Manualstyrd eller individanpassad behandling? Gerhard Andersson, professor Linköpings universitet och Karolinska Inst. www.gerhardandersson.se
Upplägg Diagnos Analys Eget val/preferens Forskning För och nackdelar igen 2
Diagnoser Kriteriebaserade Syndromdiagnos Latenta konstrukt Sociala konstruktioner (harmful dysfunction) Biologiska visioner Neurologi /neuropsykiatri R-doc 3
Problem Överlappar Konsensusbaserade Taxometristudier visar på normalfördelning Utlösande faktorer minimeras Men diagnos + modell kan ge funktionella samband och en vägledning 4
Analys Beteendeanalys, funktionell analys Kognitiv analys, fallkonceptualisering Psykodynamisk analys (kärnkonflikt) Bygger på minnen samt insikt Modeller som betonar före eller efter Inlärningshistorik Tillgångar, överskott, underskott 5
Problem Svårt att välja rätt målbeteende Reliabilitet tveksam Tveksamma datakällor (patientens minnen) Kognitiv bias hos terapeuten Risk att analysen blir endimensionell eller beroende av expertkunskap 6
Eget val Bör inte patienten få välja? Rational central del i KBT Preferens har betydelse för valet att gå i terapi Delade beslut Målformuleringen är patientens Self-efficacy (Bandura) 7
Problem Patienter ändrar preferenser Kunskap om alternativen? Reklam och övertalning? Motivation = konsekvens? 8
Forskning Emmelkamp et al. 1994 Ghaderi 2006 Johansson et al. 2012 Vem ska bort? 9
Emmelkamp, P. M. G., Bouman, T. K., & Blaauw, E. (1994). Individualized versus standardized therapy: A comparative evaluation with obsessive-compulsive patients. Clinical Psychology and Psychotherapy, 1, 95-100. Contrary to expectations the individualized treatment was not more effective than the standardized exposure therapy Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa. Behaviour Research and Therapy, 44, 273-288. However, the magnitude of effects was moderate 10
Easden, M.H., & Kazantzis, N. (2018). Case conceptualization research in cognitive behavior therapy: A state of the science review. Journal of Clinical Psychology, 74:356 384 Results from the existing studies suggest that experienced therapists can reliably construct some elements of case conceptualizations, but importance for the efficacy of case conceptualization in CBT has yet to be demonstrated. 11
14 Type of protocol (transdiagnostic vs. tailored) had no effect on anxiety (pre-post Qbet =.13, p =.714, pre-fu: Qbet =.22, p =.634), nor on depression (pre-post Qbet =.75, p =.385, pre-fu: Qbet = 1.73, p =.188).
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The Robin trial Factorial design (inspired by Ed Watkins) N=197 Self-tailored vs clinician-tailored Scheduled support vs support on demand Clients in supervision vs no supervision In total 8 groups with three main effects
Participants Mean age 36.6 yrs (range 19-79 yrs) 77% women; 75% university ongoing or completed; 52% working
Treatment 15 modules (text) Intro, Behav act 1 and 2, Cogn restructuring, Acceptance, Emotion regulation, Anxiety and exposure, Social anxiety, Worry control, Panic, Sleep, Stress, Relaxation, Closure and relapse prevention Overall grading by participants 3.4-4.4 (last module had the highest rating) 5.66 modules on average (SD = 3.48)
Results Overall large within-group improvements on the BDI-II (d = 1.23)
Beck Depression Inventory Supervision? 30 25 20 15 10 5 0 No supervision Supervision Pre Post
Beck Depression Inventory Support? 30 25 20 15 10 5 0 On demand Scheduled Pre Post
Beck Depression Inventory Tailoring! 30 25 20 15 10 5 0 Self-tailored Clinician-tailored Pre Post Self-tailored better d = 0.43
Participants were allocated to IPDT or ICBT based on their stated preference. More than half of the participants preferred ICBT (N = 30) over IPDT (N = 14). van Schaik, D., Klijn, A., van Hout, H., van Marwijk, H., Beekman, A., de Haan, M., & van Dyck, R. (2004). Patients' preferences in the treatment of depressive disorder in primary care. General Hospital Psychiatry, 26, 184-189. 25
Diskussionspunkter Bra med analys vid utbildning av terapeuter? Terapeuter mer nöjda? Errors of omission and commission? Vad går snabbast? Vad fungerar i primärvården? Koll på funktioner som förekommer i samband med vissa problem? 26
Slutsats Mkt kvar att göra Forskningen märkligt tyst Stor diskrepans mellan forskning och praktik