Er der evidens for evidensen?

Er der evidens for evidensen? Innlegg 7. oktober, 2016 v/michael Helge Rønnestad Professor Emeritus, Universitetet I Oslo DPSPs Internationale seminar i København 1

To tilsynelatende like, men likevel forskjellige definisjoner av evidence based practice : Institute of Medicine: Evidence based practice blir der definert as being the integration of the best research evidence with clinical expertise and patient preferences Sackett et al., 2001, s. 147, ref. I Barlow, 2004, s. 870 APA: Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences» APA, 2006 Problematisk oversettelse av context som defineres som sett i sammenheng med Evidence Based Practice in Psychology (2006) American Psychologist, 61, No. 4, 271 285 2

Historisk bakgrunn (1) En science practitioner utdanningsmodell (2) Helse- og sosiallovgivningen, særlig i USA; (3). Division 12/APA Task Force on promotion and dissemination of psychological procedures. (4) Innføringen av New Public Management og institusjonaliseringen av evidensbevegelsen; (5) Utviklingen innen klinisk epidemiologi (v/uffe Juel Jensen, 2007); (6) Institusjonalisering av evidensbevegelsen (ibid.). 3

Historisk bakgrunn (1) En science practitioner utdanningsmodell (2) Helse- og sosiallovgivningen, særlig i USA; the Kefauver-Harris Amendement to the Food and Drug Act ; The Health Maintenance Organization Act of 1973, Amendments to the Social Security Act fra 1983 (3). Division 12/APA Task Force on promotion and dissemination of psychological procedures. (4) Innføringen av New Public Management og institusjonaliseringen av evidensbevegelsen; (5) Utviklingen innen klinisk epidemiologi (v/uffe Juel Jensen, 2007); (6) Institusjonalisering av evidensbevegelsen (ibid.). 5

Historisk bakgrunn (1) En science practitioner utdanningsmodell (2) Helse- og sosiallovgivningen, særlig i USA; (3). Division 12/APA Task Force on promotion and dissemination of psychological procedures. Det differensieres mellom «scientifically well established» og «probably efficacious». Tre krav for well established : Krav om replikasjon, manualisering og beskrivelse av pasienten. (4) Innføringen av New Public Management og institusjonaliseringen av evidensbevegelsen; (5) Utviklingen innen klinisk epidemiologi (v/uffe Juel Jensen, 2007); (6) Institusjonalisering av evidensbevegelsen (ibid.). 6

Criteria for Well Establshed Empirically-Validated Treatments (Chambless et al., Well-Established Treatments: I. At least two good between group design experiments demonstrating efficacy in one or more of the following ways: A) Superior (statistically significantly so) to pill or psychological placebo or to another treatment. B) Equivalent to an already established treatment in experiments with adequate sample sizes. OR: II. A large series of single case design experiments (n >9) demonstrating efficacy. These experiments must have: A) Used good experimental designs and B) Compared the interventions to another treatment as in IA. FURTHER CRITERIA FOR BOTH I AND II: III. Experiments must be conducted with treatment manuals. IV. Characteristics of the client samples must be clearly specified. V. Effects must have been demonstrated by at least two different investigators or investigating teams. Criteria for Probably Efficacious treatment less comprehensive criteria (shows promise) 7

Historisk bakgrunn (1) En science practitioner utdanningsmodell (2) Helse- og sosiallovgivningen, særlig i USA; (3). Division 12/APA Task Force on promotion and dissemination of psychological procedures. (4) Innføringen av New Public Management (5) Utviklingen innen klinisk epidemiologi (v/uffe Juel Jensen, 2007); (6) Institusjonalisering av evidensbevegelsen (ibid.). 8

Uklarhet om hva evidensbasert medisin er i dag Er det cookbook medicine? 11

Evidenshierarki, eksempel I: Properly conducted randomized, controlled trial (RCT). II-1: Well-designed controlled trial without randomization. II-2: Well-designed cohort or case-control analytic study. II-3: Multiple time series with or without the intervention; dramatic results from uncontrolled experiments. III: Opinions of respected authorities, based on clinical experience; descriptive studies or case reports; reports of expert committees (US Preventive Service Task Force) 12

