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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.

In this chapter, Wampold and Imel contrast the Medical Model to a Contextual Model of psychotherapy. The Medical Model argues that there is a biological explanation for a disorder and that the basis for treatment is to address the biological system causing the disorder. Understanding the cause of the disorder (e.g., excess stomach acid) leads to an explanation of the mechanism of the disorder and of change (e.g., reduce stomach acid), which in turn leads to specific interventions (e.g., administer an antacid). Key to this model is specificity: that is, a specific disorder can be explained by a specific mechanism, and a specific treatment based on this explanation will result in alleviation of the disorder. In psychotherapy, for example, one could argue that PTSD symptoms are caused by maladaptive avoidance of traumatic memories, which can be successfully treated by repeated exposure to the traumatic memories to reduce symptoms. Exposure is the specific intervention indicated by the purported mechanism or cause of PTSD. By contrast, Wampold and Imel discuss a Contextual Model of psychotherapy. This model combines the elements of common factors in psychotherapy (e.g., the bond, real relationship, therapeutic alliance) with specific factors of interventions. The Contextual Model indicates that people are fundamentally social animals that require relationships with others to survive and to heal. That is, the initial therapeutic bond between client and therapist is the basis of psychotherapeutic practice. There are three elements to the Contextual Model. (1) The real relationship – which is based on genuineness [openness and honesty] and therapist empathy. Both genuineness and empathy are related to client outcomes. (2) Expectations – which, like the placebo effect, increases one’s readiness to benefit from treatment, is related to greater hope of improvement, and belief in the treatment. The placebo effect is associated with improvements in a pharmacological treatments of depression, and client expectations are related to psychotherapy outcomes. (3) Specific ingredients – as indicated in the Medical Model refers to psychotherapeutic interventions based on a psychological theory of a disorder. But unlike in the Medical Model, the Contextual Model sees the key element of specific ingredients as the agreement between client and therapist on the explanation for the disorder and on the treatment. In other words, a therapeutic alliance in part depends on clients and therapists agreeing on the specific tasks and goals of therapy.

Practice Implications

Patient outcomes are enhanced by a positive therapeutic bond, genuineness and congruence in the way a therapist interacts with a client, and a therapeutic alliance in which clients and therapists agree on tasks and goals of therapy. Typically, these occur within a context in which therapists use some specific techniques of therapy to which he or she feels an allegiance. It is also important that the client agree with the explanation for their disorder provided by this specific treatment model and that the client expects that this treatment will provide them with relief. Although common and specific factors of psychotherapy have been seen as having entirely separate roles in client outcomes, Wampold and Imel argue that within the Contextual Model, they are intimately tied to each other.

Kivlighan, D.M., Goldberg, S.B., Abbas, M., Pace, B.T., …Wampold, B.E. (2015). The enduring effects of psychodynamic treatments vis-à-vis alternative treatments: A multilevel longitudinal meta-analysis. Clinical Psychology Review, 40, 1-14.

There is a great deal of evidence that indicates uniform efficacy of a variety of psychotherapies for many common disorders. For example, in the July 2014 PPRNet Blog, I reviewed a meta-analysis comparing 7 psychotherapies for depression indicating no differences between the various treatments in terms of patient outcomes. Nevertheless proponents of cognitive behavioural therapy have claimed superiority to alternative treatments for decades. On the other hand proponents of psychodynamic therapies have argued that these treatments focus on personality change rather than symptoms, and so benefits of psychodynamic therapies will be longer lasting. In this meta analysis, Kivlighan and colleagues put these claims to the test. They selected studies in which a psychodynamic therapy was compared to one or more alternative treatment. Both the psychodynamic therapy and the alternative (most often CBT) had to be judged as “bona fide” therapies by independent raters (i.e., they had to be therapies that were delivered in a manner in which they could be expected to be effective by clients and therapists). Outcomes not only included specific symptoms (e.g., depression), but also non-targeted outcomes (e.g., improved self esteem in a study of treatment of anxiety), and personality outcomes. Effect sizes for outcomes were assessed at post-treatment and also at follow-ups. Twenty five studies directly comparing psychodynamic and non-psychodynamic therapies were included, representing 1690 patients. At post treatment, no significant differences were found between psychodynamic and non-psychodynamic treatments on targeted outcomes, non-targeted outcomes, and personality measures (all gs < .10). There was also no significant or meaningful effect of time to follow up on outcomes, indicating no differences between treatment types at any of the follow up periods.

