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The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

The conduct of psychotherapy trials almost always requires that therapists be adherent and competent in delivering a manualized therapy intervention. Treatment adherence usually refers to the extent to which a therapist used the intervention prescribed by a treatment manual. Therapist competence refers specifically to a therapist’s skill in delivering the therapy. So “competence” in the context of psychotherapy research typically refers only to performing a certain type of treatment. Wampold and Imel argue that these definitions are consistent with a Medical Model of psychotherapy that emphasizes delivering specific active ingredients of a treatment. The Contextual Model of psychotherapy, on the other hand might define a therapist as competent to the extent that the therapist is interpersonally skilled, empathic, and able to engage clients in the actions of the therapy. Wampold and Imel report on a meta analysis of 28 studies conducted by Webb and colleagues (2010) who found a small and non-significant relationship between therapist adherence and patient outcomes (r = .02), and a small and non-significant relationship between therapist competence and patient outcomes (r = .07). Type of treatment (e.g., CBT, IPT, dynamic) did not affect these associations – in other words adherence and competence were not more important to CBT than to other treatments. However, competence seemed to be more important for the treatment of depression (r = .28). Perhaps depression responds better to specific techniques. The finding that competence was generally not related to outcomes was surprising, however generally competence is narrowly defined as how well a therapist delivered the treatment not how well the therapist was able to establish a therapeutic context. Previous researchers concluded that when clients liked working with a therapist, clients got better, and therapists were rated as more competent as a result. A number of studies appear to indicate that therapist competence is really a function of the client’s characteristics not to what the therapist does. For example, clients with more severe personality problems could make a therapist appear less competent, and these clients may have poorer outcomes. If this is the case, it would create a paradoxical situation in which therapists’ appearance of competence (i.e., ability to deliver a manualized intervention well) is largely determined by the client and not by the therapist.

Practice Implications

In contrast to the findings about adherence and competence, the therapeutic alliance is robustly related to patient outcomes. Also in contrast, the size of the alliance-outcome relationship is almost entirely due to the skills of the therapist, not the client’s characteristics. In other words, therapist competence is not a matter of whether they can do a good job of following a manual, but rather therapist competence is likely a matter of creating the right conditions (i.e., interpersonal skill, alliance, empathy, etc.) for delivering evidence-based interventions by which many clients improve. However, some therapists are better at these facilitative interpersonal skills than others.

The Great Psychotherapy Debate: Since April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark and sometimes controversial book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

A couple of decades ago Martin Seligman famously said: “Whenever you hear someone demanding a double-blind study of psychotherapy, hold on to your wallet.” In this chapter, Wampold and Imel continue their examination of the Medical Model versus the Contextual Model for psychotherapy by discussing the viability of double-blind placebo control designs in psychotherapy. This topic sounds a little esoteric, but it’s not – this issue reaches into the very core of the definition of psychotherapy. A placebo-controlled trial in medicine often involves comparing a medication that contains an active biochemical ingredient versus a “sugar pill” that is exactly like the medication but without the active biochemical ingredient. Key to the placebo controlled design is that the health care provider, the patient, nor the researcher/evaluator knows which patient received which pill (i.e., the classic “double-blind” design). However, double-blinding is impossible in psychotherapy – the therapist must know what they are providing, which means that they know which treatment is expected to be effective, and which treatment is favoured by the researchers. Further, the researchers know which patients are getting which intervention of study condition. This affects a critical aspect of psychotherapy, that is, the therapist’s ability to provide a good rationale for the disorder and for the efficacious actions of the therapy. Additionally, patients are often aware that they are getting a pseudo-treatment in the placebo, and so their expectation of outcomes is also lowered (actually, this is often true in medical trials as well as most medications have side effects, and the absence of a side effect signals to the patient and the researcher that the patient is receiving the placebo). Wampold and Imel argue that common factors like emotional arousal, an acceptable explanation of the disorder, an understanding and empathic therapist, a structure to the treatment, and therapist and client expectations and hope are integral to the effectiveness of psychological therapies. They further argue that these are the very factors that medical trials try to control with a double-blind placebo controlled trial. Nonetheless placebo-like controls have been tried in psychotherapy to test the active or specific ingredients of a therapy – that is, to isolate the effects of active ingredients from the relationship context of the therapy. Placebo-like controls in psychotherapy have been called: minimal treatment, supportive counselling, non-directive counselling, etc. However, as mentioned, these placebo control conditions often contain elements that are integral to the effectiveness of psychotherapy, like: emotional arousal, an empathic therapist, and client expectations. And so not surprisingly, after reviewing meta-analyses of placebo-like conditions in psychotherapy research, Wampold and Imel conclude that when the studies are well constructed, these placebo-like conditions perform nearly as well as evidence-based treatments.

