Conceptual skills needed for evidence-based practice of psychotherapy: A few recommendations.

{from: Psychotherapy Bulletin 45(2): Online Version}

Kenneth L. Critchfield (University of Utah) & Sarah Knox (Marquette University)

“Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” APA Presidential Task Force on Evidence-Based Practice (2006, p. 273)

An advanced graduate student therapy trainee recently expressed concern about treatment of a difficult case seen in one of her placements. She was frustrated with a supervisor and torn between utilizing knowledge of the patient’s treatment history and family patterns versus following a different path suggested by a particular treatment manual. The frustration had been stirred up in context of a group discussion about tailoring treatments to fit individual patients, and using the empirical literature to do so. She asked: “But doesn’t the research literature say that fidelity to treatment will bring the best effects? A patient I’m seeing now doesn’t like the approach for specific reasons, and it also hasn’t worked for her in the past. But, how can I respond to my patient’s needs and still be evidence-based? Isn’t it unethical to deviate from the manual if it is empirically supported?” Her plan before this discussion was simply to comply with supervisory input to follow the manual, but without much hope for its success with this patient.
The questions asked by this psychotherapist-in-training points to several challenges we face as educators and supervisors in the age of evidence-based practice. On the one hand, we need to provide specific training for empirically supported interventions. On the other hand, we need to help therapists develop the conceptual tools necessary to continue integrating research findings into their clinical work, and apply all these skills in a manner that takes into account individual client needs, preferences, and unique context (APA, 2006).

Reflecting our field’s current emphasis, the trainee mentioned above has been taught that empirically supported treatment packages (ESTs) represent the most ethical approach to treatment because of their proven track record in research (cf. Chambless & Crits-Christoph, 2006). She has even been told to steer clear of “non-EST” approaches by some faculty advisors. Given these directives, plus the constraints of time around provision of therapy in graduate training, she has focused almost exclusively on learning ESTs. As a result, she has considerable skill implementing a number of treatment packages for specific disorders, and can cite their empirical basis in randomized control trials (RCTs) with accuracy.

Her skill set as a psychotherapist is still quite limited, however. While she is gaining skill with a few interventions developed for discrete diagnoses, she has received little encouragement to be aware of (much less think integratively about) the broader empirical literature or identify principles that could help her more flexibly generalize and tailor her interventions (e.g., Castonguay & Beutler, 2006). When faced with clients whose needs do not easily fit the molds the models she knows, she is at a loss.

As educators, we should not be pleased with this result. Without additional input, this young psychotherapist will go out into practice with a relatively rigid skill set of limited applicability. The frustration she already feels suggests she is at risk for eventual “burn out” as a practitioner.

Old and new views of evidence based practice

Our trainee’s problems reflect tensions in our field over how best to weigh and apply research evidence. The primary view that has guided this young therapist’s education has held sway for roughly a decade and places emphasis on developing, testing, and disseminating treatment packages for discrete disorders (e.g., Gotham, 2006; McHugh & Barlow, 2010; Kazak et al, 2010). A treatment qualifies as an EST based on successfully replicated, randomized control trial (RCT) studies (multiple single-case studies with strong research controls may also qualify for EST status; Chambless & Hollon, 1998). Lists of ESTs were initially compiled in an attempt to demonstrate that psychosocial treatments produced effects comparable to pharmacological interventions and should therefore receive research funding, training, and reimbursement in the era of managed care (APA Division of Clinical Psychology, 1995). An RCT study answers a single question about psychotherapy very well: “Does therapy X have an effect on disorder Y, if all other factors are controlled?” The information provided by an RCT directly addresses the needs of an administrator overseeing a large system of care who wishes to ensure that “on average” there will be a positive effect if a particular approach is implemented. In an RCT, treatments are usually applied to a single category of disorder by clinicians trained to a high level of adherence. Randomization is used to distribute pre-treatment characteristics such as personality type, age, gender, motivation, and prior treatment experience evenly across groups so that they are unlikely to be responsible for any group differences in outcome. Dissemination of an EST tends to flow logically from the same research design: psychotherapists are trained to adhere to the EST manual and apply it with patients having a particular disorder (McHugh & Barlow, 2010; Kazak et al, 2010), just as in the case of our frustrated trainee.

