We have just finished writing the 2nd edition of a book with the title The Great Psychotherapy Debate. Although there are many aspects of psychotherapy about which there is no debate, there remain some important debates about some issues. Interestingly, what we debate probably is not all that important, at one level (although it is the raison d’être for some people!).
Things we know for sure:
- Psychotherapy is remarkably effective. The effects of psychotherapy are greater than the effects of many medical practices, including flu vaccines, most interventions in cardiology, and treatments for asthma, some of which are very expensive and have significant side effects. Psychotherapy is as effective as medication for most mental disorders, without the side effects. As well, psychotherapy is longer lasting than medications (i.e., lower relapse rates after treatment is discontinued) and is less resistant to additional courses of treatment.
- Therapists in practice achieve outcomes comparable to those achieved in randomized clinical trials (RCTs). Indeed, they seem to achieve the same benefits, in fewer sessions, than in clinical trials.
- In contexts where clients can access as much therapy as they desire, patients utilize psychotherapy to progress and when they have made significant improvement, and are in or are close to the “normal” range, they terminate. Some patients progress quickly and others more slowly, but in aggregate these clients do not use “extraordinary” amounts of therapy (on average about 7 to 9 sessions).
- Therapists vary in their effectiveness: Some therapists consistently achieve better outcomes with their clients than do other therapists, in clinical trials and in practice.
- Factors, such as the working alliance, empathy, expectations, psychoeducation about the disorder, and other so-called “common factors” are robustly related to outcome. Moreover, and importantly, those therapists who can form an alliance with a range of patients, have a sophisticated set of facilitative interpersonal skills, worry about their effectiveness, and make deliberate efforts to improve are the therapists who achieve better outcomes.
- Accessibility is the major barrier in our mental health system. Most people with DSM diagnosable disorders do not have access to quality mental health services.
- Providing information about client progress to the therapist and the client improves the quality of psychotherapy, primarily by reducing the likelihood of treatment failures for clients not making expected progress. Monitoring client progress to improve the quality of services, which is often called practice-based evidence, is becoming more widely used.
Things we know (sort of)
- Therapists do not get better with time or experience. That is, over the course of the professional careers, on average, it appears that therapists do not improve, if by improvement we mean “achieve better outcomes.”
- Ratings of therapist competence at delivering a particular treatment, accomplished from ratings of actual therapy sessions, are not associated with better outcomes. Said another way, watching videos of therapy and evaluating based on theory-specific behavioral observations, does not reliably differentiate less effective therapists from more effective therapists. There are two possible reasons for this observation. First, the rating scales used in these studies are focused on competence specific to the treatment approach (e.g., CBT skills) rather than competence related to the common factors. Second, clients have an influence on how competent therapists appear to be—interpersonally aggressive clients, for example, can make therapists appear relatively incompetent.
- Adherence to a treatment protocol is not related to outcome. That is, therapists who adhere to what is expected in a treatment do not get better outcomes than therapists who deviate from the manual. Actually, it appears that therapists who, regardless of how the client responds, sticks to the treatment have poorer outcomes. It is those therapists who flexibly provide a treatment who achieve the best outcomes.
- It appears that “treatments” with no structure are less effective than treatments that have deliberate actions focused on the client’s problems. Therapists delivering non-structured treatments are not able to provide the client an explanation for his or her distress nor explain how the work the client does in therapy will help the client with his or problems, two aspects of therapy that seem to be important for producing benefits.
Things we really argue about
- Some claim that certain therapies are more efficacious than others: Most often the claim is that CBT is superior to other therapies. In cases where this evidence is presented, the effects for the superiority of CBT are small and usually limited to symptoms targeted by CBT but not the comparison treatment. There appears to be no differences among treatments for quality of life, well-being, and general psychological functioning.
- Advocates of particular treatments claim that the treatments are effective because of the specific ingredients in their treatments. Yet, in dismantling studies, where the specific ingredients are removed, treatment efficacy is not reduced, suggesting that the ingredients are not the important therapeutic factors. Studies of mechanisms of change have not established that the specific ingredients are remedial.
- Adapting evidence-based treatments (or mandating evidence-based treatments) will improve the quality of mental health services. Given the evidence that treatments are about equally effective, that treatments delivered in clinical settings are effective (and as effective as that provided in clinical trials), that the manner in which treatments are provided much more important than which treatment is provided, mandating particular treatments seems illogical. In addition, given the expense involved in “rolling out” evidence-based treatments in private practices, agencies, and in systems of care, it seems unwise to mandate any particular treatment. Instead, practice-based evidence should be used to ensure that treatments delivered in clinical settings are effective.
- Given that access to mental health care is paramount, instead of arguing about what treatment is (marginally) better than another, effort should be focused on increasing access.
The evidence discussed here is presented in detail in the recently published The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work (Routledge).
Interested readers would find the following references informative:
Baldwin, S. A., Berkeljon, A., Atkins, D. C., Olsen, J. A., & Nielsen, S. L. (2009). Rates of change in naturalistic psychotherapy: Contrasting dose–effect and good-enough level models of change. Journal of Consulting and Clinical Psychology, 77(2), 203-211. doi: 10.1037/a0015235
Baldwin, S. A., & Imel, Z. E. (2013). Therapist effects: Finding and methods. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 258-297). New York: Wiley.
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75, 842-852.
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.
Minami, T., Wampold, B. E., Serlin, R. C., Hamilton, E., Brown, G. S., & Kircher, J. (2008). Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A preliminary study. Journal of Consulting and Clinical Psychology, 76, 116-124.
Norcross, J. C. (2011). Psychotherapy relationships that work: Evidence-based responsiveness. New York City: Oxford University Press.
Shimokawa, K., Lambert, M. J., & Smart, D. W. (2010). Enhancing treatment outcome of patients at risk of treatment failure: Meta-analytic and mega-analytic review of a psychotherapy quality assurance system. Journal of Consulting and Clinical Psychology, 78(3), 298-311. doi: 10.1037/a0019247
Wampold, B. E. (2007). Psychotherapy: The Humanistic (and Effective) Treatment. American Psychologist, 62, 857-873.
Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 200-211. doi: 10.1037/a0018912