This page contains reviews of research on "what works" in therapy once reviewed on the I.S.T.C. website. As with the general "what works" page, this page of archived studies is categorized according to the four common factors. You can either skim the page or click on any of the "bookmarks" below to go to the specific factor that interests you most.

Extratherapeutic Factors / Relationship Factors / Model and Technique Factors / Placebo Factors / General Research on Common versus Specific Factors

Extratherapeutic Factors

Does Self-help Help?
Although the pace seems to have slackened in recent years, self-help books are a staple of the American diet.  Judging from the promotion blurbs on back covers, you can: lose weight, overcome co-dependence, quit drinking or using drugs, fight off fear, and ward off anxiety.  If the sales figures are any indication, the programs must be phenomenally successful.  But what does the research say?

Previous reviews on this website have found that self-help is generally as effective as professionally guided treatment when it comes to depression, anxiety–even alcohol and drug problems.  Recently, researcher Scogin (2003) reviewed the growing literature in this area and found much the same.  Self help books, manuals, tapes, computer programs, and videotapes have proven effective for depression, anxiety, alcohol abuse, smoking cessation, and child and family problems "for less intensive cases and more motivated clients."  In the case of alcohol problems, bibliotherapy–reading that is–was not found to be any more effective when it was augmented with consultation with a professional!

Bottom line?  Self-help should perhaps be viewed as the best, "first line" of care for most people.  While this may be suprising to some, research summarized by the founders at ISTC shows that the single largest contributor to change in treatment is the client–responsible for between 40-87% of the variance in treatment outcome.
Scogin, F.R. (2003).  The status of self-help adminsitered treatments.  Journal of Clinical Psychology, 59(3).

People find strength NOT weakness in disaster!
One of the curious images from the recent Columbine murders is the march of numerous mental health professionals to the disaster scene. Several sources noted, for example, that the glut of therapists led local officials to ask that "the community be left alone to grieve in their own way." Other sources reported that most people involved in the event preferred to talk with friends and to seek solace in church. In the US, One can hardly miss the therapists usually caught on video commenting on or rushing to the aid of the latest disaster victims. Apparently, modern people are simply incapable of coping without the help of professional crisis debriefers. Now, some research shows how far off the field may be. Researchers at Washington University found that most people feel they actually grow following a tragic event or experience. Rather than rushing in to see what marvelous techniques can be used to aid the victims, therapists would do well to help communities and individuals access and better utilize their own resources. The body of this literature is reviewed in a new book by Tedeschi et al. (1999) who have also compiled a manual for helping therapists capitalize on client strengths in crisis situations.

Psychology Today (April, 1998). The Flip Side of Disaster. 31(2), 18.

Tedeschi, R.G., Park, C., and Calhoun, L. (1999). Post-traumatic Growth: Positive Changes in the Aftermath of Crisis. LEA: Mahwah, NJ.

What Makes Therapy Work? It's the Client, Stupid!
Given how long as the field of mental health has been around, you'd think the experts would have at least agreed on the ingredients of successful psychotherapy. Instead, widely divergent hypotheses have been and continued to be advanced--everything from straightening out dysfunctional thinking to resolving traumatic memories resulting from an alien abduction. And yet, whenever large scale studies are done, the same factors consistently emerge. In this study, researchers re-analyzed data from the now famous TDCRP, at the time the single largest ever funded comparative study on the treatment of depression. Recall, that several different modalities of treatment were compared (including the darling child of the moment--medication) and found to achieve largely similar results. This failure of the research to support the moment's theoretical fashion caused a collective gasp among supporters of various models of treatment as well as the now usual cat calls regarding problems in research design. Taking a more constructive approach to problem, researchers Ablon and Jones set out to determine if models made a difference and to whom. As predicted by Miller, Duncan, and Hubble (1997) in their book Escape from Babel, the researchers did find that models significantly affected the behavior of clinicians. However, client characteristics that were the same across treatment conditions predicted treatment outcome. How long will it take the field to accept what is so patently obvious: clients--not therapists--make therapy work. As every clinician on the front lines knows. in order to maximize clinical outcome, therapists need to attend and tailor treatment to the client's characteristics not delivery a standardized treatment model.

Albon, J.S., and Jones, E.E. (1988). Psychotherapy process in the NIMH TDCRP. Journal of Consulting and Clinical Psychology, 67(1), 64-5.