Practice Implications

Psychodynamic and non-psychodynamic treatments were equally effective at post treatment and at follow ups for all outcomes, including personality variables. This challenges the belief that psychodynamic treatments uniquely affect personality and have longer lasting effects compared to other treatments. It also challenges the notion that CBT (by far the most common comparison treatment) is a superior therapy for patient outcomes. Pan-theoretical psychotherapy factors (client contributions, expectations, therapeutic alliance) may be more promising factors in understanding the long term benefits of psychotherapy. 

Author email: kivlighan@wisc.edu

Mallinckrodt, B. & Jeong, J. (2015). Meta-analysis of client attachment to therapist: Associations with working alliance and pretherapy attachment. Psychotherapy, 52, 134-139.

Attachment theory has become one of the most important conceptualizations of affect regulation and interpersonal relationships. John Bowlby and others suggested that attachment behaviour is hard wired so that infants can gain proximity to caregivers which is necessary for infant survival. Repeated interactions with caregivers coupled with the variety of caregiver responses (i.e., available, unavailable, or inconsistently available caregiving) lead to children developing internal working models of attachment. These models become the basis for attachment styles in adulthood. Attachment security in adults is associated with the ability to give and receive caring and love, and to adaptively regulate emotions. Attachment avoidance is associated with a tendency to dismiss relationships as important, and to downregulate emotional experiences. Attachment anxiety is associated with a preoccupation with relationships, and to upregulated emotional experiences. In a previous meta analysis, client general attachment security was modestly but significantly associated with higher levels of therapeutic alliance (r = .17). In another meta analysis, higher client general attachment anxiety was associated with poorer client outcomes (r = -.22). In this meta analysis, Mallinckrodt and Jeong assessed whether client attachment to the therapist was associated with client general attachment style and with the therapeutic alliance with the therapist. They included 13 studies representing 1051 client-therapist dyads. Client pre-therapy general attachment avoidance and anxiety were negatively associated with client-therapist attachment security, and the effects were modest but significant (r = -.12, r = -.13). Client-therapist attachment security was positively associated with therapeutic alliance (r = .76) and client-therapist attachment avoidance was negatively associated with therapeutic alliance (r = -.63), and these effects were large.

Practice Implications

Client pre-therapy attachment styles appear to have an impact on their attachment to the therapist. A client pre-therapy attachment style characterized by preoccupation with relationships and an over-emphasis on emotions (i.e., attachment anxiety) will likely lead to similar behaviors and preoccupations in the relationship with the therapist. Mallinckrodt and Jeong suggest that this might be the basis for transference-related phenomenon that therapists and clients experience in the therapeutic relationship. That is, client attachment anxiety and avoidance likely interfere with developing a secure attachment to the therapist. Further, client attachment avoidance with regard to the therapist may result in lower therapeutic alliance, which is key to achieve improved patient outcomes. Despite these challenges, therapists who can facilitate a secure psychotherapy attachment experience for their clients are more likely to see improvements in their clients’ functioning.

Author email: bmallinc@utk.edu

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.

Abbass, A., Kisely, S., Rasic, D., Town, J.M., & Johansson, R. (2015). Long-term healthcare cost reduction with Intensive Short-term Psychodynamic Psychotherapy in tertiary psychiatric care. Journal of Psychiatric Research, http://dx.doi.org/10.1016/j.jpsychires.2015.03.001

