Five components: (1) disorder, (2) psychological explanation of the disorder, (3) mechanism of change (i.e., theory about how changing part of the system will eliminate the illness), (4) therapeutic procedures (a treatment containing therapeutic procedures, (5) specificity (treatment shown to be more effective than a placebo treatment and treatment shown to operate through its intended mechanism).
Freudian example: (1) disorder (hysteria), (2) psychological explanation of the disorder (repressed traumatic events), (3) mechanism of change (insight into consciousness), (4) specific therapeutic actions (free association).
Evidence-Based Practice
EBP is based on the medical model -- e.g., the treatment must be focused on fixing a problem and cannot be seen "as an opportunity to grow or as an opportunity to make meaning."
The Contextual Model
Basic premise: "the benefits of psychotherapy accrue through social processes" and "the relationship, broadly defined, is the bedrock of psychotherapy effectiveness." Humans are ultra-social, or eusocial, species. We've "evolved to heal through social means."
There are three pathways that explain the benefits of psychotherapy.
The Initial Therapeutic Bond
"Before the three pathways can be employed, the therapist and the client must form an initial bond." People make "very rapid determination (within 100 ms), based on viewing the face of another human, whether the other person is trustworthy or not." Clients probably make rapid judgments based on how the therapist dresses, arranges their office (e.g., diplomas on the wall), etc. Clients go into the first session with preconceptions based on their experiences with previous mental health professionals, etc. People are "generally predisposed to have a positive orientation toward healing, but only if the healing practice is consistent with their cultural traditions and accepted with a positive orientation."
Pathway 1: The Real Relationship
The real relationship: "the personal relationship between therapist and patient marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that befit the other" (Gelso). The real relationship is based on genuineness, "the ability and willingness to be what one truly is in the relationship -- to be authentic, open, and honest" and realistic perceptions. Also important: synchrony in vocal tone and nonverbal movement.
The relationship "will be therapeutic in and of itself." Human connection is necessary for healthy functioning. Empathy important; definition: the process in which "an individual can be affected by and share the emotional state of another, assess the reasons for another's state, and identify with the other by adopting his or her perspective."
Pathway 2: Expectations
The client comes to therapy demoralized, not only because they're distressed but because they have repeatedly tried and failed to overcome their problems. The client generally believes that the therapy will be beneficial, and the mere act of setting up the first appointment tends to be ameliorative. It's important to instill hope in the initial sessions. Once clients start therapy, they come to believe that "participating in and successfully completing the tasks of therapy" will help with their problems, "which then furthers for the client the expectation" that they have "the ability to enact what is needed."
"What is important for creating expectations is not the scientific validity of the theory but the acceptance of the explanation for the disorder, as well as therapeutic actions that are consistent with the explanation." "If the client believes the explanation and that engaging in therapeutic actions will improve the quality of their life or help them overcome or cope with their problems, expectations will be created and will produce benefits." The therapeutic alliance -- which includes "agreement about the goals and tasks of therapy" -- "is predictive of outcome across treatment."
Pathway 3: Specific Ingredients
The "specific ingredients in all therapies induce the client to do something that is salubrious. That is, the client engages in some action that is health promoting in that the activity results in an increase in something healthy or a decrease in something unhealthy." The efficacy of lifestyle interventions has often been ignored.
Similarities in all therapies: e.g., dynamic therapists do different things than cognitive therapists, but they too focus on changing cognitions; most treatments of avoidant patients involve exposure; most treatments involve improving interpersonal relationships.
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Effect Sizes
Effect size (d) is "a standardized index that measures the strength of a relationship. In group designs, the effect size is the standardized difference between the means of the distributions for two groups."
An effect size of .8 is large, .5 medium, and .2 small. Suppose that a treatment was found to be superior to no treatment with an effect size of .6 >> that means that "the average treated person will have a better outcome than 73 percent of those who are untreated." See Cohen's chart on page 70. If the treatment has an effect size of 0, "then the average person receiving the treatment will be better off than 50 percent of untreated persons."
R-squared. Effective size of .80 "implies that 14 percent of the variability in outcomes is associated with the factor." (See page 70.) Example: people treated for depression
d Effect size Proportion of control patients less than mean of treatment
1.0 0.84
0.9 0.82
0.8 Large 0.79
0.7 0.76
0.6 0.73
0.5 Medium 0.69
0.4 0.66
0.3 0.62
0.2 Small 0.58
0.1 0.54
0.0 0.50
Methodological problems with RCTs (p. 77).
The Medical Model holds that "the specific ingredients are what make psychotherapy work." It further holds that therapist differences, if present, are due to lack of adherence. The Contexual Model posits that all treatments will be equally effective "provided they contain the elements of the three pathways." The Contextual Model holds that some therapists will be better than others and that "therapist differences will not be due to adherence to a treatment protocol."
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Absolute Efficacy
Absolute efficacy = does a treatment work better than no treatment.
Tests of statistical significance: e.g., ANOVA, ANCOVA, or multilevel modeling of longitudinal data.
