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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.

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

The narrative about the relative efficacy of psychotherapies for depression has shifted over the past several decades. In the early days (1970s – 1980s) there appeared to be accumulating evidence that cognitive behavioural therapy (CBT) was more efficacious than “other psychotherapies”. However, today one look at the Society for Clinical Psychology list of empirically supported treatments for depression indicates that a variety of interventions are efficacious. In this part of their book, Wampold & Imel examine this change. Early in their book, they defined psychotherapy as: (1) based psychological principles, (2) involving a trained therapist and a client who is seeking help for a mental disorder, (3) intended to be helpful for the client’s complaints, and (4) adapted to the client’s problem. Wampold and Imel argue that many of the treatments compared to CBT in the early days did not meet this definition of psychotherapy. That is, many of the early comparison treatments were not bona-fide therapies; so the comparisons were not expected to be therapeutic. Common comparisons to CBT were “usual care”, “supportive therapy”, and “self directed care” that for the most part did not meet the definition of psychotherapy. Further, the providers of usual care or supportive therapy had no allegiance to the treatment or expectation that the intervention was useful, which eroded the credibility of these interventions for the client. When bona-fide psychotherapies are compared to each other, the effect sizes tend to be small or negligible. For example, Braun and colleagues (2013) conducted a large meta analysis of 53 studies with nearly 4,000 patients.  When they looked specifically at studies of bona fide therapies, and pairs of treatments that were compared in at least 5 studies, there were no differences between the treatments. Similar findings are reported in large a network meta analysis by Barth and colleagues (2013) (198 studies with 15,118 patients) that was summarized in the July 2014 PPRNet Blog.

Practice Implications

Psychotherapies that are based on sound psychological principles, delivered by trained therapists for clients who seek help and that are intended to be helpful for the client’s complaint are likely to be equally effective for depressive disorders. A variety of psychotherapies including, CBT, emotionally-focused therapy, interpersonal psychotherapy, and short-term psychodynamic therapy have demonstrated empirical support for their efficacy in treating depression. Client expectations of receiving benefit and therapist allegiance to treatment enhance the effectiveness of treatments.

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.

Why We Should Care About Allegiance Effects in Psychotherapy Research

Allegiance in psychotherapy refers to the degree to which a researcher or therapist believes that the therapy they are studying or delivering is effective. Clients have an expectation that therapists have an explanation for their disorder and that the therapy used to address that explanation will lead to improvements. On their part, psychotherapists choose a therapeutic approach that is consistent with their understanding of psychological distress. Wampold and Imel argue that therapist allegiance is a common factor across therapies that contributes to good patient outcomes. Although allegiance is an important therapeutic factor, it complicates the conduct of psychotherapy research. In a trial comparing two treatments, for example, researchers and therapists tend to be affiliated with one of the treatments and so they believe in the effectiveness of their treatment. They often do not feel the same way about the comparison treatment, or they may desire that their preferred treatment be more effective than the comparison. In medication trials, this allegiance effect can be controlled by a double blind placebo controlled design in which both therapist and patient are not aware of who is receiving which active medication, or who is receiving a placebo. It is impossible to blind therapists in psychotherapy trials – therapists have to know what treatment they are providing. When doing a meta analytic review of psychotherapy trials, it is possible and relatively easy to identify the allegiance of the researchers in a particular study by looking at their past publications, and by reading what they say about the therapies they are comparing. Often, the developer of a treatment manual is a co-author of the trial. Wampold and Imel review several meta analyses that assess the allegiance effects. In three meta analyses from published in 1980, 1999, and 2013 the correlation between ratings of researcher allegiance and effects of psychotherapy on patient outcomes ranged from moderate to large (r = .26 to r = .85). One interesting meta analysis illustrates the magnitude of this effect. The reviewers looked at 69 studies on self statement monitoring (SSM), a type of cognitive therapy developed by Meichenbaum. The average effect of SSM compared to controls in all studies was d = .53 to d = .74, which is moderate. However, effect sizes found in the studies co-authored by Meichenbaum were nearly twice as large, d = d = 1.23. Being a co-investigator in a study of a therapy that one develops, apparently doubles the effect of the treatment on patient outcomes.

