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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.

Erekson, D.M., Lambert, M.J., & Egget, D.L. (2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and Clinical Psychology.

The dose-response model of psychotherapy suggests that a single session is like a “dose” of therapy, and that each session adds to a cumulative response by the client. For example, research indicates that between 13 and 18 sessions are required for 50% of patients to improve significantly, but with diminishing returns for clients after 18 sessions. In this very large study in a naturalistic setting, Erekson and colleagues studied the question of the effects of the “dose” or quantity of therapy a little differently. What if the spacing or frequency of sessions rather than the total number of sessions was important to patient outcomes? That is, if psychotherapy reinforces adaptive behaviors, then less learning might occur if time between sessions increases. With greater time between sessions clients may miss timely support from a therapist, and the therapeutic alliance may not be as solid. Erekson examined the impact of session frequency in a very large sample of university students (N = 21,488) seen by therapists (N = 303) for individual therapy lasting about 50 minutes per session. Clients typically received between 6 and 21 weeks of therapy. The data were collected at a counselling center over a 17-year period. Therapist orientations included CBT, psychodynamic, existential, and integrative. Patient outcomes were measured after each session with a reliable measure that allows one to evaluate if a client recovered from symptoms, reliably improved but did not recover, or reliably deteriorated. The authors found that compared to less frequent sessions (approximately every 2 weeks), more frequent sessions (approximately weekly) was associated with faster improvement and faster recovery. The statistical models predicted that 50% of individuals being seen weekly would reliably improve in 8 sessions, whereas 50% those seen every 2 weeks would reliably improve in 12 sessions. That is, clients seen every two weeks required 50% more sessions to achieve the same level of improvement as clients seen every week.

Practice Implications

Clients that are seen weekly may have a better therapeutic experience and develop a better therapeutic alliance with their therapists, which may in turn result in faster improvements. More frequent meetings may suggest to clients that their needs are important to the therapist. Institutions may have the opinion that lower session frequency is a way of saving resources, but in the end patients seen less frequently may require more therapy to achieve outcomes at the same rate as patients seen more frequently. Higher frequency of sessions may increase the efficiency of the psychotherapy and possibly reduce the amount of resources invested by the institution to improve patient mental health outcomes.

Stiles, W.B., Barkham, M., & Wheeler, S. (2015). Duration of psychological therapy: Relation to recover and improvement rates in UK routine practice. British Journal of Psychiatry, 207, 115-122.

In this very large study from the UK National Health Service (NHS), Stiles and colleagues assessed whether more therapy is better. That is, do people continue to get better with more sessions or do patients reach a certain level of improvement and terminate therapy regardless of number of sessions. The “dose-effect model” of psychotherapy suggests that patients continue to improve with more sessions, although the rate of improvement slows down after 18 sessions. However, large naturalistic studies from the UK health system show that patients have similar rates of recovery regardless of the number of sessions they attend (i.e., up to 20 sessions). These findings suggest that patient improvement may follow a good-enough or “responsive regulation model” of improvement, in which patients responsively regulate the number of sessions that they need. This could have implications for policies regarding how many sessions are prescribed to patients. In this study, Stiles and colleagues drew data from the NHS data base of over 26,000 adult patients who were seen by 1,450 therapists. These were patients who provided enough reliable outcome data, who attended 40 or fewer sessions, and who had a planned ending. Many patients had multiple problems including anxiety, depression, bereavement, and trauma and abuse. Patients who were selected for the study had initial symptom scores in the clinical range. The most common therapy approaches included integrative, psychodynamic, CBT, and supportive. Patient “recovery” was defined as no longer scoring in the clinical range at the end of therapy. Patient “improvement” was defined as a reliable drop in symptom scores on a psychometric measure. Patients received an average of 8.3 sessions, 60% recovered, and an additional 19% improved but did not recover. Rates of reliable improvement were negatively correlated (r = -.58) with number of sessions, and the effect was large. That is, patients who stayed in therapy longer had lower rates of recovery. These patients were more symptomatic at the outset.

Practical Implications

The results of this very large naturalistic study suggest that therapists and clients should regularly monitor improvement and adjust the treatment duration based on whether clients improve to a satisfactory level. The authors refer to this as “responsive regulation” of treatment duration. In practice, this means that therapists and clients end treatment when patients have improved to a “good-enough” level, which is likely balanced against costs and alternatives. These findings should encourage therapists and agencies to shift their attention away from prescribing a pre-specified length of treatment at the beginning of therapy towards evaluating on an ongoing basis what constitutes good-enough gains for each client.

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.

Owen, J., Adelson, J., Budge, S., Wampold, B., Kopta, M., Minami, T., & Miller, S. (2015). Trajectories of change in psychotherapy. Journal of Clinical Psychology, 71(9), 817–827.