The Role of Social Support in Good Outcomes
Research has long established that extra-therapeutic factors (e.g., client factors combined with chance events) make the single largest contribution to change in psychotherapy. In this study, researcher Mallinckrodt adds one more piece of evidence that factors outside of therapy are more important to change than factors occurring within the therapy. Basically, this study found that the client's perception of increased social support outside of the treatment relationship was more important in terms of symptom reduction than growth in the strength of the therapeutic alliance! Perhaps it is time to help clients directly increase their external supports rather than focusing on changing supposed internal psychological variables, eh?

Mallinckrodt, B. (1996). Change in working alliance, social support, and psychological symptoms in brief therapy. Journal of Counseling Psychology, 43(4), 448-455.

Relationship Factors

Just How Important is the Alliance? Further Evidence
Believe it or not, the importance of the therapeutic alliance is still a hotly debated topic in research and therapeutic circles. In many studies, in fact, measuring the alliance is an after thought. Those who develop models of therapy claim invariably that the alliance is necessary BUT not sufficient for successful outcome. Of course, why buy their books otherwise. Still others, largely from the cognitive behavioral camp, claim that alliances are either formed or strengthened after success in therapy. The latter argument is addressed in the summary below. As far as the importance of the alliance goes, however, yet another study finds that the therapeutic relationship predicts 30% of the outcome variance. What's more, researchers Kivlighan et al. (2000) found that alliances with "tears-and-repairs" were better predictors of subsequent client improvement than those that were stable or grew linearly. Of course, a linearly increasing alliance does not allow people to learn about the effective management of conflict in interpersonal relationships--of which, in spite of the increasing medicalization of the field, psychotherapy continues to be.

Kivlighan, D. (2001). Patterns of working alliance development. Journal of Counseling Psychology, 47, 362-71.

The bottom line? If given the choice between "treating" someone or establishing a relationship with them in therapy, therapists should opt for the latter. Literally, thousands of findings support the importance of the therapeutic alliance in achieving good outcomes in clinical practice. Barber, J. (2000). Alliance predicts patients' outcome beyond in-treatment change in symptoms. Journal of Consulting and Clinical Psychology, 68, 1027-1032.

What really matters in the much ballyhooed Cognitive-Behavior Therapy?! The Relationship...
Thank goodness we've got CBT. If you believed the promoters, nothing therapists did before the advent of this protocol-drive, technique-heavy approach worked. With the backing of the Division 12 within APA, the approach is widely touted as the most effective treatment for an ever widening group of DSM diagnostic categories. As noted before on this website, the promotion is more science fiction than science. In yet another review of the CBT literature, researchers Keijsers et al. note two clusters of therapist behaviors that are associated with outcome: (1) the Rogerian conditions of empathy, warmth, positive regard, and genuineness; and (2) the therapeutic alliance.

How to Prevent Drop Out? Give Clients Choices!
In this study, researcher Rokke tested whether giving clients a choice about their treatment goals would result in better treatment outcomes--in this case, for clients who were experiencing depression. Interestingly enough, while choice of treatment goal was not related to outcome, it did predict drop out from treatment. Specifically, clients who were given a choice were much less likely to drop out compared to those not given a choice (20% versus 75%). Bottom line: it doesn't really matter that the outcomes were not different for the clients who stuck around in both groups. More important is the fact that therapists are not likely to be of much help to those who drop out of treatment!

Rokke, P.D. (1999). The role of the client choice and target selection in self-management therapy for depression in older adults. Psychology and Aging, 14, 155-169.

Making Treatment Acceptable . . . A Key to Success
Treatment acceptability refers to the degree to which clients accept and agree with a particular treatment model or technique (Kazdin, 1980). Growing empirical and clinical interest in this topic is based on the obvious yet crucial notion that "a treatment that is not used is no treatment at all" (Witt & Elliott, 1985, p. 253). Some treatments might be very effective, but are of no use if clients perceive them as unrealistically demanding (e.g., a daily one-hour exercise routine). The topic of acceptability underscores the notion that the ultimate effectiveness of a therapeutic intervention is influenced by the client’s perception of the intervention. More specifically, acceptability is influenced by the client’s perception of the proposed treatment’s sensibility, practicality, and potential for success. Research has supported that interventions rated by clients as more acceptable are implemented more often than those rated as less acceptable (Reimers et al., 1992).