Kilder til å forstå variasjonen det terapeutiske resultat Process-outcome forskningen Kunnskaps-summeringene til John Norcross Kunnskapssummeringen til Bruce Wampold Forskning om terapeuters livskvalitet og selvforståelse 13

A generic model of psychotherapy Orlinsky, D. E., & Howard, K. I. (1987). A generic model of psychotherapy. Journal of Integrative and Eclectic Psychotherapy, 6, 6-36. Modellen er utviklet og endret ved flere anledninger i forbindelse med Orlinskys process-outcome kapitler i Bergin and Garfields Handbook of Psychotherapy and Behavior Change. Siste beskrivelse: Orlinsky, D. E. & Rønnestad, M. H., Willutzki, U. (2005). Fifty years of psychotherapy process-outcome research: Continuity and change. In: M. Lambert (Ed.). Bergin and Garfield's Handbook of Psychotherapy and Behavior Change, Fifth Edition. New York: John Wiley & Sons, s. 307-389. (powerpointene er kopiert derfra) 14

Empirically supported elements in the therapeutic relationship: Alliance in Adult Individual Therapy Alliance in Youth Therapy* Alliance in Couple/Family Therapy* Cohesion in Group Therapy Empathy Goal Consensus & Collaboration Positive Regard* Etter Norcross 2010 17

Allianse i individuell terapi Det sterkeste sammenhengen mellom prosessog utfall er grad av samarbeidende forhold. (Orlinsky, Rønnestad, & Willutzki, 2004) Allianse er et aspekt av dette 201 studier av individualterapi med voksne klienter: median r mellom allianse og utfall: r =.275 (medium effektstørrelse, d=.57) /iflg. Norcross. 18

Allianse i terapi med barn og ungdom Iflg. Norcross: Dokumentert av 29 studier av terapi med barn og ungdom (2.600 klienter). Korrelasjon (gjennomsnitt) =.19 of child & adolescent therapy (N 2,600), the mean r between the alliance and tx outcome =.19 Korrelasjone varierte ikke med behandlingsform 19

Allianse i par og familieterapi NB. Multiple allianser som interagerer systemisk På individnivået: (selv-med-terapeuten) og på gruppenivå: (par med terapeuten) Konklusjon på bakgrunn av 24 studier (7 par og 17 familier): Gjennomsnitts r mellom allianse og resultat: =.26 Lik r for par og familier Norcross, 2010 20

Cohesion i gruppeterapi Meta-analysis, 40 studier med tilsammen 3.323 klienter): Gjennomsnittskorrelasjonen mellom cohesion og resultat: r =.25 Gruppeledere med høyeste interpersonlig orintering, oppnådde høyest ES (r=.58). Norcross 21

Mål-enighet og Samarbeid Meta-analyse av 19 nyere studies (N 2,260) av samarbeid: r =.33 med resultat Meta-analyse av 15 nyere studier (N 1,300) av enighet om mål: r =.34 med resultat Norcross, 2010 22

Empati Terapeutens sensitive forståelse av klientens følelser og streven, vurdert av klienten Meta-analyse av 58 studier, gjennomsnitt empatiutfallskorrelasjon: r=.31 Norcross, 2010 23

Positive Regard/Support Opplevelsen å bli satt pris på/verdsatt: Meta-analyse av 18 godt kontrollerte studier (1,067 patients): gjennomsnitlig: r =.29 (NB: klientvurdering) Høyere effektstørrelser for etniske minoritetsklienter. Norcross, 2010 24

Klientfeedback Meta-analyser av 9 RCT er r =.23 til.25 Reduserer i betydelig grad risikopasienters sjanser til forverring (halverer denne) Wampold/Norcross, 2010 25

Probably Effective Elements of Therapy Relationship Congruence/Genuineness Collecting Client Feedback* Repairing Alliance Ruptures Self-Disclosure Countertransference Management Quality of Relational Interpretations 26

Congruence/Genuineness Probably the most fundamental of Roger s facilitative conditions, but most studies riddled with inadequate methods and small Ns Nonetheless, a meta-analysis of 16 studies (N = 863 patients) yielded a mean r of.24 for the congruence-outcome association Higher ESs obtained for group therapy (r =.36) and older, more experienced therapists 27