Knowing the rate, or the trajectory, or the shape of client change across sessions of therapy can inform our understanding of how patients change, our policies of how many sessions to provide clients, and our clinical decisions if clients are no longer improving. The most popular models of client change across sessions include the “dose-effect model” and the “good-enough level model”. The dose-effect suggests that the more therapy patients receive the more they improve but, at a certain point, more sessions result in diminishing returns. In the August, 2013 PPRNet blog, I reviewed a chapter suggesting that 17% to 50% partially improve after about 7 sessions, and 50% patients fully recover after receiving about 21 sessions of therapy. Dose effect models might encourage some agencies to provide only the average number of sessions so that most patients will improve. The good-enough level model, on the other hand suggests that patients stay in therapy for varying lengths of time, and the number of sessions is determined by the point at which they feel better. In this study by Owen and colleagues, the authors take a different approach by looking at the patterns or trajectories of change that represent how and at what rate patients improve over time. In this very large study, they gathered session-by-session outcome data for over 10,000 clients seen at 47 treatment centres by over 500 different therapists. Client presenting problems and therapy orientations varied. Owen and colleagues identified 3 classes of patient change trajectories by using advanced statistical modeling of general distress outcomes across 5 to 25 sessions of therapy (average = 9.4 sessions). The largest class, representing 75% of clients, typified those who rapidly improved to session 5 and whose improvement plateaued to session 11, after which they improved again. This was called the “early and late change” class. The second largest class of patients, representing almost 20% of the sample, showed consistent linear change across the sessions. This was called the “slow and steady change” class. The third class of clients, representing about 5% of the sample, showed an initial decline in functioning up to session 5, followed by a steady improvement up to session 9, and then a plateau in improvement after session 9. This was called the “got worse before they got better” class.  This last group of clients had the most severe symptoms at the outset.

Practice Implications

This study indicates that one size does not fit all when it comes to how rapidly and in what manner patients change. “Early and late change” patients improve early on and then show another round of improvement later on in therapy. “Slow and steady” change patients show mild but consistent improvement across sessions of therapy. And those whose symptoms are more severe at the outset may “get worse before they get better”. This means that it may not be feasible to set an average fixed number of sessions for all patients, but rather therapists and agencies must rely on indices of reliable or good-enough change to determine optimal therapy length for each client. For example, “early and late change” patients may be working on different issues at different stages of therapy. Whereas clients who “show slow and steady” change may need to be in therapy longer before they realize sufficient improvement. For those patients with more severe symptoms who “get worse before they get better”, the therapy initially may be difficult but may ultimately induce change in the long run. In this case, therapists may need to provide enough of the current therapeutic approach before considering a change in the course of therapy.

Author email: Jesse.owen@louisville.edu

Farrell, N.R. & Deacon, B.J. (2015). The relative importance of relational and scientific characteristics of psychotherapy: Perceptions of community members vs. therapists. Journal of Behavior Therapy and Experimental Psychiatry. DOI: 10.1016/j.jbtep.2015.08.004

The American Psychological Association defines evidence-based practice (EBP) in psychotherapy as based on: (a) research evidence, (b) clinical expertise, and (c) client characteristics and preferences. We know for example, that clients who receive their preferred treatments better engage with therapy, drop out at a lower rate, and achieve better symptom outcomes. However, we know very little about clients’ preferences for the relative importance of the therapeutic relationship with an empathic therapist versus the scientific merit of the treatment they receive. We do know that therapists generally prefer research on the therapeutic relationship, and that therapists may place greater value on relationship issues versus research support for the treatments they provide. In this study Farrell and Deacon sample 200 members of the community about the relative importance of the relationship with a therapist versus the scientific basis of the treatment. The authors also surveyed a similar number of therapists about what therapists thought clients would prefer (relationship vs research evidence) in psychotherapy. Not surprisingly, community members rated both the therapeutic relationship and research evidence highly when indicating what they preferred should they receive psychotherapy. However, the authors found that members of the community rated the therapeutic relationship much more highly than they rated research evidence (d = 1.24). But the difference shrank (d = .24) when it came to treating panic disorder or obsessive compulsive disorder. Therapists tended to under-estimate the importance of community members’ preferences for scientific evidence for psychotherapy. The under-estimation was greater for therapists who placed less value on research. In other words, therapists who valued research less in their own practice were more likely to underestimate the importance of scientific credibility to members of the general public.

Practice Implications

This is by no means a perfect study. As readers of this blog know, I prefer to write about meta analyses, which are much more reliable than findings from a single study. However, it is quite rare to have a study on a large sample of members of the community, let alone one that asks about their perceptions and preferences about psychotherapy. The findings from this study suggest that members of the community highly value the therapeutic relationship and factors like therapist empathy. However, members of the community also place much faith in the scientific evidence that supports the use of psychotherapy. The preference for both a good therapeutic relationship coupled with research evidence may be very important to most people who may seek therapy. Therapists, particularly those who place less weight on research, should keep in mind that clients value the scientific evidence for psychotherapy.

Author email: bdeacon@uow.edu.au