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Coming to a Consensus About Psychotherapy

Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back? American Psychologist, 74(4), 484-496.

In this thoughtful piece, Marvin Goldfried, one of the pioneers of psychotherapy research, discussed the lack of consensus that holds back progress in the science and practice of psychotherapy. He argued that there are three main blocks to moving the field forward. First, disagreement across theoretical orientations results in different language systems that prevents the field from learning of similarities or points of connection. At last count, there are over 500 schools of psychotherapy resulting in an absence of a common language. A lack of consensus and disparate languages means that identifying the key factors that may underlie the effectiveness of psychotherapy is difficult if not impossible. The second block to progress in psychotherapy practice and research has to do with the practice-research divide. Despite the large body of research on psychotherapy systems, many clinicians rely more on their own experience rather than the research evidence. Therapists also complain that research tends to be conducted by individuals who know little of the reality of providing clinical services, and so some of what is researched (e.g., short-term treatment packages of one theoretical orientation) may not be relevant to everyday practice. For their part, researchers have tended not to consult with or include clinicians in their research endeavors, thus resulting in research that is disconnected from practice. The third block is related to the disconnection between the past and current contributions. That is, psychotherapy schools and orientations tend to emphasize and reward what is new without acknowledging the historical, intellectual, and practical theories that preceded. As a result, there is a constant reinventing of the wheel and a tendency not to learn from past advances and failures. This creates a stagnation in advancing both research and practice. As one example of this phenomenon, Goldfried quoted the psychoanalyst Otto Fenichel in 1941 who described the effects of what we now call behavioral extinction. Yet Fenichel and his work is never cited by behavior therapy research, and so there is no opportunity to examine common underlying processes of change or the evolution of the concept over time.

Practice Implications

Goldfried ended this paper by suggesting how to move the field of psychotherapy forward. He suggested that rather than focusing on new approaches to treatment, the field should reward new knowledge grounded in research and that belongs to the field in general and not to a particular school, orientation, or person. The emphasis of research in psychotherapy should not be on who is right but on what is right. In other words, research questions should emphasize “What did a therapist do to make an impact?” For example, psychotherapy process research on the therapeutic alliance, stages of change, therapist interpersonal skills, empathy, and client factors focus on transtheoretical constructs that inform therapists on how best to work with particular clients. This PPRNet blog often summarizes psychotherapy research for its readers.

Client Stage of Change Predicts Their Outcomes in Psychotherapy

Krebs, P., Norcross, J.C., Nicholson, J.M., & Prochaska, J.O. (2018). Stages of change and psychotherapy outcomes: A review and meta-analysis. Journal of Clinical Psychology, 74, 1964-1979.

Next to the therapeutic alliance, client stage of change is one of the most researched concepts in psychotherapy. The theory posits that clients come for treatment with varying levels of motivation, preparation, and capacity for behavior change. And their overall readiness for change influences the process and outcome of the psychotherapy they receive. Researchers have identified five stages that clients may go through during the change process, and they identified most effective therapist stances to help clients move from one stage to the next. Precontemplation is the stage in which the client has no intention of changing, and they may have been coerced into coming to therapy. During this stage therapists may help the client increase their awareness of the advantages of changing and the costs of not changing. Contemplation is the stage in which the client is aware that there is a problem, but has not yet made a commitment to take action. During this stage the client may face the sadness or anxiety related to letting go of behaviors that no longer work. Therapists may help a client to re-evaluate themselves should they change their behaviors. Preparation is a stage in which the individual is fully intending to take action, and they may make small behavioral changes. Therapists may help clients in this stage to act on their belief that they have the ability to change their behavior. Action is the stage in which clients modify their behaviors or environment to overcome their problems. Therapists may help clients at this stage by ensuring clients perceive adequate reinforcements for their efforts and resist the tendency to avoid problematic situations or feelings. Finally, the maintenance stage is the point at which clients have made desirable changes and now work to prevent relapse and consolidate gains. Therapists may help individuals during the maintenance phase to be prepared for or to avoid situations that may induce relapse. A key aspect of therapist stances related to client stages of change is exemplified by the process of motivational interviewing, in which the therapist works with the client’s resistance rather than taking a confrontational stance. In this meta-analysis, Krebs and colleagues systematically reviewed the literature on stages of change and summarize 76 studies with over 21,000 clients. The association between stage of change and client outcome was significant and moderate in effect size (d = 0.41; 95% CI: 0.34, 0.48). That is the stage of change at which the client starts has a measurable impact on their outcomes, with pre-contemplation being related to poorest outcomes, and action being related to best outcomes. These results were consistent across theoretical orientations. In a second meta-analysis, the authors found that tailored interventions to move clients to more advanced stages of change were significantly related to better outcomes, though the effects were small (d = 0.18; 95% CI: 0.16, 0.20).