Collecting Client Feedback The Process: Inquire directly about client s progress; compare those data to benchmarks; provide that feedback immediately to therapist; address explicitly with client in-session The Research: Meta-analysis of 9 RCTs shows its use associated r =.23 -.25 with tx outcome and reduces by about half the chances of at-risk patients experiencing deterioration 28

Repairing Ruptures A tension or breakdown in collaboration Most clients have some negative feelings about tx or relationship but most do not tell us about ruptures unless asked Repairs facilitated by therapist responding nondefensively, attending directly to relationship, adjusting behavior, & collecting feedback 29

Managing Countertransference Research confounded by small number of quant studies and disparate definitions of CT Meta-analysis of 11 studies shows r =.16 between CT and worsening therapy outcomes In 7 studies, mean r =.56 between CT management and therapy outcome Successful CT management entails: self-insight, self-integration, anxiety management, empathy, and conceptualizing ability 30

Tim Anderson et al., (2011) Facilitative Interpersonal Skills (FIS) Performance Task. FIS ratings and scoring. FIS item content was selected from the clinical and research literature (e.g., Norcross, 2002) on common therapist interpersonal skills and facilitative conditions. Specifically, the FIS items included ratings of verbal fluency, emotional expression, persuasiveness, hopefulness, warmth, empathy, alliance-bond capacity, and problem focus. FIS KORRELASJON MED OUTCOME: r=.47 FIS KORRELASJON MED TERAPEUT ALDER: r=.45 31

The Contribution of the Therapist to Psychotherapy: Characteristics and Actions of Effective Therapists Bruce Wampold, I: A.v.d.Lippe, H. A. Nissen- Lie, & Oddli, H. (Red.) (2014). Psykoterapeuten: En antologi om terapeutens rolle i psykoterapi. Oslo: Gyldendal Akademisk. 32

Table 1. Effect sizes for common factors and specific ingredients* Factor # Studies # Patients Effect Size d % of variability in outcomes Common Factors Alliance a 190 2630.57 7.5 Empathy a 59 3599.63 9.0 Goal Consensus/collaboration a 15 1302.72 11.5 Positive Regard/Affirmation a 18 1067.56 7.3 Congruence/Genuineness a 16 863.49 5.7 Therapists-- RCTs b 29 }14,519.35 3.0 Therapists-- Naturalistic b 17.55 7.0 Specific Ingredients Differences between treatments c 295 >5900 <.20 <1.0 Specific Ingredients (dismantling) d 30 871.01 0.0 Adherence to protocol e 28 1334.04 <0.1 Rated competence in delivering particular 18 633.14 0.5 treatment e a Norcross (2011) b Baldwin & Imel, 2013 c Wampold et al. (1997); confirmed by various other metaanalyses for specific disorders. d Bell et al.,2013 (targeted variables); see also Ahn & Wampold (2001) e Webb, DeRubeis, & Barber (2010). *Wampold, B. (2014). The Contribution of the Therapist to Psychotherapy: Characteristics and Actions of Effective Therapists. I: A.v.d. Lippe, H. A. Nissen-Lie, & H. W. Oddli (Red.). (2014). Psykoterapeuten: En antologi om 33 terapeutens rolle i psykoterapi. Oslo: Gyldendal Akademisk.

Sammenhengen mellom terapeuters livskvalitet og utvikling av arbeidsalliansen Nissen-Lie, H. A., Havik, O. E., Høglend, P. A., Monsen, J. T., & Rønnestad, M. H. (2013). The Contribution of the quality of therapists' personal lives to the development of the working alliance. Journal of Counseling Psychology 2013, 60, s. 483-495 Personal burdens scale: How stressful is your life at present? How frequently do you feel a heavy burden of responsibility, worry, or concern? How frequently do you feel a sense of significant conflict, disappointment, or loss? Personal satisfactions scale: How satisfying is your own life at present? How frequently do you experience a sense of being genuinely cared for and supported? How frequently do you experience moments of unreserved joy? How frequently do you freely express your private thoughts and feelings? How frequently do you feel a satisfying sense of emotional intimacy and emotional rapport? 35