In addition to its relevance in the therapy context, treatment acceptability is an important consideration in providing "indirect services" such as parent and teacher consultation on school-related problems and organizational consultation. Conoley et al. (1992) found that the rationale used to present an intervention significantly influenced the degree to which it was acceptable to teachers. An intervention presented with a rationale that closely matched the teacher’s perception of the causes and severity of a school problem were significantly more acceptable than the same intervention presented with a rationale that mismatched the teacher’s perception. Empirical findings on acceptability point to the pragmatic benefits of collaborating with (vs. dictating to) clients by accommodating their perceptions when it comes to selecting and developing interventions. Careful consideration of treatment acceptability on the part of practitioners enhances outcomes.

Conoley, C. W., Ivey, D., Conoley, J. C., Scheel, M., & Bishop, R. (1992). Enhancing consultation by matching the consultee's perspectives. Journal of Counseling Development, 69, 546-549.

Kazdin, A. E. (1980). Acceptability of alternative treatments for deviant child behavior. Journal of Applied Behavior Analysis, 13, 259-273.

Reimers, T. M., Wacker, D. P., Cooper, L. J., & DeRaad, A. O. (1992). Acceptability of behavioral treatments for children: Analog and naturalistic evaluations by parents. School Psychology Review, 21, 628-643.

Witt, J. C., & Elliot, S. N. (1985). Acceptability of classroom management strategies. In T. R. Kratochwill (Ed.), Advances in school psychology (Vol. 4, pp. 251-288). Hillsdale, NJ: Lawrence Erlbaum.

The Relationship, again . . .
The history of psychotherapy has much in common with the "Search for the Holy Grail." The theory that answers all questions, the approach or magic bullet treatment that will best all others. In spite of the many claims and counter claims, the research thus far has found little evidence for either. All approaches work about the same. One variable that continues to be consistently associated with effective clinical work--regardless of theoretical orientation or professional discipline--is the strength of the relationship or alliance between therapist and client. In particular, the client's assessment of the relationship. Now a study shows that the attitude of the therapist--specifically, their perception of the working alliance has a strong effect on the client's present and future perception of the alliance. Bottom line: developing a strong alliance means attending not only to the client's perception, but also to the client's perception of the therapist's view of the therapeutic relationship. Client's who think their therapist is confident about their work together, rate alliances higher, and we all know that higher alliances are associated with better treatment outcomes!

Brossart, D.F. et al. (1998). A time series model of the working alliance. Psychotherapy, 35, 197-205.

Why do some people drop out of treatment?
Drop out from treatment is a large problem in the field. Some studies indicate that as many as 50% of people fail to return after their initial visit. Knowing why this happens could go a long way toward both improving treatment as well as decreasing the costs associated with opening cases that fail to return. For many years, pre-mature termination has been variously attributed to client pathology (e.g., flight from transference) or, in these more lean managed care times, client improvement (e.g., client got better and didn't need to return). This study suggests something more troubling: it's the therapist's fault.

In the study, 23% of patients in interpretative (anxiety-producing) psychotherapy dropped out, whereas only 6% of patients in supportive therapy dropped out. Dropouts could be predicted only by therapy process variables, and not by patient variables. In other words, only what happened in the sessions predicted whether the client failed to return--not who the patient was and what the patient brought
to the process. The session prior to dropout had nine recurring qualities:

	The client made his or her thoughts about dropping out clear, usually early in the session.
	The client expressed frustration about the therapy sessions. This often involved expectations that were not met and the therapist's repeated focus on painful feelings.
	The therapist addressed the difficulty by focusing on the patient-therapist relationship and making transference interpretations (e.g., links were made to other relationships).
	The client resisted focus on transference by expressing verbal disagreement, and being silent.
	The therapist persisted with transference interpretations.
	The client and therapist argued with each other. They seemed to be engaged in a power struggle. At times the therapist was drawn into being sharp, blunt, sarcastic, insistent, impatient, or condescending.
	Although most of the interpretations were plausible, the client responded to the persistence of the therapist with continued resistance.
	The session ended with encouragement by the therapist to continue with therapy and a seemingly forced agreement by the client to do so.
	The client never returned.