Practice Implications

Therapist allegiance to a treatment is important to the effectiveness of the treatment in that therapist allegiance increases the therapist’s confidence in the treatment’s effectiveness and increases a patient’s expectation of getting better. However, when interpreting psychotherapy trials, especially those that pit one type of therapy against another, it is important to keep in mind the researchers’ allegiance. It is rare to see trials that compare two interventions in which the research team is made of up proponents of the two interventions. However such trials are important and necessary.

Boswell, J.F., Kraus, D.R., Miller, S.D., & Lambert, M.J. (2015). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, 25, 6-19.

Routine outcome monitoring (ROM) refers to: (1) systematically assessing patient outcomes at every session, (2) comparing patient scores and progress to a database of similar patients, (3) using algorithms or decision tools to identify patients who are not improving or deteriorating, (4) providing regular and immediate feedback to therapists about the patient, and (5) in some cases providing clinical decision aids to help therapists improve outcomes for patients who are not improving or who are deteriorating. Boswell and colleagues review the research related to ROM. Generally, about 30% to 50% of patients do not respond to treatment, and 8% of patients tend to get worse during treatment. Therapists tend to overestimate their patients’ improvement, and so therapists may not always identify patients who do not respond or get worse. Therapists may need assessment aids to help them make decisions about patient progress and treatment. Boswell and colleagues point out that ROM have a proven ability to predict treatment failure and other negative outcomes. In a meta analysis of over 6,000 patients, the patients at risk of a negative outcome whose therapist received ROM feedback prior to every session were better off than 70% of at-risk patients whose therapist received no feedback. When therapists are provided feedback and suggestions for interventions, their patients had almost four times higher odds of achieving clinically significant improvement. Boswell and colleagues list a number of barriers that psychotherapists and agencies experience to implementing ROM in their practices. Many therapists are not aware of or have no experience with ROM, and so they may not be aware of its benefits to their practice and patients. Time and money are two practical issues that may arise. This type of assessment is not always reimbursed and the average clinician may feel that they do not have enough time to reflect on routine assessment and feedback so as to reconsider their interventions. Agencies may not understand the value of allocating resources to this type of testing (although medically oriented agencies would not hesitate to order a blood test or an x-ray). Finally, some therapists might experience ROM as intrusive, as impeding the therapeutic relationship, and as a means for an agency to control therapist decisions.

Practice Implications

Routine outcome monitoring (ROM) has clear benefits to patients, therapists, and agencies. To overcome barriers, therapists and agencies could implement ROM as part of routine clinical care, and advertise this as an evidence-based practice that will benefit prospective patients. Clients generally appreciate knowing that they will receive the best possible care. ROM can enhance the therapeutic relationship if it is presented to clients as a collaborative endeavor. For example, if a patient is not improving or is deteriorating, therapists can discuss this with patients as well as a plan to alter aspects of the treatment in order to improve the prospects for a better outcome. Therapists can choose from a number of possible ROM options to best tailor the approach to their clients based on cost, time, and relevance. Currently, there are several outcome monitoring systems available to clinicians including: the Partners for Change Outcome Management System (PCOMS), the Treatment Outcome Package (TOPS), the Clinical Outcomes in Routine Evaluation (CORE), and the Outcome Questionnaire (OQ) system.

Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51(4), 467-481.