Resultater: Livskvalitet og utvikling av arbeidsallianse, forts.. The Personal Burdens scale was strongly and inversely related to the growth of the alliance as rated by the patients, but was unrelated to therapist-rated alliance. Dvs. dårlig livskvalitet påvirker i forventet retning (negativt) klientvurdert allianseutvikling. Conversely, the factor scale of therapists Personal Satisfactions was clearly and positively associated with therapist-rated alliance growth, but was unrelated to the patients ratings of the alliance. Dvs. Jo bedre livskvalitet terapeutene mener de har, desto bedre vurderer de selv allianseutviklingen. It seems that patients are particularly sensitive to their therapists private life experience of distress, which presumably is communicated through the therapists in-session behaviors, whereas the therapists judgments of alliance quality were positively biased by their own sense of personal well-being. Nissen-Lie et al., 2013 36

Nissen-Lie, H. A., Monsen, J. T., Ulleberg, P., & Rønnestad, M. H. (2013). Psychotherapists self-reports of their difficulties and interpersonal functioning in practice as predictors of patient outcome. Psychotherapy Research, 23(1), 86 104. DOI:10.1080/ 10503307.2012.735775. Professional self doubt and outcome The results also demonstrated that certain therapist selfperceptions were clearly related to patient outcome. For example, therapists' scores on a type of difficulty in practice called "Professional self-doubt" (PSD) (denoting doubt about one's professional efficacy) were positively associated with change in IIP global scores. It is suggested that therapists' selfreported functioning can be of value in understanding how individual therapists contribute to therapeutic change although their influence is not necessarily exerted in expected directions. 37

Eksempler på ledd som inngår i Professional Self Doubt (Orlinsky & Rønnestad, 2005) Lacking in confidence that you might have a beneficial effect on the patient Unable to comprehend the essence of a patient s problems. Unable to generate sufficient momentum in therapy 38

TAKK FOR OPPMERKSOMHETEN 39

M. H. Rønnestad, S. Gullestad, M. S. Halvorsen, H. Haavind, A.v.d. Lippe, H. A. Nissen-Lie & S. Reichelt (2015). An intensive process-outcome study of the interpersonal aspects of psychotherapy. Growth curves: IIP-64 total for Long-term Tx* 1., 6., 12., 20., 40., 60., 80., 100. session; T2=End of Tx; T3= 1-2 yrs post Tx; T4= 3-4 yrs post Tx 40

Kunnskap generert ved kontrollerte design iflg. Lebow Beck s Cognitive therapy and Klerman s interpersonal therapy for depression Barlow and Craske Panic Control treatment for panic disorder Foa s exposure and ritual-prevention therapy for OCD Berkowec s CBT therapy for generalized anxietydisorder 12 step and CBT treatments for substance-use disorders Men Lebow skriver også: Under rigorous examination, no one therapy has ever been demonstrated to achieve results that are consistently better than those of any other (s. 45). Lebow, J. (2007). A look at the evidence: Top ten research findings of the last 25 years. Psychotherapy Networker, March/April. Rønnestad 41

Handbook chapter 42

Resultater: Livskvalitet og utviklng av arbeidsallianse. The Personal Burdens scale was strongly and inversely related to the growth of the alliance as rated by the patients, but was unrelated to therapist-rated alliance. Dvs. dårlig livskvalitet påvirker i forventet retning (negativt) klientvurdert allianseutvikling. Conversely, the factor scale of therapists Personal Satisfactions was clearly and positively associated with therapist-rated alliance growth, but was unrelated to the patients ratings of thw alliance. Dvs. Jo bedre livskvalitet terapeutene mener de har, desto bedre vurderer de selv allianseutviklingen. It seems that patients are particularly sensitive to their therapists private life experience of distress, which presumably is communicated through the therapists in-session behaviors, whereas the therapists judgments of alliance quality were positively biased by their own sense of personal well-being. 43

En fordypning i hva et strategisk utvalg av terapeuter som er stressende involvert selv formidler om sine begrensninger som terapeut. Maren Helland s hovedoppgave. SPR CRN data. Begrensninger i relasjonellværemåte (relational manner) For reservert For nær For rask Begrensninger knyttet til holdning til egen prestasjon. Beretninger om prestasjonsopptatthet, perfeksjonisme, frykten og higen etter perfeksjon, og frykten for å feile. Ytre begrensninger Organisasjon, system, kvaliteten påarbeidsmiljøet. 44