By contrast, “evidence-based practice of psychology” (EBPP) has been defined by an APA Presidential Task Force (2006) as invoking all available research methodologies and focusing treatment on individual clients:

“It is important to clarify the relation between EBPP and empirically supported treatments (ESTs). EBPP is the more comprehensive concept. ESTs start with a treatment and ask whether it works for a certain disorder or problem under specified circumstances. EBPP starts with the patient and asks what research evidence (including relevant results from RCTs) will assist the psychologist in achieving the best outcome. In addition, ESTs are specific psychological treatments that have been shown to be efficacious in controlled clinical trials, whereas EBPP encompasses a broader range of clinical activities (e.g., psychological assessment, case formulation, therapy relationships). As such, EBPP articulates a decision-making process for integrating multiple streams of research evidence—including but not limited to RCTs—into the intervention process.” (p. 273)

Ultimately, the APA application of EBPP requires a higher standard from therapists and educators, and is likely to be worth the effort if it allows therapists like our trainee to effectively answer the questions she poses and meet the needs of her client. In addition to training with discrete treatment packages and intervention “tool kits,” the most successful therapists will also be prepared with sufficient background and conceptual skills to integrate what is known from across the research literature, combine it with clinical expertise, and apply it in ways that are flexible and responsive to client characteristics.

Skills needed for successful EBPP

The “competencies movement” in psychology seeks to identify the skills and attitudes that need to be acquired for professional development (Fouad et al, 2009; Kaslow et al, 2009). Its focus is comprehensive and sees psychotherapy skill acquisition as unfolding across levels of graduate training and professional practice. Competencies are divided into two broad classes, those that are “functional,” reflecting discrete domains of professional activity (assessment, intervention, consultation, supervision, research/evaluation, supervision, teaching, administration, and advocacy), and those that are “foundational,” cutting across functional domains (professionalism, reflective practice, knowledge of scientific methods and findings, relationship skills, sensitivity to individual differences and cultural diversity, attention to ethical and legal standards and policies, and ability to interface with interdisciplinary systems). We wish to draw particular attention to foundational competencies that involve scientific method and recommend a particular kind of scientifically-minded thinking style vital for evidence based practice.

Scientific-mindedness

By scientific-mindedness, we refer to a clinician’s willingness to engage in a process of inquiry that should involve not just consideration of the empirical literature, but also evidence available directly from clients. Ideally, the process begins with careful assessment that results in an individual case formulation, that is, a set of hypotheses about the sources and maintaining factors associated with an individual’s problems. Interventions are then selected in light of the relevant literature, and in consultation with the patient about his or her needs and preferences. Ongoing evaluation of therapeutic impact then provides data about the effects of the intervention and can lead to flexible modification or a change in course as needed, and in collaboration with the client. Lambert and colleagues (e.g., Slade, Lambert, Harmon, Smart, & Bailey, 2008) provide evidence that feedback from formal, ongoing monitoring of symptom states can improve outcome. To extend this logic, depending on the individual formulation of a client, relevant outcome data may also involve clients’ patterns of thinking, feeling, or relating with others, motivation for change, quality of the in-session relationship, and more. To summarize, the proposition here is that psychotherapists be trained in a manner that leads to primary identity as a clinical scientist whose work places emphasis on generating and testing individual-level hypotheses about change, in a context of collaboration with clients and consultation with the empirical literature.

Critical thinking and integration

Critical thinking involves evaluating logic and weighing evidence. As applied to psychotherapy, it involves the ability to understand and evaluate published research results as well as to accurately assess the circumstances and experiences of individual clients. The complement to critical thinking is integrative ability, which involves being able to pull together different studies, different strands of data, and synthesize them into a specific hypothesis with associated plans of action. Examples of integrative thinking would include pulling assessment data together into a case formulation with clear implications for treatment, detecting areas of overlap and convergence between multiple treatment methods, and using clinical experience to inform treatment decisions. With critical thinking, clinicians learn how to break problems into separate parts, evaluate and analyze underlying logic. Then, using integrative abilities they shuttle in the opposite direction, synthesizing information, generating new hypotheses and possible solutions that respond to unique circumstances. Both skills are needed.