Practice Implications

What is the take home message for the clinician of this seemingly esoteric topic about research design? Although the placebo-controlled double-blind randomized design is the gold standard in medical research, this design is not possible or even logical for psychotherapy. The relationship, therapist factors, expectations, and contextual factors that one tries to control in a placebo-controlled trial are some of the very ingredients that are active in psychotherapy. The technical and specific ingredients of psychotherapies (e.g., transference interpretations, cognitive restructuring, two-chair techniques, etc.) are also part of the mix; but in the end, one cannot separate contextual relationship factors from techniques when it comes to providing psychotherapy.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the book, Wampold and Imel discuss the importance of client expectations on psychotherapy outcomes. In particular, they equate client expectations with the placebo effect. In the July, 2015 PPRNet blog, I discussed Wampold and Imel’s distinction between the Contextual Model of psychotherapy and the Medical Model of psychotherapy. One pathway of the Contextual Model indicates that patients who accept an explanation for their disorder and who agree with therapists about therapy interventions, experience expectations that have a powerful impact on patients’ emotions and cognitions. The placebo effect has long been known to improve patients’ response to medical interventions. The placebo effect is defined as the difference between a supposedly inert event or medication and the natural course of the disorder. By contrast, the specific effect of an intervention or medication (e.g., an antidepressant) is defined as the difference between the medication and the placebo (i.e., the effect of a medication over and above the effect of a placebo). In one important meta analysis, the placebo effect accounted for about 68% of the antidepressants’ impact on depression scores. In other words, the placebo effect (i.e., the expectation of receiving help) has a powerful impact on depression. Generating an expectation of improvement (“this pill is an antidepressant that will reduce your depression”) involves: (1) providing a plausible explanation for the disorder (“depression is biochemical imbalance, and this pill [actually an inert placebo] will help”), and (2) having a relationship with an empathic provider. Client expectations of improvement result in mental health outcomes that approach the effects of standard medical treatment for depression. In psychotherapy, creating expectations about the effectiveness of the intervention, providing an explanation of the disorder based on psychological and biological theories, and agreeing on the tasks and goals of therapy are an integral part of the treatment. In other words, the placebo response is part of what makes psychotherapy work, and good therapists capitalize on its effects.

Practice Implications

Patient expectations about the effectiveness of the therapy, their agreement with the therapist on the tasks and goals of therapy, and the therapist’s empathy toward the patient are key aspects that will increase the effectiveness of a therapeutic intervention. The explanation of the disorder and the treatment approach are embedded in psychological theories that typically underpin evidence-based psychotherapies.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the book, Wampold and Imel reviewed the research literature on the therapeutic alliance. The therapeutic alliance is considered a pan-theoretical construct that is critical to the success of all psychotherapies. Alliance is defined as the: (a) agreement on the goals of therapy, (b) agreement on the tasks of therapy, and (c) the bond between therapist and client. Numerous meta analyses across several decades demonstrate a robust relationship between the alliance and therapy outcome. For example, Horvath and colleagues (2011) conducted a meta analysis with 190 studies that included over 14, 000 clients in which the average effect size was r = .28, indicating a moderate and significant association between alliance and outcomes. Some researchers argued that this is an under-estimation of the alliance outcome relationship. In Horvath and colleagues’ meta analysis, they found no difference between type of psychotherapy (CBT, interpersonal, dynamic) and the alliance – outcome relationship. However, the alliance may work differently in some therapies. For example, in CBT there is some evidence that the collaborative bond is not related to outcomes, but rather the agreement on tasks and goals is related to patient outcomes. This highlights that an alliance cannot happen without techniques; in other words, if techniques fail to engage the patient in the work of therapy, then the technique is not working properly. Wampold and Imel also reviewed the research on whether the therapist or the patient is most influential in developing an alliance. Using sophisticated statistical techniques, they were able to disentangle the effects of therapists and clients. More effective therapists were those who had stronger alliances with patients, and their patients had better outcomes. However, the patient’s contributions to developing an alliance were not significant. Finally, Wampold and Imel reviewed the research on whether early alliance causes good outcomes, or whether early outcomes causes a good alliance. If the latter were true, then the therapeutic alliance would simply be an artifact of early improvement – that is, the alliance would not be necessary for patients to improve. Most of the studies, which were conducted by researchers of different theoretical orientations, concluded that early alliance predicts outcomes and not the other way around. There is some evidence that change in the alliance and change in symptoms have a reciprocal impact – as the alliance grows the patient subsequently improves and as the patient improves the alliance subsequently grows.