Practice Implications

The stage of change theory is transtheoretical – that is, it operates across most therapeutic situations and clients. The findings of this meta-analysis indicate that therapists who know the client’s stage of change and who act accordingly will improve their client’s outcomes. Many therapists tend to believe that their clients are at the action stage, but this may not be the case. Treating someone who is contemplating change as if they are ready to make changes may be counter-therapeutic as it represents a mismatch of goals. Hence, therapists should work with clients to set realistic goals for therapy, and therapists should keep in mind that a patient who is not ready to change will not likely change if confronted. The best strategy may be to discuss with the client the risks and benefits of their behaviors, and help them make a decision of how or if to move forward with therapy.

Sakaluk, J. K., Williams, A. J., Kilshaw, R. E., & Rhyner, K. T. (2019). Evaluating the evidential value of empirically supported psychological treatments (ESTs): A meta-scientific review. Journal of Abnormal Psychology, 128(6), 500-509.

In the 1990s the Clinical Division of the American Psychological Association commissioned a Task Force to identify “Empirically Supported Treatments” (EST). The Task Force decided that psychotherapies that repeatedly showed statistically significant improvements over no treatment, placebos, or another treatment would be designated as “Strongly” supported. They also designated some treatments as “Modestly” supported or with “Controversial” support. The EST movement continues to have a great impact on the practice, research, and funding of psychotherapy. Time-limited, diagnosis-focused therapies, tested in randomized controlled trials became the “gold standard”. Clinicians are expected to practice these ESTs, research agencies focus funding on these models, and some governments and insurance companies provide reimbursements only for these types of therapy. The Empirically Supported Treatments (EST) movement redefined the practice of psychotherapy as short-term, symptom-focused, technically-oriented, and mostly cognitive-behavioral. In this meta-scientific review Sakaluk and colleagues asked: how good is the evidence for the ESTs? The authors were particularly concerned with the quality of the studies from a methodological and statistical point of view: how likely was it that these findings could be replicated, or how reliable were the findings? The good news is that there were few instances (about 10%) of research supporting ESTs in which researchers mis-reported the statistics (i.e., error in the reporting of statistical findings). This is quite a bit lower than previously identified mis-reporting rates (about 50%) in psychological research in general. However, only about 19% of ESTs were supported consistently by high quality studies. Over half of ESTs were supported consistently by poor quality studies. Most of the studies supporting ESTs were not sufficiently powered to detect differences between treatments or conditions. That is, often the sample sizes of patients in the studies were too small, and so the significant results were not likely reliable or perhaps not plausible. Also, those therapies that the EST list defined as having “Strong” support were not backed by more higher quality research compared to therapies considered to have “Moderate” support. In other words, the decision to designate treatments as “Strongly” or “Moderately” supported appears to have almost no relationship with the quality of the research.

Practice Implications

Embedded in this dense methodological paper are some troubling findings and important practice implications. The authors suggested that there are a number treatments on the EST list that have dubious research support because the studies of those treatments may not stand up to replication (a critical test in scientific research). It is not clear that ESTs are any more effective than other bona-fide psychotherapies that are not on the list. (Bona-fide psychotherapies are those that are based on a psychological theory, delivered by trained therapists, and in which the patient and therapist develop a relationship). The findings question whether dissemination of and training in ESTs to the exclusion of other psychotherapies can be justified given the quality of the evidence. In other words, it is possible that other bona-fide psychotherapies that are not on the EST list may be just as effective. This does not imply that psychotherapy is not effective or that anything goes when it comes to the practice of psychotherapy. Evidence-based practice in psychotherapy should guide psychotherapists’ clinical choices. However, the EST list is not the final word on what constitutes “evidence-based” practice in psychotherapy, or on what treatments should be researched and funded.

Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance–outcome relation in couple and family therapy. Psychotherapy, 55(4), 356-371.

In individual psychotherapy the therapist’s tasks include to develop an alliance with one patient. Goals and tasks of therapy need to be collaboratively negotiated, and therapists need to develop an emotional bond with the patient. The alliance also has to be nurtured continuously throughout treatment. This process is more complicated in couple and family therapy. Only in couple and family therapy (and in group therapy) does a therapist have to develop an alliance with multiple people simultaneously. The challenge is greater when family members are in conflict, or when the therapist’s alliance is stronger with one member than another. Such “split” alliances can be problematic especially when family members view their experiences of the therapist differently. To complicate things more, therapists have to be aware of the alliance within the family or couple system. That is, are the family members allied with each other – do they agree on therapy goals and tasks, and are they able to maintain an emotional connection to each other? In addition, just as therapeutic alliance ruptures can occur in individual therapy, so can they occur in couple and family therapy. An alliance rupture may occur when a there is a “split” alliance or when a patient responds to the therapist or other family members with confrontation or withdrawal behaviors. In this meta-analysis of therapeutic alliance in couple and family therapy, Friedlander and colleagues included 48 studies with a total of 2,568 families and 1,545 couples. The correlation between quality of the alliance and outcome was significant (r = .297, 95% CI [0.223, 0.351], p < .001), indicating that a stronger alliance was related to better outcomes. There was some evidence of publication bias suggesting that this estimate may be over-inflated, but even after adjusting for publication bias the correlation was still significant. The correlation between split alliances and outcome was also significant (r = .316, 95% CI [0.157, 0.458], p < .001), indicating that more split alliances contributed to poorer outcomes. The correlations were similar in strength both in couple and in family therapy, and the alliance was important in all therapeutic orientations. However, correlations were larger when the targeted child in the family was younger, and when families were seeking help and not mandated.

Practice Implications

Like in individual therapy, the therapeutic alliance in couple and family therapy is important to improve the outcomes of patients. Regardless of therapeutic orientation, therapists must spend time and effort developing therapeutic alliances with each member of the system, and must try to maintain relatively equal alliances with each family member to avoid splits in the alliance. Therapists should be particularly aware of any confrontation and withdrawal behaviors towards the therapist or within the family or couple as these may indicate an alliance rupture. In such instances, therapists should emphasize shared goals and feelings, validate the common struggle among family members, and focus on the emotional bond with the disaffected patient. Each person’s alliance matters, and family member alliances are not interchangeable. Assessing the alliance with each member throughout therapy will identify potential problems and facilitate better outcomes.

Nehrig, N., Prout, T.A., & Aafjes-van Doorn, K. (2019). Whose anxiety are we treating, anyway? Journal of Clinical Psychology. Online first publication.