Supervisors and educators can model these thinking skills and invite the same from trainees in concrete ways. For example, problems presented by an individual client could be used to demonstrate and directly apply principles of evidence-based practice. Students could be assigned to scour the empirical database about some aspect of the client’s presentation. The contents of EST manuals and other relevant material would be reviewed with an eye toward finding specific interventions of relevance. Once this review has occurred, the underlying logic and evidentiary base for treatment would be taken into consideration, as would areas of potential convergence across multiple studies or schools of thought. A mindful, collaborative, application of what has been learned would then be applied with the specific case. Optimally, supervisor and trainee would become engaged in an active, collaborative, evidence-based endeavor involving careful assessment, consultation with the empirical literature, hypothesis formation about useful interventions, and systematic evaluation of their impact for an individual case. Three key elements of EBPP are present in the foregoing suggestion: primary focus on the individual through use of case conceptualization methods, active use of the existing evidence-base, and exercise of EBPP as a process of decision-making and empirical inquiry. At first, the training model would be slow and resource intensive, with a great deal of time spent focused on individual cases. With time and practice, the process can be abbreviated and tailored to training needs as clinical skills are effectively practiced and internalized.

Relationship skills and EBPP

One of the more consistent findings in psychotherapy research studies with many different treatments and disorders is that a positive therapeutic relationship correlates with improved outcome (Horvath & Bedi, 2001; Wampold, 2001). Resources are increasingly available to summarize empirical work on the alliance and provide specific training recommendations (e.g., Muran & Barber, 2010; Norcross, 2002). The most studied aspect of the therapeutic relationship is the alliance, which consists of the affective bond between a patient and therapist, as well as their agreement about goals and therapeutic tasks for reaching them. Evidence-based practice may be particularly well-suited to enhance collaboration to the degree that it begins with focus on the individual client, thereby planting the seeds for a strong alliance.

Final comments

The approach outlined here suggests that the curriculum for psychology training needs to include greater emphasis on “foundational” competencies so that skilled intervention is learned and applied in broader context of EBPP. Scientific-mindedness, critical thinking, integrative capacity and relational skills all must be modeled and practiced across the curriculum so that they become part of the language and culture of evidence-based professional practice. We believe that a basic introduction to evidence-based practice should occur from the earliest phases of psychotherapy training, rather than being treated as an ‘advanced topic’ to be learned only after diagnosis-specific interventions and ESTs have been mastered. Perhaps the easiest place to start implementing EBPP in training settings is simply to introduce the APAs definition of evidence-based practice and encourage critical thought and discussion about its elements and implications, as recommended by Levant and Hasan (2008). An edited volume by Norcross, Beutler, and Levant (2006) also provides a related, excellent overview of the issues and challenges our field faces integrating science and practice as the empirical database continues to grow.

Ultimately, our hope for future trainees is that they will continue to push and expand boundaries of our current knowledge, improving client outcomes through a process of active engagement with the evidence-base. 

References

APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.

American Psychological Association Division of Clinical Psychology. (1995). Training in and dissemination of empirically-validated psychological treatments: Report and recommendations. The Clinical Psychologist, 48, 3–27.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that work. New York: Oxford University Press.

Chambless, D. L., & Crits-Christoph, P. (2006). What should be validated? The treatment method. In J. C. Norcross, L. E., Beutler, & R. F. Levant, (Eds.) Evidence-based practice in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association, (pp. 191-200).

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7-18.

Fouad, N. A., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings, P. S., Madson, M., et al. (2009). Competency benchmarks: A model for the understanding and measuring of competence in professional psychology across training levels. Training and Education in Professional Psychology, 4(Suppl.), S5–S26.

Gotham, H. J. (2006). Advancing the implementation of evidence-based practices into clinical practice: How do we get there from here? Professional Psychology: Research and Practice, 37, 606–613.

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In Norcross, John C. (Ed), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. (pp. 37-69). New York, NY, US: Oxford University Press.

Kaslow, N. J., Grus, C. L., Campbell, L. F., Fouad, N. A., Hatcher, R. L., & Rodolfa, E. R. (2009). Competency Assessment Toolkit for professional psychology. Training and Education in Professional Psychology, 3, S27-S45. doi: 10.1037/a0015833

Kazak, A. E., Hoagwood, K., Weisz, J. R., Hood, K., Kratochwill, T. R., Vargas, L. A., Banez, G. A. (2010). A meta-systems approach to evidence-based practice for children and adolescents. American Psychologist, 65(2), 85-97.
Levant, R. F., & Hasan, N. T. (2008). Evidence-based practice in psychology. Professional Psychology: Research and Practice, 39(6), 658-662.

McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments: A review of current efforts. American Psychologist, 65(2), 73-84.

Muran, J. C., & Barber, J. P. (2010). The therapeutic alliance: An evidence-based approach to practice and training. New York: Guilford.

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.

Norcross, J. C., Beutler, L. E., & Levant, R. F. (2006). Evidence-based practice in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association.

Slade, K., Lambert, M. J., Harmon, S. C., Smart, D. W., & Bailey, R. (2008). Improving psychotherapy outcome: The use of immediate electronic feedback and revised clinical support tools. Clinical Psychology & Psychotherapy, 15, 287-303. doi: 10.1002/cpp.594

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ, US, Lawrence Erlbaum Associates Publishers.

Jeffrey Barnett

Jeffrey Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola Univeristy Maryland and a licensed psychologist in practice in Arnold, Maryland. He is a Diplomate in Clinical Psychology and in Clinical Child and Adolescent Psychology of the American Board of Professional Psychology and a Distinguished Practitioner of Psychology in the National Academies of Practice. He is a recent past chair of the Ethics Committee of the American Psychological Association and has previously been chair of the Maryland Psychological Association Ethics Committee. Dr. Barnett has published numerous articles, chapters, and books on ethics and professional issues in Psychology and has given numerous presentations and continuing education ethics workshops for psychologists and other mental health professionals. His most recently published books include Ethics Desk Reference for Psychologists (APA Books, 2008, with Brad Johnson), Ethics Desk Reference for Counselors ( ACA Books, 2009, with Brad Johnson), and Financial Success in Mental Health Practice (APA Books, 2008 with Steve Walfish).

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University of Massachusetts Amherst

A voluminous and ever-expanding research literature points to the general effectiveness of psychotherapy (Lambert & Ogles, 2004). Through the use of controlled clinical trials, psychotherapy researchers have identified many empirically-supported treatments for specific clinical phenomena (Roth & Fonagy, 2005). The extant research also suggests that, with just a few exceptions, different therapy modalities yield comparable clinical effects (Lambert & Ogles, 2004). From a glass-half-full perspective, the field has made impressive strides in legitimizing the power of psychosocial interventions. Furthermore, as reflected in the long-standing “Dodo bird” interpretation of the comparative outcome literature, it can be asserted that everybody has indeed won and all should have prizes.

From a glass-half-empty perspective, psychotherapy’s general effectiveness is tempered by its clear limitations. For example, effective treatments for some psychological conditions have yet to be established, and the generalizability to everyday practice of treatments tested in controlled efficacy contexts remains tenuous. Furthermore, even when provided the “gold standard” treatment for a particular condition, some patients fail to respond, only partially respond, or respond but relapse; others drop out of treatment or even deteriorate (Lambert & Ogles, 2004). Thus, it seems that the Dodo verdict can be reconsidered to suggest that all therapies can be improved (Castonguay, Reid, Halperin, & Goldfried, 2003).

Although efforts toward improvement can come in many shapes and sizes, some scholars have argued that improvement may perhaps best be achieved through (a) theoretical humility and openness to the contributions of other (and perhaps historically incompatible or rival) orientations (e.g., Castonguay et al., 2003), and (b) treatment modifications based on process research (e.g., Grawe, 1997). Such approaches preserve the field’s advances in empirically supporting certain treatment packages, while inherently recognizing the complexity of change and the need to move forward creatively in refining treatments to both embrace and address such complexities.

Both of the aforementioned pathways to improvement reflect a specific model of psychotherapy integration (see Norcross & Goldfried, 2005). The former captures assimilative integration, or the attempt to improve an established system of psychotherapy by carefully considering the potential contributions of other systems. The latter captures common factors integration, which focuses on the conceptual and empirical contributions of pantheoretical and pandiagnostic therapeutic ingredients, and the inevitable influence of the momentary and dynamic context on the treatment process.