Practice Implications

Clearly, developing and maintaining a therapeutic alliance is important to achieving good patient outcomes in psychotherapy. The alliance is not independent from techniques of psychotherapy. In other words, therapists and clients have to agree on the tasks and goals of treatment, and this agreement is fundamental to all treatment modalities offered to patients. If there is no agreement, then therapists have to consider changing course or discussing with the client ways of achieving an agreement. Over and above that, therapists and clients must have some interpersonal bond that is likely underpinned by the therapist’s empathy, positive regard, and concern for the client. The research is clear that it is the therapist who most strongly contributes to the development of an alliance, and so it is the therapist’s responsibility to nurture a positive working alliance.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

Some therapists achieve better patient outcomes than others. This seems obvious on the surface and yet few people talk about it, and the research literature seems to downplay or ignore this fact. To illustrate the differing outcomes achieved by therapists, I reviewed a unique study in the September 2013 PPRNet Blog. In that study, 10 cases were randomly selected from 700 therapists (N = 7000 patients), and therapist outcomes were assessed by averaging their patient outcomes. Depending on the presenting problem, as many as 67% of therapists were reliably effective, but as many as 16% were reliably harmful. Clearly therapists differ. Yet psychotherapy research typically treats therapists as if they are uniformly effective. In their chapter, Wampold and Imel review some of the research that estimates the therapist’s effect on outcomes. In other words, what is the impact of the particular therapist on the patient outcomes? Even in studies in which: (a) therapists are selected as experts to provide a specific type of therapy (i.e., CBT, psychodynamic, interpersonal, etc.), (b) therapists are highly trained to be adherent to a manual with repeated supervision, and (c) patients are randomly assigned to treatments, there remains a significant amount of variability in therapist outcomes. Indeed in many studies the therapist effect is as large or larger than the effect of the intervention that is being delivered. In other words, which therapist a patient gets in a treatment study matters just as much or more than what type of therapy they receive. This is also true in medication trials. Better psychiatrists (i.e., those with overall better patient outcomes) who gave a placebo had better patient outcomes than poorer psychiatrists who gave the active medication. A recent large meta analysis found that about 5% of patient outcomes in controlled psychotherapy trials was attributable to the therapist, and the effect is as high as 7% in naturalistic settings. For treatment of PTSD, therapist effects are as high as 12%. On the surface these look like small effects, but in reality they can have a big cumulative impact. Therapists with the best and worst outcomes differ dramatically. For example in one large study, the best performing therapists had a patient response rate of 80% compared to the worst performing therapists who had only 20% of their patients improve. Which therapist would you want a loved one to see?

Practice Implications

Wampold and Imel reported that that therapist effects generally exceed the effects of the specific treatment that is being tested or provided. Some therapists consistently achieve better patient outcomes than others. What are the characteristics and actions of effective therapists? Factors like therapist allegiance to the therapy, empathy, and the ability to form and maintain an alliance with clients appear to differentiate therapists who consistently have good patient outcomes versus those whose patients tend to have poor outcomes.

Angus, L., Watson, J.C., Elliott, R., Schneider, K., & Timulak, L. (2015) Humanistic psychotherapy research 1990–2015: From methodological innovation to evidence-supported treatment outcomes and beyond. Psychotherapy Research, 25, 330-347.

In this wide-ranging review, Angus and colleagues provide an overview of humanistic psychotherapy research from 1990-2015. For this blog I will focus on the efficacy research that they review. Humanistic psychotherapy addresses how people can come to know themselves and each other, and to fulfill their aspirations. This type of therapy emphasizes the personal, interpersonal, and contexts within which clients reflect on their relationships with the self, others, and the world. Carl Rogers is probably the best known early proponent of humanistic client centred psychotherapy. Humanistic psychotherapy focuses on a genuinely empathic therapeutic relationship to promote in-therapy client emotional experiencing, emphasizes meaning-making, and is person-centred. One of the questions raised by Angus and colleagues was: are humanistic psychotherapies efficacious. Here they mainly summarize a previous review by Elliot and colleagues (2013). In a meta analysis of 191 studies and over 14,000 clients, humanistic psychotherapies are associated with large pre to post therapy client change (g = .93) which are maintained over early (< 12 months) and late (> 12 months) follow ups. Further, in 31 studies of over 2,000 clients, those who received humanistic therapies show large gains compared to those who receive no treatment (g = .76). In 100 studies of over 6,000 clients, humanistic therapies had equivalent outcomes to other therapies (g = .01), including CBT (22 studies, g = -.06). Humanistic therapy was most effective for interpersonal/relational trauma, and depression (for which it is considered an evidence supported treatment). There is also good evidence for the efficacy of humanistic therapy for psychotic conditions. However, humanistic therapies may be less effective than CBT for anxiety problems.

Practice Implications

Humanistic psychotherapy that focuses on a genuinely empathic therapeutic relationship that emphasizes client emotional experiencing and meaning-making is efficacious for a number of mental health problems. Rogers argued that non-judgemental acceptance, warmth, and congruence were necessary for good client outcomes, and an accumulating body of research is supporting these early propositions. The evidence for the importance of therapist empathy to improve client outcomes is particularly compelling.

Author email: langus@yorku.ca