Yulish, N. E., Goldberg, S. B., Frost, N. D., Abbas, M., Oleen-Junk, N. A., Kring, M., . . . Wampold, B. E. (2017). The importance of problem-focused treatments: A meta-analysis of anxiety treatments. Psychotherapy, 54(4), 321-338.
Typically, meta-analyses indicate that the differences between treatments in client outcomes are small or non-existent. When a treatment is found to be more effective than a comparison condition, it is usually because the treatment (and not the comparison) is focused on the particular problem that is measured as the main outcome variable. The contextual model of change in psychotherapy posits three paths to client change: 1) therapist empathy and the real therapeutic relationship; 2) client expectations related to the therapist’s explanation of the problems and of how the therapy will reduce these problems (e.g., agreement on tasks and goals, which are aspects of therapeutic alliance); and 3) the direct specific interventions of the therapy to address these problems. In this meta-analysis, Yulish and colleagues examine aspects of the second and third component of the contextual model by examining if the difference between treatments for anxiety disorders is due to the relative differences in their focus on symptoms. In this systematic review, the authors identified 135 randomized controlled trials of direct comparisons of psychotherapy for anxiety disorders. They then rated each treatment and control condition for: the amount of explanation provided to clients for their symptoms, the amount of explanation provided to clients for the treatment approach, and the specificity of the interventions to address the symptoms. In a series of meta-regressions the authors found that: 1) explanations for the symptoms and for the treatment approach, and 2) treatments that were more symptom focused resulted in larger treatment effects. When the authors pit explanations against symptom focus to predict outcomes, they found that providing clients with an explanation for symptoms and interventions (which resulted in higher client expectations of receiving benefit) was more important than the symptom focus of the treatment.
This study suggests three mechanisms by which psychotherapy may lead to symptom relief for anxiety disorders: 1) providing clients with a clear explanation of symptoms and of therapeutic interventions, 2) having an agreement about the tasks and goals of therapy (i.e., therapeutic alliance), and 3) engaging in specific therapeutic actions that derive from the explanation of symptoms. Sitting with a client, being warm and accepting, expressing empathy and understanding, but not providing the client an explanation for his or her distress or a means to overcoming that distress may not be good enough. Such approaches may be beneficial for some with anxiety disorders, but they fail to fully make use of the factors that lead to effective therapy. The expectations of benefit created by the explanation of symptoms and interventions, in addition to specific therapeutic actions that are consistent with the explanation, may play a critical role in reducing symptoms of anxiety.
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