In this wide ranging review of the Common Factors (CF) perspective in psychotherapy, Laska and colleagues tackle the complex issues of defining CF and describing the evidence. The authors argue that CF in psychotherapy are not a vague set of ideas that fit under the label of “non-specific factors” or “relationship factors”. They also state that there is an unnecessary dichotomy between the concepts of empirically supported treatments (EST) and CF. In EST, specific and brief manualized therapies for specific disorders are tested in highly controlled randomized trials. ESTs purport that efficacious psychotherapies contain specific techniques based on an articulated theory of the disorder, and a specific mechanism of change for that disorder (e.g., depression is partly caused by depressogenic beliefs and so CBT for depression specifically targets cognitive distortions). There are published lists of ESTs for many disorders. However, Laska and colleagues argue that there is little evidence of the specificity of these treatments. For example, in dismantling studies an intervention like CBT for depression is compared to a dismantled version that removes an “active ingredient” [e.g., by providing only behavioral activation as an intervention], with little difference in patient outcomes between the full and dismantled versions. Further, for a number of disorders, several therapies based on very different theories of the disorder and of change are equally effective. In contrast to the EST approach, Laska and colleagues describe the CF approach which focuses on factors that are necessary and sufficient for patient change across psychotherapies, such as: (1) an emotional bond between client and therapist, (2) a healing setting for therapy, (3) a therapist who provides a theoretically and culturally relevant explanation for emotional distress, (4) an adaptive explanation that is acceptable to clients, and (5) procedures that lead clients to do something that is positive and helpful. Nevertheless, CF does not provide therapists with a license to do whatever they want without considering the evidence of a therapy’s efficacy. Rather CF does encourage therapists to make use of specific factors found in ESTs and to practice with a purpose. In support of the importance of CF, Laska and colleagues review the evidence from a number of meta analyses that show that CF (i.e., alliance, empathy, collaboration, positive regard, genuineness, therapist effects) each account for 5% to 11.5% of patient outcomes. These are moderate effects. Specific ingredients of psychotherapies or differences between ESTs account for 0% to 1% of patient outcomes, which represent small effects.

Practice Implications

An excessive focus or reliance on empirically supported therapies (EST) may unnecessarily limit what the profession and funders consider to be evidence-based practice. A common factors (CF) approach provides scientific evidence for effective therapeutic practices that are necessary in addition to the specific treatments found in lists of ESTs. To be effective, therapists should be able to: (1) develop a therapeutic alliance and repair ruptures to the alliance, (2) provide a safe context for the therapy, (3) be able to communicate sound psychological theory for the client’s distress based on evidence, (4) suggest a course of action that is based on evidence, and (5) conduct therapy based on established theories of distress and healing. Laska and colleagues argue that systematic patient progress monitoring and ongoing monitoring of the therapeutic alliance may be an effective method of quality improvement of therapists’ outcomes. Progress monitoring may provide therapists with information about areas for continuing education to improve their patients’ outcomes.

Safran , J. D. & Kraus , J. (2014). Alliance ruptures, impasses and enactments: A relational perspective. Psychotherapy, 51, 381-387.

In this clinically oriented review, Safran and Kraus discuss the evidence related to alliance ruptures, repairing alliance ruptures, and methods of training in alliance rupture repair. Safran’s work represents “second generation” research on the therapeutic alliance. The therapeutic alliance refers to the relational bond between client and therapist and their agreement on tasks and goals of therapy. A positive alliance is associated with good client outcomes across a variety of therapeutic approaches. Therapeutic alliance ruptures in psychotherapy are inevitable, such that the alliance is continually being re-negotiated, both implicitly and explicitly, throughout the therapy. Such ruptures might include strains, tensions, or breakdowns that could interfere with the ongoing collaboration between therapist and client. Ruptures are associated with re-enactments of dysfunctional relational patterns, but they also may provide opportunities for change and growth in therapy. Safran’s model of alliance ruptures and repairs sees the processes in the client-therapist relationship as key to understanding the client’s relationship problems. Collaboratively addressing tensions in the alliance allows the client to develop more flexible ways of being in relationships and of experiencing themselves. Research by Safran and Muran (2000) suggest that it is rare not to have some minor strain occurring in the therapeutic alliance. Ruptures may occur in half of therapy cases within the first six sessions. Research indicates that unresolved ruptures are associated with deterioration in the alliance, poor outcome, and patients dropping out. In a meta-analysis, repairing alliance tensions by using evidence-based strategies was associated with improved patient outcomes and the effect was large. Alliance ruptures occur across theoretical orientations. For example, research on cognitive therapy showed an improvement in therapist-client interpersonal processes after therapists were trained in techniques to resolve alliance ruptures.

