Blog

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.

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.

Elliott, R.E., Greenberg, L.S., Watson, J. Timulak, L., & Briere, E. (2013). Research on humanistic-experiential psychotherapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 495-538). New York: Wiley.

Humanistic or experiential psychotherapies (HEP) include: person centred therapy, gestalt therapy, emotion-focused therapy, existential psychotherapy, and others. Elliott and colleagues argue that each of these approaches share the characteristic of valuing the centrality of an empathic and therapeutic relationship. That is, an authentic relationship between patient and therapist provides the client with a new and emotionally validating experience. HEP methods that deepen client emotional experiences occur within an empathic relationship, and interpersonal safety is key to enhancing a client’s attention for self awareness and exploration. Despite the long history of research in HEP, these treatments are often used as “control” conditions in outcome studies of psychotherapies – that is, to control for “non-specific” or relationship factors. Elliott and colleagues conducted meta analyses on the effectiveness of humanistic-experiential therapies. Overall, they included 199 studies of over 14,000 patients. Pre to post treatment effect sizes were large (d = .95), indicating a positive effect HEP across a wide range of clients. (A note on effect sizes: Cohen’s d < .20 represents a negligible effect; d = .20 to .49 is a small effect; d = .50 to .79 is a moderate effect; and d > .80 is a large effect). Compared to a wait-list control (62 studies), the positive effect of HEP was significant with a moderate effect size for the difference (d = .76).  There were 135 studies that compared HEP to other active forms of psychotherapy. The difference between HEP and non-HEP therapies were trivial and non significant (d = .01). In the 76 studies that compared HEP to cognitive behavioral therapy (CBT), those who received CBT had better outcomes, but the effects were negligible (d = .13). The authors reported that there is enough evidence to indicate that HEP are efficacious for depressive disorders, substance misuse, and relationship problems; and HEP are probably efficacious for anxiety and psychotic disorders.

Practice Implications

The research on outcomes of humanistic-existential psychotherapies (HEP) provides support for the effectiveness of these therapies for a variety of disorders, and provides further support for the importance of the facilitative and relationship factors that help patients get better. Empathy, genuineness, positive regard each comes with research support to indicate their importance to patient outcomes.  Elliot and colleagues conclude that the education of psychotherapists is incomplete without greater emphasis on HEP and its facilitative components.

Barber, J.P., Muran, J.C., McCarthy, K.S., & Keefe, J.R. (2013). Research on dynamic therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 443-494). New York: Wiley.

In this part of their chapter, Barber and colleagues (2013) summarize the research on the efficacy of dynamic therapies for personality disorders. As the authors indicate, dynamic therapies refer to a family of interventions that: focus on the unconscious, affect, cognitions and interpersonal relationships; use interpretations and clarifications; consider transference and countertransference; and use the therapeutic relationship to improve self understanding and self-awareness. Following Magnavity (1997), the authors describe dynamic therapies specifically for personality disorders as identifying maladaptive, recurring patterns of thinking, behaving and emotional responding with the intent of restructuring these through linking current and transference patterns to early attachment and trauma. Barber and colleagues conducted meta analyses of available research on dynamic therapies for personality disorders. They combined several outcomes based on patient and observer reports as an index of general outcome. In seven studies representing 452 patients, dynamic therapies for personality disorders were more effective than control conditions (i.e., treatment as usual, or wait-lists), and the size of the effect was moderate. They found no significant differences between dynamic therapies and other types of therapy for personality disorders. Dynamic therapies had significant advantages over control conditions for general symptomatology, interpersonal problems, personality pathology, and suicidality. These therapeutic effects were maintained to short-term follow up.

Practice Implications

There are now several dynamic therapies for personality disorders that have substantial research evidence for their efficacy. For example, Transference Focused Psychotherapy for borderline personality disorder is considered a “well-established” treatment by the American Psychological Association Division 12. Mentalization-based treatment is also considered to be “probably efficacious”. Other “probably efficacious” dynamic therapies include: McCullough-Vaillant’s short term dynamic psychotherapy (STDP) and brief relational therapy for Cluster C personality disorders (i.e., avoidant, dependent, obsessive-compulsive); and intensive STDP for general personality disorder.

Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.

Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.

Practice Implications

CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from thenHandbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Burlingame, G.M., Strauss, B., & Joyce, A.S. (2013). Change mechanisms and effectiveness of small group treatments. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^thed.), pp. 640-689. Hoboken, N.J.: Wiley.

Group treatments are the most common types of interventions offered in community, organizational, institutional, and hospital settings. They occur in many contexts including: outpatients, inpatients, day hospital, private practice, community health, support groups, drop-in centres, and educational organizations. Despite the extent of their application, group treatments receive relatively little research attention compared to individual psychotherapy or medication interventions. (Not to mention the pervasive and mistaken notion that group therapy is like doing individual therapy with 8-10 patients at once, or that individual therapy training is sufficient to be expert in group therapy). There are many reasons for this relatively lower amount of research, including the lack of expertise in and understanding of group practice among clinical researchers, and the substantially greater difficulty in running a clinical trial of group therapy (of the latter I have ample experience and war wounds). Nevertheless, Burlingame and colleagues summarized more than 250 studies that estimated the efficacy or effectiveness of group therapy for 12 disorders or populations. The findings indicate good or excellent evidence for the efficacy of group treatments for many disorders or patient groups (e.g., panic, social phobia, OCD, eating disorders, substance abuse, trauma related disorders, coping with breast cancer, schizophrenia, and personality disorders). There are also promising results for other disorders (e.g., mood, pain, and inpatients). Although there are substantially more studies on group CBT, most studies that compare different models (including IPT, psychodynamic, DBT, etc.) often produce equivalent outcomes. There is also lots of evidence that group therapy is as effective as individual therapy or medications for most disorders. In one U.S. study on panic disorder, group psychotherapy was the most cost effective (i.e., cost per rate of improvement) of the interventions ($246) compared to individual therapy ($565) and medications ($447). There is also research on the effects of specific characteristics of groups. For example, research on group composition (i.e., heterogenous vs homogeneous in terms of patient population or functioning) has produced mixed results, though there is emerging evidence that heterogeneous groups tend to benefit those who are lower functioning. Further, research on group cohesion (i.e., the bond between the individual and the group) which is a construct related to but distinct from alliance, is positively associated with treatment outcomes with a moderate effect size.

Practice Implications

Group treatments are as effective as individual therapy or medications, and are likely more cost effective. However group therapy is more complicated to practice and to study. Burlingame and colleagues suggest using empirically validated interventions, and ongoing assessment of client outcomes. They also suggest following the American Group Psychotherapy Association (AGPA) practice guidelines (see the Resources page on our web site), that include best practices for creating a successful group, appropriately selecting clients, preparing clients for group, evidence based interventions, and ethics issues related to group practice. Finally, Burlingame and colleagues emphasize using AGPA recommended measures and resources in developing and assessing a therapy group. These include: (1) group selection and group preparation which may involve handouts for group leaders and members about what to expect and how to get the most from group therapy; (2) assessing group processes repeatedly during group therapy using measures like the Therapeutic Factors Inventory or the Working Alliance Inventory; and (3) measuring client outcomes by using an instrument like the Outcome Questionnaire-45. Repeated measurement and feedback of processes and outcomes to the therapist may improve the group’s effectiveness.