hindering events: Therapy Results Practice Oriented Research: How to facilitate it? Avoiding drawback and pitfalls Foster attachment during training Ask and tell Learn form past experiences of partnerships Work locally and collaborate globally Adopt guiding principles

31 Drawbacks to and pitfalls of Practice Oriented Research Doing it for the Dean Forgetting the mission Not learning form past experiences of partnerships Throwing the baby out of the tub Repeating all-or-none thinking Resisting actualization Foster attachment during training Training Clinics: Confounding three tasks PSU PRN (Castonguay, Pincus, & McLeavey, 2015) Components Core outcome battery Standardized assessment procedures Review committee Agreement with Office of Research Protection Ask and Tell What do clinicians think about research? - Adam-Term et al., 2010 What is the experience of clinicians in conducting research? - Castonguay et al., Garland et al., 2006 What do clinicians want to know? - CCMH survey What is the experience of clinicians in using research based interventions? - Martin et al., Goldfried et al., 2014

32 Learn from past experiences of partnerships Psychotherapy Research series (Castonguay & Muran, contributions reflecting different naturalistic sites, different countries, different types of initiatives Issues addressed: - Context of collaboration and studies conducted - Lessons learned: Obstacles & Solutions - Benefits - Recommendations Work locally collaborate globally Network of PRNs (Castonguay & Kraus) Network of Training Clinics (Borkovec) - Association of Psychology Training Clinics Collaborative Research Network - Canadian Universities - US Universities Psychotherapy Practice Research Network (Tasca) Network of Counseling Centers (Locke) Guiding principles Conduct studies that address clinicians questions and that are designed, in part, on their knowledge and observations Make the research for and by clinicians counts Think beyond the bridge between science and practice and aim for the creation a new, unified landscape of knowledge and action.

33 Research can Suggest first lines of attack Provide lessons of humility Confirm clinical theories and observations Surprise us Provide political tools