Efficacy = "the benefits of psychotherapy that are derived from comparisons of the treatment and a no-treatment control in the context of a well-controlled clinical trial." Effectiveness = "the benefits of psychotherapy that occur in community settings [a.k.a. real-world settings]." Some argue that clinical trials do not replicate how treatment is applied in the real world. Wampold uses the terms efficacy and effectiveness interchangeably.
Evidence indicates that treatment in clinical settings is more effective than treatment in community settings, meaning that you can't generalize the results of clinical tests and that more real-life studies must be conducted. Benchmarking = comparing results of clinical studies to real-life studies.
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Relative Efficacy
Relative efficacy = does Treatment A work better than Treatment B?
Relative efficacy is usually established through a comparative design: patients are randomly assigned to Treatment A or Treatment B, treatments delivered, and post-tests administered. Comparative designs usually contain a control group, such as a waitlist control group, so that treatments can be compared to no-treatment.
There are many problems with comparative design studies. First, "statistical theory predicts that by chance some comparisons of treatments will produce statistically significant differences when there are no true differences (i.e., Type I errors)." This is why meta-analyses are important. One type of meta-analysis: (a) two treatments compared by looking at studies in which Treatment A compared to no-treatment and then looking at studies in which Treatment B compared to no-treatment. One problem with these meta-analyses: e.g., "studies that compare CBT with a no-treatment control group may differ from studies that compare dynamic treatments with no treatment controls on such factors as outcome, variables used, severity of disorder, comorbidity of patients, treatment standardization, treatment length, and allegiance of the researcher."
One solution to this is to only look at studies that directly compare two psychotherapies. Problem is that some confounds would still remain, especially skill of therapist and allegiance. In order for these head-to-head studies to work, the following conditions must be present: (a) both treatments need to appear efficacious to patients and the rationale would need to be cogent and acceptable, (b) the therapist needs to believe in the efficacy of treatment, (c) the treatment needs to be given "in a manner consistent with the rationale provided and contain actions that induce the patient to participate in therapeutic actions that reasonably address his or her problems," (d) the treatment is delivered "in a healing context." Problems: comparative studies often include sham treatments (a.k.a. pseudo-placebos) that the therapists do not view as legitimate. Example of a pseudo-placebo: supportive counseling for PTSD in which patients were discouraged from talking about the traumatic event (few real-life therapists would support this strategy).
Allegiance is "the degree to which the therapist or researcher believes that the therapy is efficacious." A central tenet of psychotherapy is that the therapist believes in the efficacy of the treatment. In other words, therapist allegiance is "a basic common factor that should exist across therapies as they are typically delivered." It is common in comparative studies for the therapists and researchers to be affiliated with one treatment. In medicine you have randomized double-blind placebo studies in which clinician does not know which drug they are administering; treatment blinding impossible in psychotherapy studies. Study after study shows that therapist and researcher allegiance affects outcome; specifically, the great the allegiance of the therapist, the greater the outcome; the effect size is usually large.
"The Dodo bird conjecture has survived many tests and must be considered 'true' until such time as sufficient evidence for its rejection is produced." The fact that many treatments are equally efficacious is evidence against the medical model.
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Therapist Effects
The Medical Model holds that who delivers the treatment is not that important, whereas the Contextual Model holds that who how the treatment is delivered is critical to its success.
Nested experimental design: therapists randomly assigned to treatments. Crossed design: therapists deliver each treatment being studied.
"[T]he preponderance of the evidence indicates that there are important therapist effects" and that therapist effects "generally exceed treatment effects."
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General Effects
Evidence for common factors.
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Specific Effects
(did not read chapter)
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Beyond the Debate: Implications
(did not read first part of chapter)
Practice
There is "insufficient evidence to privilege some treatments over others," meaning that therapists "can deliver the treatment of their choosing." Three caveats:
- Therapists must "deliver a treatment that is coherent, explanatory, and facilitates the patient's engagement in making desirable changes in their lives." The explanation and trust must (a) be "acceptable to the patient," (b) lead to "expectation that the patient will have control over his or her problems," and (c) engage "the patient in some type of action." The therapist must realize that the patient comes with a distinct culture and background and will prefer some treatments over others; this means that therapists "may well need to be skilled in delivering more than one treatment."
- Therapists are "responsible for the outcomes achieved by their patients." It's true that some patients will have poorer prognoses than others, "but overall therapists should achieve reasonable benchmarks for the types of patients being treated." Therapists must measure the progress of their patients (whether by using measures or talking to patients). "Essentially, therapists who do not systematically monitor the effectiveness of their interventions cannot claim to be providing ethical treatment that meets current standards of care."
- Not all therapies are bona fide -- e.g., rebirthing therapies.
Therapist allegiance to the treatment being delivered is important. In other words, the therapist must believe in the efficacy of the treatment.
Therapists must develop their skills over time. Training must involve both learning specific therapeutic modalities (more than one) and learning relationship skills.
Patients should look for the following in a therapist: (a) a treatment plan that they find acceptable and that they believe will lead to improvement, (b) the therapist and patient agree on the goals of therapy and the tasks needed to achieve those goals, (c) the patient feels understood and respected, (d) the patient steadily makes progress towards the goal.
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