Bottom line? Interpretive therapy was associated with 5 times more drop out than supportive work. Stop talking and start listening!

Piper, W. H., Ogrodniczuk, J. S., Joyce, A. S., McCallum M., Rosie, J. S., O'Kelly, J. G. & Steinberg, P. I. (1999). Prediction of dropping out in time-limited interpretive individual psychotherapy. Psychotherapy, 36, 114-122.

Does gender matter?
Gender is a hot topic in the field of therapy today. Most often, the question is, "does the gender of the therapist matter in terms of outcome?" Building on a plethora of studies, researchers examined whether therapist gender, congruence of client and therapist gender, or clients' gender-linked expectations of therapists' helpfulness affected outcome in the Treatment of Depression Collaborative Research Project--the largest ever funded, multisite, comparative study on the treatment of depression. The answer: nope! Change at the end of treatment, attrition from treatment, ratings of therapist empathy were not affected at all! In the face of this, and other reams of research, one has to wonder why do such clinical myths persist.

Zlotnick, C. et al (1998). Does the gender of a patient or the gender of a therapist affect the treatment of patients with a major depression? Journal of Consulting and Clinical Psychology, 66, 655-659.

Here's a novel idea . . . Tailoring treatment to the Client's wishes
Researcher Stephan Price has a radical idea when it comes to the treatment of folks diagnosed as schizophrenic: solicit the client's ideas and then conduct treatment according to those ideas. In this pilot study of clients described as "resistant to treatment," following the client's recommendations led to significant changes in client's self-rating and assessment of treatment. Moreover, in contrast to what was expected, the clients wishes were, "surprisingly modest" including such things as changing medications, altering their participation in various treatment offerings, or arranging a special meal. Hmm. Amazing that an article like this needs to be written. The fact that such a simple point needs to be said points out what the profession really thinks of the people who get the diagnosis.

Priebe, S., and Gruyters, T. (1999). A pilot trial of treatment changes according to schizophrenic patients' wishes. Journal of Nervous and Mental Disease, 187(7), 441-443.

What makes a good alliance with clients? Uh hem, apparently not experience!
Researchers Dunkle and Freidlander investigated the relationship between selected personal qualities of the therapist and client perceptions of the therapeutic alliance early in treatment. Consistently with previous studies, the researchers found that therapists' degree of comfort with closeness in interpersonal relationships, low hostility, and high social support predicted clients' ratings of the alliance early in treatment. Additionally, they found that therapist experience was not predictive of the strength of any aspect of the therapeutic relationship including: emotional bond, negotiation of goals, or assignments of tasks! Apparently, some therapists can and some can't! So much for all the emphasis on treatment models and techniques!

Dunkle, J.H., and Friedlander, M.L. (1996). Contribution of therapist experience and personal characteristics to the working alliance. Journal of Counseling Psychology, 43(4), 456-60.

Forming Alliances with Families
Forty years of outcome research demonstrate the importance of the therapeutic alliance in treatment outcome. Such data suggest that as much as 30% of the outcome in therapy is attributable to the alliance. Forming an alliance, the data shows, requires different skills when working with a family versus an individual. In this study, researchers Dozier, Hicks, Cornille, and Peterson showed 40 family triads (mother, father, and adolescent son) a five minute videotape of 4 different interviewing styles and had them complete the Family Therapy Alliance Scale. The results indicated that the family groups as a whole gave significantly higher ratings to circular and reflexive rather than linear and strategic interviewing styles. The authors define the four questions types:

	Linear: Problem explanation and definition questions.
	Strategic: Leading and confrontation questions.
	Circular: Behavior effect and difference questions.
	Reflexive: Future-oriented and observer perspective questions.

The authors conclude that , "the types of questions one uses in therapy may be the critical factor that determines the level of joining the therapist system is able to make with the patient (sic) system" (p. 199). Perhaps the study also highlights how relatively unimportant it is for the therapist to find and solve a problem since both strategic--typically considered "helping" style questions--and linear--typically seen as diagnostic questions--resulted in poorer alliances ratings.

Dozier, R., Hicks, M., Cornille, T.A., Peterson, G. (1998). The effect of Tomm's questioning styles on therapeutic alliance: A clinical analog study. Family Process, 37(2), 189-200.