Among others, process research has persuasively implicated two common factors in the change process – the therapeutic alliance and patient expectations (see Castonguay, Constantino, & Holtforth, 2006; Greenberg, Constantino, & Bruce, 2006). To date, a facet of my research program has been directed at developing, systematizing, and experimentally testing alliance and expectancy-based treatment modules as a means to improve the efficacy of a particular empirically-established treatment (i.e., cognitive therapy; CT) for a specific condition (i.e., adult major depressive disorder; MDD). Although CT is an efficacious treatment for depression, recent estimates from controlled trials suggest that over half of MDD patients do not remit at posttreatment (De Matt, Dekker, Schoevers, & De Jonghe, 2006), while an even higher percentage fail to maintain lasting improvements (Hollon et al., 2005). Thus, there is room for significant improvement in CT for depression, and there remains a pressing need to refine treatments to increase response and decrease relapse. My collaborators and I have embarked on two such efforts. The alliance-based effort focuses on incorporating humanistic and interpersonal alliance-rupture repair strategies into standard CT and, thus, fits the assimilative and common factors models. The expectancy-based effort focuses on incorporating into CT systematic and responsive efforts to foster, manage, and change patients’ treatment expectations, which follows the common factors pathway. Below I describe each research line, including (a) a brief review of process findings that led to the treatment development, (b) a brief overview of the treatment module, and (c) a summary of our preliminary research to date.

Therapeutic Alliance Process Research and Integrative Cognitive Therapy

Pantheoretically defined, the therapeutic alliance reflects the quality of the patient-therapist working collaboration and affective bond (Bordin, 1979). As reflected in our own reviews and process-outcome studies (e.g., Constantino, Arnow, Blasey, & Agras, 2005; Constantino, Castonguay, & Schut, 2002), the alliance is a well-established predictor of treatment success across a variety of psychotherapies and presenting problems. The alliance not only predicts outcome, but it also provides a dynamic context for the implementation and utility of other interventions. For example, in a study of CT for depression, Castonguay, Goldfried, Wiser, Raue, and Hayes (1996) found that strict therapist adherence to prescribed CT techniques in the context of an alliance rupture was negatively related to outcome. Inspired by these findings, and guided by an assimilative integration model, Castonguay (1996) developed Integrative Cognitive Therapy (ICT), which is an approach to depression that remains grounded in CT but systematically incorporates humanistic and interpersonal strategies for identifying, addressing, and repairing emergent alliance ruptures.

Based on the contributions of Burns (1989) and Safran and Segal (1990), ICT presupposes that CT therapists can be more effective in dealing with alliance strains by exploring the source of the difficulty (including their own contributions) rather than increasing their adherence to core CT interventions. In this vein, the ICT manual outlines a 3-step rupture-repair sequence in which the therapist: (1) Invites the patient to discuss his negative reaction to the therapy or therapist; (2) Empathizes with the patient’s feelings and invites additional emotional disclosure in the service of understanding, respecting, and validating the patient’s subjective experience; and (3) Disarms the patient’s antagonism, anger, and/or other negative feelings by acknowledging his or her own contribution to the rupture. Such action promotes a restoration or enhancement of the collaborative working relationship, at which time the therapist then resumes standard CT techniques.

In an initial pilot investigation of ICT, Castonguay et al. (2004) found that ICT produced significantly superior outcomes than a wait-list control condition. As a follow-up, my research team conducted a pilot study (Constantino et al., 2008) to test further ICT’s efficacy and specificity by directly comparing it to standard CT. In this sense, the study employed an additive design, the strength of which resides in its high level of control across the independent treatment variable (e.g., Behar & Borkovec, 2003). With the exception of ICT’s additional rupture-repair strategies, the treatments were delivered according to the same CT protocol, thereby reducing the likelihood that outcome differences are a function of “nonspecific” factors and strengthening the causal inferences that can be made about the alliance manipulations. Furthermore, by using CT-as-usual as a control group, the additive design (a) transcends the specific versus common factors debate by assessing whether rupture-repair interventions work additively or synergistically to improve an already established treatment package, and (b) adds a cause-and-effect dimension to the alliance-outcome link. In our study, using clinicians-in-training, we found preliminary evidence that ICT could be distinguished from CT, and that ICT outperformed CT (small to medium effects) in terms of reducing depressive and global symptomatology. Furthermore, relative to CT, there were fewer dropouts, higher quality alliances, and higher perceived therapist empathy in ICT (medium to large effects). Thus, ICT may be considered a promising limited support treatment (Roth & Fonagy, 1996) worthy of future rigorous study.