Several years ago Lazar (2010) published a book detailing the cost-effectiveness of psychotherapy for a variety of disorders. That is, her systematic review found that on most economic indicators (lost income, decreased disability, decreased health utilization) psychotherapy resulted in an immediate cost reduction over and above the cost of the treatment. In this study from Halifax, Canada, Abbass and colleagues looked at the effects of psychotherapy, specifically of Intensive Short-term Dynamic Psychotherapy (ISTDP), on the long-term reduction in hospital costs and physician visits. Abass and colleagues argue that adverse childhood events are an important determinant of adult mental health problems and of increased costs to the health system likely because of the consequence of problems with emotion regulation. Psychotherapies like ISTDP specifically address issues that are a consequence of childhood maltreatment and so might reduce some of the consequent health care costs. Abbass and colleagues provided ISTDP to 890 patients in the Halifax health care system who were referred to the psychotherapy service from emergency departments, physicians, and mental health providers. These patients’ outcomes were compared to 192 patients not seen by the clinic for various reasons. Most common diagnoses of the total sample were: somatoform disorder, anxiety disorder, personality disorder, and depressive disorder. Participant completed measures of psychological distress, and the research team were able to access provincial health usage data tracked over 3 years. Fifty eight therapists of various skill levels (psychiatrists, psychologists, family physicians, trainees) provided ISTDP. The average patient attended 7.3 sessions which cost $708 (estimated by salaries in 2006). Patients receiving psychotherapy had physician and hospital costs that decreased from $3,224 to $4759 in Canadian dollars per year over three years (again in 2006 dollars). Patients in the control condition not receiving ISTDP showed health care costs that increased from $368 to $2,663 per year. These trajectories of health care costs were significantly different. Yearly physician and health care costs for patients prior to being treated with ISTDP were greater than those of the general Canadian population, but 3 years post ISTDP their health care costs were less than the general Canadian population. In addition, compared to control patients those treated with psychotherapy showed a significant reduction in psychological distress.

Practice Implications

This study by Abbass and colleagues demonstrates that short term psychotherapy provided to a broad range of patients and targeting health and illness behaviors related to problems with emotion regulation can reduce health care costs. These reductions in hospital and physician visits occurred in the short term and were sustained over several years. Some patients may require longer treatment, but the evidence suggests that short term interventions should be tried first.

Author email: allan.abbass@dal.ca

Johnsen, T. J., & Friborg, O. (2015, May 11). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015

Depression is a highly debilitating disorder and ranked third in terms of disease burden in the world. Cognitive behavioral therapy (CBT) is an effective treatment for depression that was introduced over 40 years ago. In part, CBT sees depression as caused by maladaptive thoughts that maintain emotional distress and dysfunctional behavior. Reducing depression is achieved by eliminating the impact of or chancing maladaptive thoughts. CBT is the most researched psychological treatment for depression, and the research goes back several decades. A number of technical variations and new additions have been made over the years to CBT to improve patient outcomes. The volume of research and its history provides a unique opportunity to assess time trends in the effects of CBT. In this meta analysis, Johnsen and Friborg asked: “have the effects of CBT changed over time”? They also looked at whether client factors (e.g., demographics, symptom severity), therapist factors (e.g., age, experience, training), common factors (e.g., therapeutic alliance, client expectancies), and technique factors (e.g., fidelity to a treatment manual) can explain these trends. Johnsen and Friborg reported on 70 studies of 2,426 patients conducted from 1977 to 2014. Males accounted for 30.9% of patients, 43% had comorbid psychiatric conditions, and the average patient was at least moderately depressed. The average effect of CBT in reducing depression was large (g = 1.46 after accounting for publication bias). Women had better outcomes, studies with poorer methodological quality showed larger effects, and patients of more experienced therapists had better outcomes. There were too few studies measuring therapeutic alliance to assess the effect of common factors on outcomes. Most interesting was a significant relationship between effect sizes and year of publication. That is, the effects of CBT declined significantly over the years, though the average effect remained large. Surprisingly, there was a steeper decline for studies that used a treatment manual compared to those that did not. No other variables were reliably associated with this decline.

Practice Implications

Women and patients of more experienced therapists appear to benefit most from CBT. Although the effects of CBT declined over time, the treatment remained highly effective. Johnsen and Friborg’s study could not easily explain this decline. The authors suggested that the placebo effect (expectation on the part of patients, researchers, and therapists) is typically stronger for new treatments. However, as time passes the strong initial expectations tend to wane thus reducing the overall effect of the intervention. They also suggested that CBT treatment outcomes may be improved not by technical variations and new additions, but by better ways of integrating common, therapist, and client factors.

Author email: tjj@psykologtromso.no