OverviewI. Process vs. Outcome DistinctionA. Process – describing events within sessions associated with change

B. Outcome --effectiveness of therapy (TX ): A pre- post-changeII. Measuring Process VariablesA. Measures of change in--

B. Compliance with model

- Aspects of client verbalizations
- Depth of emotion
- Therapist interventions and consequences therefrom

- Did therapist do X, Y, or Z as stated in the treatment manual?
- Someone rates session for therapist behaviors
III. Measuring OutcomesA. Pre-, Post-, Follow-up

- Controlling for repeated measures?
- Intervening "treatments"?
- Deterioration effect (does anyone get worse?)

- First lecture of course, again!
- Who decides? Who can tell?
- Review assessment weapons stockpile!
- What assessment devices do we have to index outcomes?

- B. Distinguishing between what is taught and what is
therapeutic

People can learn what you taught them, but is that therapeutic ?

I can learn to spin around but what condition does that improve?

C. Ecological or External validity

Who's responsibility is it to show
that the skills taught in treatment

ARE effective (i.e., the right ones)
for bringing about a better

relationship ?

D. Sources of information

From whom do we get reports
of improvement?

Clients, Therapist (?), Outsiders

**
Review your "Consumer’s
Guide to Evaluating Therapy Studies**"

- Non-random assignment to treatments

Differential therapist experience

Small n's per treatment

Inconsistent application of treatment elements

Failure to consider maturation effects

Attrition rates in treated group

Etc. etc. etc.

**VI. Assessing Outcome Reliability**

- A. Box Score Approach

Count the

- B. Meta-analysis: what it is and isn't

Meta-analysis techniques review the literature for studies that compare

treatment to a no treatment (a control condition). The studies are rated

as you did in HW-1; that way quality is controlled. Instead of counting

studies which show improvement, the idea is to express numerically

how much improvement there was (relative to a control standard) using

a comparison statistic that allows us to compare studies of different

measures and scales. (That way the units are made equivalent.)

- When repeated testings yield same result
- When test is long enough to sample the domain adequately
- When the Standard Error of measurement is small
- SD = variability around the mean for a single sample
- SE = variability of sample of MEANS around the "true" mean;

- Express change relative to a control
group

- Effect Size =

S.D. Control

the TX mean differs from the Control mean in terms of distance from

the control mean. (Also a measure

C. Calculating Effect Size

Based on *area* under the
normal probability curve, use the formula:

- (.50 + Z area ) * 100 = % Better Than

Probability curve):

- If

- .40 66%

.50 69%

.60 72%

.70 76%

.80 79%

.90 82%

1.00 84%

1.10 86%

**I. Making Pre- Post- Comparisons**

- A. Therapy effectiveness means change from Pre to Post
on some MEASURE

B. Real Change vs. Noise

Depends upon the Reliability
of the Measure

C.When is a Measure reliable?

The larger the

very wide window. SE is given by the formula

E. All of this is to get to this point: we want
to express outcome success of

individuals. How *many people*
in the treatment group showed significant

improvement? Improvement over what?
Where they started from;

how much is significant? If their
change score is divided by the *SE of the*
* measure (e.g., DAS) *we can
determine whether they changed significantly.

Reliable Change Index = *RC* = __Post - Pre__

SE

Note:
SE in this case is the *standard error of measurement,* which is

estimated by the equation

where r_{xx} =
the reliability of the test, and SD = the sigma of test mean.

The change is relative to error units! We can now count
the percentage

of people
who *improved significantly*.

F. Clinical vs. Statistical Significance

It is possible to
show statistically significant change based on the R-C score,

but this may be
different from
*clinically significant change*. A person (couple)

may move from a
low DAS score of 75 to 85, pre- to post-therapy. But 85 on

the DAS is still within
the distressed range for that test!

G. Also note that we have the option of reporting
individual spouse scores
* or*
couple scores. Couple scores would be the avergae of each person's

score. But
what to do when one person is 85 and the other is 110? Is the

average meaningful
in this case since it yields a score of 97.5, which is

almost "normal"
although one person is clearly distressed.

**I. Alternatives to Control Groups**

A. Treatment on demand (TOD): control over control group

B. Minimal contact agreements

C. Non-specific controls

**II. Ethical Issues in Marital
Therapy **(AAMFT
Ethics)

- A. Who is the
client?

B. Issues of confidentiality

C. Therapist values vs. client values

D. Therapist quality assurance issues

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