Although preliminary, our emerging ICT findings suggest that psychotherapists should not only strive to foster good initial alliances with their patients, but also constantly assess for any deviations in the relationship climate. In the face of potential or actual alliance ruptures, clinicians should resist rigid adherence to the techniques they have been employing (e.g., standard CT interventions) and work through such relationship issues directly, openly, and nondefensively. The use of gentle probing, active listening, empathizing, and disarming may not only help to get the relationship back on track, but such metacommunication strategies may also promote a corrective relational experience (see also Safran & Muran, 2000).

Expectancy Process Research and the Expectancy Enhancement Treatment Module

Patients’ expectations have long been considered a common treatment factor (e.g., Frank, 1961). Outcome expectations refer to a prognostic belief that therapy will help, while process expectations reflect beliefs about what will transpire during therapy. As reflected in our own review and process-outcome studies (e.g., Constantino et al., 2007; Greenberg et al., 2006), expectations have been shown to be important contributors to adaptive during- and post-treatment outcomes. However, the expectation construct has been remarkably undervalued (Weinberger & Eig, 1999). Although many therapies include elements that address patient expectations in some manner, expectancy strategies are often neither explicit nor systematic. Moreover, in experimental treatment studies, expectations have been traditionally viewed as artifacts to be controlled – a perspective that now seems outdated. Thus, we have developed a treatment manual that outlines an explicit and systematic approach to enhancing patient expectations about therapeutic change and the treatment course.

The expectancy enhancement (EE) manual (Constantino, Klein, & Greenberg, 2006) addresses pre- and during-treatment expectations. Specifically, it comprises (a) an initial session EE interview to enhance patients’ outcome expectations and their expectations about the length and nature of treatment, (b) ongoing standard and reactive EE strategies, (c) general relationship strategies to be considered in light of patients’ expectations, and (d) a termination component that aims to enhance patients’ posttreatment expectations for maintaining their treatment gains. The present version of EE was designed as a companion manual to CT for depression. However, we suspect that such strategies can eventually be adapted for a wide range of clinical conditions and for other treatment modalities. We are currently conducting another pilot study, again utilizing an additive design, to foster the development of the EE manual and to test preliminarily its causative enhancement of standard CT. Although the outcome data are still forthcoming, we have been able to successfully train graduate trainees on the protocol, and they have been able to implement the treatment with good fidelity and competence.

Despite not yet having data on the specific efficacy of our EE manual, psychotherapy process research points consistently to the clinical importance of patients’ process and outcome expectations. Moreover, most psychotherapies involve some level of manipulation, exploration, challenge, and/or revision of patient expectations (Greenberg et al., 2006). Thus, clinicians should carefully assess patients’ expectations at the beginning of treatment in order to inform prognosis, case formulation, and treatment-planning. Regarding process expectations, clinicians may need to spend time socializing patients to the treatment process (e.g., typical role behaviors; duration), as well as checking in on patients’ met and unmet expectations as the therapy work unfolds. Regarding outcome expectations, clinicians should make a concerted effort to offer personalized hope-inspiring statements (e.g., “Your problems are exactly the type for which this therapy can be of assistance”) at the treatment’s outset, and to respond appropriately to hope-diminishing moments with both alliance-based sensitivity and expectation-enhancing strategies (e.g., reminding patients of depression’s recurrent nature; drawing on past successes) (Constantino et al., 2006).

Conclusions

The lines of research discussed above are representative of my overarching research program that focuses on understanding patient, therapist, and relational processes that influence the course and outcome of psychosocial treatments, and on the development and systematization of therapeutic interventions that address pantheoretical principles of clinical change. The overarching aim of the program is the development of empirically-grounded skills on which therapists can be trained to negotiate effective therapeutic relationships and to enhance patients’ treatment expectations. This focus on two key common factors adds a much-needed complement to the testing and training of theory-specific treatment techniques that have, to date, received much more empirical attention. Of course, the efficacy findings discussed above should be interpreted within their preliminary spirit. However, our hope is that when the jury returns, we will have uncovered two promising common factor treatment modalities that can be assimilated into CT to augment its effectiveness. If so, our work will have helped substantiate a glass-not-yet-full-but-still-full-of-promise perspective on psychotherapy outcome research.