Attending to the Client's Theory of Change
Therapists-in-training typically learn a variety of therapy models and theories of change which they, in turn, apply to their clients to help them resolve their problems. Recent research suggests, however, that clients present for treatment with their own theories. Ignoring them, this research suggests, may delay or obviate change. A good example of this research was conducted by Hayes and Wall (1988). In their study of nearly 400 psychologists, these researchers found that clinicians' theoretical orientation and clients' responsibility attributions did not significantly affect clinicians' attributions regarding responsibility for problem resolution--a potential major mismatch that may affect the quality of the therapeutic alliance. The authors suggest that treatment effectiveness may be enhanced by carefully attending to clients' attributions concerning their difficulties and tailoring interventions accordingly.

Hayes, J.A., and Wall, T.N. (1988). What influences clinicians' responsibility attributions? The role of problem type, theoretical orientation, and client attribution. Journal of Social and Clinical Psychology, 17, 69-74.

It's the Relationship, Stupid!
Of all mental health disciplines, the field of family therapy has probably been the most enthusiastic supporter of particular models of treatment. Over the last 20 years, numerous approaches have captured the attention of this segment of the helping professions. As researchers Quinn, Dotson, and Jordan (1997) demonstrate in the well-written and well-researched study, however, when all is said and done, the most important element in family therapy is the alliance--not the fancy technique--but the strong therapeutic relationship between the provider and clients. The study is particularly important because it underscores research from individual therapy showing that the clients' perception of the relationship--not therapists'--is the best predictor of outcome from treatment. In fact, in this study, the woman's perception of the alliance was more important than the man's in predicting good outcome.

Psychotherapy Research. 1997 Win Vol 7(4) 429-438

Is it time for transference to transfer out of professional discourse?
n this study, researchers Raue, Goldfried, and Barkham (1997) compared ratings of the therapeutic alliance in psychodynamic-interpersonal therapy and cognitive-behavioral therapy of 57 people being treated for depression and found higher impact sessions in both therapies were characterized by higher therapeutic alliance scores. On a whole, CBT had significantly higher alliance scores, a finding which the authors attribute to the fact that a tenet of the psychoanalytic-interpersonal model/school is to view strains in the alliance (e.g, transference) as necessary to resolving client difficulties. Given the finding, however, one is left to wonder whether or not it is time for this belief go the way of the way of other outdated concepts from the field. Here is a summary of what 40 years of outcome data say about the therapeutic alliance:

	Ratings of the therapeutic alliance predict client improvement across treatment modalities and populations.
	Clients' ratings of the therapeutic alliance have a stronger correlation with outcome than therapists'.
	Ratings of the therapeutic alliance at early stages of treatment are more predictive of outcome than ratings taken later in the treatment process.
	In most studies, the variance attributable to the technique under study is usually less than the variance attributable to the different therapists or sites participating in the study indicating that technique is subordinate to the alliance.

Raue, P.J., Goldfried, M.R., and Barkham, M. (1997). The therapeutic alliance in psychodynamic-interpersonal and cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology, 65(4), 582-587.

Placebo Factors

Why Helping Clients Figure out What's Wrong is Plain Wrong!
Standard practice in the therapy industry to think that focusing on what's wrong with people and helping them fix or avoid it in the future is the most helpful. This idea, based on the medical model, simply isn't the truth in the relationship-based world of psychotherapy. In fact, a University of Arkansas team has determined that mulling over events that had negative outcomes is counterproductive. Contrary to the conventional wisdom, counterfactual thoughts about negative events, commonly known as hindsight, only causes sadness and doesn’t change behavior, Dr. Denise Beike, of the University of Arkansas in Fayetteville, said Friday at the Society for Personality and Social Psychology meeting in Nashville, Tennessee.

Dr. Beike and graduate student Deirdre Slavik enlisted two groups of University of Arkansas students to record their thoughts each day in a diary in order to "look at counterfactual thoughts as they occur in people’s day-to-day lives." In the first group, graduate students recorded their counterfactual thoughts, their mood, and their motivation to change their behavior as a result of their thoughts. After recording two thoughts per day for 14 days, the four male and five female students reported that negative thoughts depressed their mood and increased their motivation to change their behavior. The researchers then enlisted a group of three male and five female undergraduate students to keep similar diaries for 21 days, to determine if any actual change in behavior would result from counterfactual thinking. Three weeks after completing their diaries the undergraduate students were asked to review their diary data and indicate whether their counterfactual thinking actually caused any change in behavior. "No self-perceived change in behavior was noted," Dr. Beike told Reuters Health. Counterfactual thoughts about negative events in everyday life cause us to feel that we "should have done better or more," Dr. Beike said. "These thoughts make us feel bad, which motivates us to sit around and to feel sorry for ourselves."