Practice Implications

Alliance ruptures can range in intensity from minor tensions to major rifts in collaboration. They may occur at any time in treatment, and may be present in single or across multiple sessions. Safran and Kraus describe two general types of ruptures. First, withdrawal ruptures occur when clients deal with ruptures or misunderstandings by falling silent. The resolution may involve the therapist exploring the client’s interpersonal fears, reasons for inhibiting negative feelings, and providing the client with an opportunity to communicate their needs. Second, confrontation ruptures occur when clients directly express anger, resentment or dissatisfaction with the therapist or therapy in a blaming manner. The resolution may involve the therapist empathically engaging with the client to facilitate feelings of disappointment, hurt, and vulnerability. Key to this process is the therapist’s meta-communication or mindfulness abilities. The therapist must be aware of the behavior associated with the rupture, collaboratively explore the rupture experience, help the client overcome avoidance of feelings related to the rupture, and explore the client’s needs and wishes that emerge while working through the rupture.

Hoglend, P. (2014). Exploration of the patient-therapist relationship in psychotherapy. American Journal of Psychiatry, 171, 1056-1066.

In this overview of patient-therapist relationship factors, Per Hoglend reviews research on transference in psychotherapy. He argues that transference and transference work is a specific technique that focuses on exploring the patient-therapist relationship. Hoglend takes a broad definition of transference as: the patient’s pattern of feelings, thoughts, perceptions, and behaviors that emerge in the therapeutic relationship and reflect the patient’s personality functioning. Hoglend also defines transference work as any therapist intervention that refers to or explains the patient’s experience of the therapist and their interaction. These interventions include the therapist: (1) addressing transactions in the patient-therapist relationship; (2) encouraging exploration of feelings and thoughts about the therapy or therapist; (3) encouraging the patient to discuss how he or she believes the therapist might feel or think about the patient; (4) including him or herself in interpreting the patient’s dynamics; and (5) interpreting repetitive interpersonal dynamics and linking these to the therapy relationship. More than 30 studies have been published on providing empirical evidence for the relationship between transference work in psychotherapy and positive patient interpersonal outcomes. Effect sizes of the association between transference work and patient outcomes tend to be large. Some of the research indicates that low frequency of transference interventions is useful, but that a higher frequency may lead to negative effects on the patient. Research on transference-focused psychotherapy indicates that it is as effective as dialectical behavior therapy and supportive psychotherapy for borderline personality disorder, but that transference-focused therapy produced better outcomes for attachment related functioning like mentalizing. In the First Experimental Study of Transference Work (FEST), Hoglend found that patients with low quality of object relations (i.e. a poorer ability to maintain close relationships and to regulate affect) benefited most from transference focused therapy. However, those with high quality of object relations did not require the transference work to get better. Also, women responded better to transference work than men. There are some studies of therapeutic approaches like cognitive behavior therapy, in which patients with depression had better outcomes when the patient-therapist relationship was explicitly discussed.

Practice Implications

Hoglend argues that transference work in psychotherapy is an active ingredient that can lead to specific change in some patients. Most studies that Hoglend reviewed showed significant and large associations between transference work and interpersonal changes in patients. Exploring the patient-therapist relationship appears to be most useful for female patients, those with difficult interpersonal relationships, and those with more severe personality pathology. Patients with more mature relationships may not benefit as much from transference work. Although generally effective, if transference work is used too frequently in a session it can also lead to negative patient outcomes.