References

Behar, E. S., & Borkovec, T. D. (2003). Psychotherapy outcome research. In J. A. Schinka & W.

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Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, 16, 252-260.

Burns, D. D. (1989). The feeling good handbook. New York: William Morrow & Co.

Castonguay, L. G. (1996). Integrative cognitive therapy for depression treatment manual.  Unpublished manuscript, The Pennsylvania State University.

Castonguay, L. G., Constantino, M. J., & Holtforth, M.G. (2006). The working alliance: Where are we and where should we go? Psychotherapy, 43, 271-279.

Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. M. (1996).  Predicting outcome in cognitive therapy for depression: A comparison of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497-504.

Castonguay, L. G., Reid, J. J., Jr., Halperin, G. S., & Goldfried, M. R. (2003). Psychotherapy integration. In G. Stricker & T. A. Widiger (Eds.), Handbook of Psychology, Vol. 8 (Clinical Psychology; pp. 327-345). New York: Wiley.

Castonguay, L. G., Schut, A. J., Aikins, D., Constantino, M. J., Laurenceau, J. P., Bologh, L., & Burns, D. D. (2004). Repairing alliance ruptures in cognitive therapy: A preliminary investigation of an integrative therapy for depression. Journal of Psychotherapy Integration, 14, 4-20.

Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S., (2005). The association between patient characteristics and the therapeutic alliance in cognitive behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203-211

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Constantino, M. J., Klein, R., Greenberg, R. P. (2006). Guidelines for Enhancing Patient Expectations: A Companion Manual to Cognitive Therapy for Depression. Unpublished manuscript.

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Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.

Weinberger, J., & Eig, A. (1999). Expectancies: The ignored common factor in psychotherapy. In I. Kirsch (Ed.), How expectancies shape experience (pp. 357-382). Washington, DC:  American Psychological Association.

Garrison Keillor observes of the residents of Lake Wobegon, “All the women are strong, all the men are good-looking, and all the children are above average.” As psychotherapists, it is likely that we similarly believe we are above average, but as Keillor’s folksy humor reminds us, it ain’t so—half of us are below average, as a statistical necessity! Moreover, the variability in outcomes due to psychotherapists is greater than what is expected by chance (Wampold, 2001) and the differences are meaningful. In practice settings, some psychotherapists consistently attain better outcomes than others and this seems to be true regardless of patient diagnoses, age, developmental stage, medication status, severity, and so forth—good psychotherapists get consistently better outcomes across a range of patients (Wampold & Brown, 2005). The Wobegon flip side, is that some psychotherapists consistently have poorer outcomes.

What characterizes the psychotherapy provided by psychotherapists who consistently get better outcomes and how can we all adopt such practices to improve our effectiveness?

Unfortunately, definitive answers to this question have eluded us for decades and distressingly, as Beutler (2004) suggests, interest in psychotherapist variables is waning.  Nevertheless, there are some emerging trends that we should consider. But first, we should be clear about what does not appear to make a difference. The particular treatment delivered by psychotherapists does not appear to make a difference, in clinical trials (see Wampold, 2001) or in practice (e.g., Stiles et al., 2006). Indeed, and this is very good news for clinicians; it appears that services delivered in private practice, using a variety of treatments, produces benefits equivalent to those obtained by empirically supported treatments (ESTs) in clinical trials (Minami et al., in press). So, don’t give up your preferred treatment model in favor of an EST.

There are three areas where we should focus our attention with regard to increasing benefits to our patients. First, to attain benefits of psychotherapy, patients must be engaged in the therapeutic process. We know that many patients in clinical trials drop out of treatment and those who do have poorer outcomes than those who remain in treatment (Westen & Morrison, 2001). Patients engage in psychotherapy when, it appears, that they received a treatment that is consistent with their expectations, have positive expectations for success, and feel understood by the psychotherapist (Wampold, in press). Rather than administer OUR preferred treatment to all patients, we must be exquisitely sensitive to how patients wish to heal—they have expectations for the nature of treatment and we cannot think that “one size fits all.” CBT for PTSD (prolonged exposure, relaxation, and cognitive restructuring) is an effective treatment (although not more effective than some very different alternatives), but in clinical trials nearly half of patients prematurely terminate (McDonagh et al., 2005). This does not mean that we should rapidly change our approach, but rather we should be attuned to patients’ attitudes, values, context (including culture), and expectations and to be convincing in our presentation of treatment rationales, whether we do this implicitly or explicitly. We should be aware of each client’s motivation for change, their coping styles, and their tendency to resist, and select or adapt treatments accordingly (see Norcross, 2002). Our power to create positive expectations is great—but that task is accomplished in large part by employing treatment procedures that patients find acceptable.