Evidence-based practice (EBP) in psychotherapy is defined by the American Psychological Association as the deliberate integration of: (1) the research evidence, (2) clinician expertise in making treatment decisions, and (3) client characteristics, preferences, and culture. The EBP statement was meant to supplant an older model of prescriptive psychotherapy practice that resulted in the creation of lists of empirically-supported treatments (EST). The ESTs were defined as: (1) manualized therapies, (2) shown to be efficacious in randomized controlled trials, (3) for patients with a specific diagnosed mental disorder. However, manualized therapies are not necessarily more effective than non-manualized treatments, and patients in randomized controlled trials may not represent those typically seen by therapists in everyday practice. Although EBPs are the current standard by which psychotherapists should practice, many therapists and organizations focus almost exclusively on the first of the EBP criteria (the research evidence of ESTs) to the exclusion of the second and third criteria (clinician expertise, and patient characteristics, preferences, and culture). In this review article, Nehrig and colleagues speculated about why this is the case by asking: “whose anxiety are we treating?” They argued that manualized therapies identified as ESTs reduce therapists’ anxiety caused by: uncertainty about treatment outcomes, the emotional toll of providing psychotherapy to people who are suffering, and the negative emotions (anxiety, despair, cynicism) that sometimes arises in therapists from the work. Nehrig and colleagues argued that ESTs provide therapists with a sense of control and certainty, while limiting therapists’ attention on relational challenges in the work of therapy. However, this emphasis on ESTs comes at a cost for therapists and patients. Therapists may not focus on developing skills to manage the relational challenges inherent in providing psychotherapy, greater certainty may reduce therapists’ engagement in sufficient self-reflection, and therapists may attend only to patients’ symptoms and not to the patient as a whole person. Nehrig and colleagues also discuss the preference for ESTs among institutions, insurance companies, and government funders of psychotherapy. ESTs reduce anxiety in these contexts because ESTs are seen by managers as methods to enhance accountability and standardization of treatment, to uphold standards of care, and to reduce potential liability. The short-term nature of most ESTs also assuages economic concerns for institutions and funders who wish to manage costs. However, this emphasis on short term manualized treatment also reduces psychotherapy from a complex interpersonal process with inherent uncertainty to one that resembles a clear-cut medical procedure that encourages top-down decision-making about clinical practice.

Practice Implications

Anxiety about the complexity of psychotherapy can cause therapists, institutional managers, and government funders to place greater value on ESTs rather than on clinical expertise of the therapist and patient characteristics. Patient characteristics, preferences, and culture are related to developing the therapeutic alliance and to patient outcomes. Astute therapists can learn to adjust their interventions to these patient characteristics, which may mean using clinical judgement to alter or deviate from a prescriptive manual. An EBP approach that integrates research, clinical expertise, and patient characteristics allows therapists to take into account transtheoretical factors known to affect outcomes like the therapeutic alliance, repairing alliance ruptures, empathy, and to use their clinical expertise to adjust their interpersonal stances to relevant patient characteristics, preferences, and culture.

Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4), 341-355.

Over the past decades there has been increasing research on the efficacy of psychotherapy for children and adolescents, but outcomes have not always been positive. Treatment of children and adolescents comes with challenges that are unique from those experienced in therapy of adults. For example, unlike most adults, children and adolescents may not be the ones to choose to attend therapy - that decision is often made by adults in their lives. Furthermore, psychotherapists must also develop and maintain a collaborative relationship with parents, on whom the therapist and child/adolescent rely in order to be able to engage in treatment. Because of the unique characteristics of working with children and adolescents, negotiating, developing, maintaining, and repairing the therapeutic alliance is potentially complex. The therapeutic alliance is defined as an agreement on tasks of therapy, an agreement on goals of therapy, and the relational bond between therapist and client. In this meta-analysis, Karver and colleagues reviewed 28 studies of psychotherapy with children and adolescents. The mean age was about 12 years, most children/adolescents had internalizing problems, but others had problems with externalizing behaviors, and substance abuse. Almost two thirds of the studies involved a version of behavior or cognitive behavioral therapy. The therapeutic alliance was measured from the perspective of the client, therapist, and/or the parent. The overall mean effect size of the alliance-outcome relationship was small to moderate: r = .19 (p < .01, 95% confidence interval [CI] [0.13, 0.25]). Larger effect sizes were seen in those therapies of children and adolescents with internalizing disorders (r = .19), and when the therapist – parent alliance was measured and correlated with outcomes (r = .30). In other words, a positive alliance was most important for internalizing disorders, and for the relationship between therapist and parent.

Practice Implications

The findings of this meta-analysis indicate that the therapeutic alliance, especially with the parent, is important to the outcomes of children and adolescents in psychotherapy. Clinicians should not only develop an alliance with the youth, but also with the parent/caregiver. Therapists should also consider measuring the alliance regularly during therapy as a means of heading off any ruptures (with the youth or the parent) that might endanger the therapy. The authors recommended using the Therapeutic Alliance Scale for Children – Revised with children/adolescents, and the Working Alliance Inventory with parents.