So what does work? The study found that "credit-taking thoughts"--a practice highlighted three years ago in the chapter on placebo factors in Escape from Babel : Toward a Unifying Language for Psychotherapy Practice --in which individuals reflect on success and congratulate themselves, reinforce appropriate behavior and help people "feel more in control of themselves and their circumstances."

The wages of negativity? Yikes, death!
The results of a 30 year study by researchers at the Mayo clinic parallel the findings reported in the previous study noting that pessimistic people have a 19% increase in the risk of death when comparing their expected life span with their actual life. Optimistic people, on the other hand, was significantly better than expected. Interestingly, most of the people in the study were a mix of optimistic and pessimistic attitudes. These folks did not show a trend in either direction. For therapists though, the data seem to indicate that taking a negative or pessimistic stance toward life and the possibility of change could be, well . . .

Read the entire reports at:

http://psychiatry.medscape.com/reuters/prof/2000/02/02.14/c102140e.html

Which is more Important in Health and Well Being: Money or Sense of Control?
There is a wealth of research showing a strong correlation between social class and having health and a sense of well being. There is also a great deal of data documenting a connection between a sense of control with both physical and psychological health. The question is: which is more important? In this study, researchers Lachman and Weaver found that for all income groups having higher perceived mastery and lower perceived constraints were related to better health, greater life satisfaction, and lower depressive symptoms. Importantly, people in the lowest income group who had a high sense of control showed levels of health and well being comparable with the higher income groups.

Such data go a long way toward supporting therapies and treatment interventions which highlight and underscore client power and control rather than take over and do for the client. Indeed, the research indicates that such treatment systems may undermine the people they purport to help.

Lachman, M.E., and Weaver, S.L. (1998). The sense of control as a moderator of social class differences in health and well-being. Journal of Personality and Social Psychology, 74(3), 763-773.

Mental Viagra: The Placebo and the Penis
Men are running out to buy it and women are singing it's praises but recent research says that the biggest aphrodisiac is the oldest: the lie! "You're the best lover I ever had," "You give me the most pleasure," blah, blah, blah. Researchers found that men who thought they'd drunk alcohol--commonly though mistakenly believed to improve sexual functioning--had harder erections while watching erotic videos than knowingly sober porn oglers. Similarly, researchers have found that actively doing something to "get healthy" has a restorative effect separate from the activity. The common ingredient: placebo factors, shown by the way by research to contribute as much as 15% to the variance in outcome for psychotherapy.

Schoofs, M. (May 12, 1988). Healing head trips. Village Voice, p. 22.

Miller, S.D., Hubble, M.A., and Duncan, B.L. (1997). Escape from Babel. New York: Norton.

Model and Technique Factors

Relationship of Therapist Competence to Outcome
The American Psychological Association and the National Association of Social Workers are busy creating lists of so-called "empirically validated" treatment approaches in spite of literally years of research which finds no evidence that any model, method, or approach produces reliably superior results. Now a re-analysis of the large, multi-site, Treatment of Depression Collaborative Research Project, shows once again that the specific model of treatment is not what really matters in effective therapy. Recall that the study compared CBT, IPT, Meds, and a placebo and found all treatments roughly equivalent in the treatment of depression. Unwilling to let go of the "Models Matter Most" philosophy that dominates thinking in the field, however, researchers investigated the impact of therapist competence at cognitive therapy on treatment outcomes. What did they find? "The results are not as strong or consistent as predicted." What did matter? In a vindication of the common factors, the researchers found that, "the therapists ability to structure the treatment" was most highly related to outcome. This is exactly the point made some time ago by the Founders of ISTC in the book Escape from Babel : Toward a Unifying Language for Psychotherapy Practice.

Shaw et al. (1999). Therapist competence ratings in relation to clinical outcome in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 67(6), 837-46.