A second critical component of effective therapy is a positive working alliance, as noted previously in News You Can Use. It is important to keep in mind that alliance is more than the relationship formed by being empathic and caring—it is also an agreement about the goals and tasks of psychotherapy. Again, the acceptance of the treatment provided is critical—the working alliance will be weak if the patient does not find the treatment convincing. The literature points to a few critical aspects of the alliance. Psychotherapy involves considerable risk to patients—we ask them to change core aspects about their beliefs in themselves and others. Patients naturally are willing to undergo this change only if they believe the psychotherapist understands them and that the treatment offered will benefit them (Wampold, in press). Moreover, alliance research points to the importance of collaborative work between the psychotherapist and the patient (Hatcher & Barends, 2006). Finally, we must recognize that some patients, perhaps due to poor attachment history, will have difficulty forming an alliance, but we should not be deterred, as it is the psychotherapist’s contribution, not the patient’s contribution, to the alliance that makes a difference (Baldwin, Wampold, & Imel, in press).

A final way to increase effectiveness is to monitor the outcomes we produce.  Michael Lambert’s groundbreaking research on providing feedback to psychotherapists demonstrably has shown that such feedback systematically leads to increased benefits to patients (Lambert et al., 2005). Without such feedback, we really are blind to whether we belong to the Lake Wobegon “false” above average folks or not. Reliable benchmarks exist for disorders (Minami et al., 2007) and we need to understand how effective we arewith our patients relative to benchmarks and to use that feedback to improve the quality of our services. There are a number of outcomes systems available and more on coming on line, including

• Miller and Duncan’s ORS ASIST (http://www.talkingcure.com/bookstore.asp)

• Lambert’s OQ Analyst (http://www.oqmeasures.com/)

• Grissom’s Polaris Mental Health Measures (http://www.polarishealth.com/index.html)

• Brown’s ACORN project (http://www.clinical-informatics.com/), among others. 1

Typically, the measures asses psychological functioning generically by assessing general symptoms, well-being, and social and role functioning, Although the use of outcomes in practice is not without significant issues for clinicians, the benefit of receiving feedback about the quality of our services seems to be great enough that we should pursue outcome-informed practice (Miller, Duncan, & Hubble, 2005).

In summary, our efforts to improve the effectiveness of our psychotherapy could profitably focus on ensuring engagement in the psychotherapy process, attending to the working alliance by focusing on the collaborative nature of our work, and receiving feedback about our effectiveness by measuring outcomes.

Footnotes

1Please note that I am not endorsing these particular measures and systems or recommending these over others. Psychotherapists will need to determine which set of measures and systems is cost effective for their particular practice, should they decide to use outcomes to inform their delivery of service.

References

Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (in press). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology.

Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., et al. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 227-306). New York: Wiley.

Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165-174.

McDonagh, A., Friedman, M., McHugo, G., Ford, J., Sengupta, A., Mueser, K., et al. (2005). Randomized trial of cognitive–behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73, 515-524.

Miller, S. D., Duncan, B. L., & Hubble, M. A. (2005). Outcome-informed clinical work. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed.). (pp. 84-102). New York: Oxford University Press.

Minami, T., Wampold, B. E., Serlin, R. C., Hamilton, E., Brown, G. S., & Kircher, J. (in press). Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A preliminary study. Journal of Consulting and Clinical Psychology.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.

Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centered and psychodynamic

therapies as practised in UK National Health Service settings. Psychological Medicine, 36, 555-566.

Wampold, B. E. (2001). The great psychotherapy debate: Model, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates.

Wampold, B. E. (in press). Psychotherapy: The humanistic (and effective) treatment. American Psychologist.

Wampold, B. E., & Brown, G. S. (2005). Estimating therapist variability: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73, 914-923.

Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorders: An examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69, 875-899.