What makes "master therapists" effective . . .Not their model!
Every year, thousands of therapists attend workshops around the country with recognized experts in the field. The focus of these workshops is generally on the acquisition of technical skills associated with the model of therapy developed and promoted by the workshop leader. In an ingenious study, researchers Goldfried, Raue, and Castonguay viewed tapes of 36 therapists identified by their peers as "master therapists." The master therapists actually chose the tape based on their belief that it provided an example of a session that they considered significant. When the researchers reviewed the tapes, however, they found that regardless of theoretical orientation, the parts of the sessions that the master therapists considered significant were very similar! One more time, the common factors carry the day!

Goldfried, M.R. et al. (1998). The therapeutic focus in significant sessions of master therapists. Journal of Consulting and Clinical Psychology, 66, 803-810.

Feedback to clients that actually works!
Most therapists provide feedback to their clients. This study by Hanson, Claiborn, and Kerr (1997) found, however, that how you give feedback may be more important than what feedback you give. The researchers compared whether didactic or interactive feedback was more likely to be accepted. Importantly, they found participants more likely to accept interpretations when they were presented interactively and collaboratively. Participants also found the interactive condition deeper and more valuable and rated their counselors as more expert, trustworthy, and attractive than those in the didactic condition.

Hanson, W.E., Claiborn, C.D., and Kerr (1997). Differential effects of two test-interpretations styles in counseling: A field study. Journal of Counseling Psychology, 44, 400-405.

Empirically Valid Treatments really Common Factors Treatments!
Division 12 within the American Psychological Association has been trying to keep up with medicine by identifying psychological interventions that are supposedly "better" or "more scientifically established" than other therapies--the psychological equivalent of a pill in other words. In this study, researchers Wampold et al. (1997) show that the efficacy of the so-called empirically valid treatments are roughly equivalent--once again proving the "Dodo Bird hypothesis" that "all have won and therefore all deserve prizes." More importantly, these researchers found that the homogeneity of effect sizes were not related positively to publication date, putting to rest once and for all the silly idea that the failure to find differences among models was due to methodological weaknesses in early research. Neither did they find any difference between models that were more dissimilar.

When will APA learn that therapists do therapy, not their models! Rather than looking for so called better treatments, the APA would do well to foster a reliable and valid program for insuring the delivery of effective treatment services by it's members.

Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215.

More on the Apparently not-so Empirically Valid more likely Common Factors Treatments
Researchers Hellerstein et al (1998) compared 40 sessions of manual based brief supportive therapy with manual based short-term dynamic therapy in a group of 49 people with Cluster C disorders (e.g., obsessive, avoidant, self-defeating, and dependent) and found ONCE AGAIN that both treatments resulted in similar degrees of improvement at termination and 6-month follow-up on several measures of symptom distress as well as client-rated progress. Moreover, in contrast to what might be expected, brief supportive therapy resulted in changes in interpersonal functioning not witnessed in clients treatment by the dynamic approach. Authors conclude that, "supportive psychotherapy may prove to be as effective as other manual-based therapies for some conditions."

Hellerstein, D.J. et al. (1998). A randomized prospective study comparing supportive and dynamic therapies. Journal of Psychotherapy Practice Research, 7, 261-271.

Empirically-Validated Treatments not Empirically Valid

(Editorial)

A powerful, but really rather small group of politically active members within Division 12 (known as the Task Force on the Dissemination of Psychological Procedures) of the American Psychological Association is arguing for the identification and primary use of "empirically validated treatments." These are treatment approaches for which this group believes there is significant "proof" of specific effects to warrant their primary use in the treatment of specific mental problems. Members of this group assume the moral high ground asserting that using "EVT's" is correct because "clients deserve treatment that is supported by empirical research." The argument, however, is mostly flash and little substance. Of course "clients have a right to effective treatment." Unfortunately, they are dead wrong when they link therapeutic effectiveness to so-called empirically validated treatments (EVT's). In drawing their conclusions, members of the Task Force of Division 12 have ignored the conclusion of nearly 40 years of sophisticated outcome research as well as the protests of most of the major voices in psychotherapy outcome research (see Psychotherapy [1997, 33(2)]; and, American Psychologist [1996, 51(10)].

To begin, in spite of the intuitive appeal of the argument for EVT's, existing efficacy research simply does not support the conclusion that certain psychological procedures or approaches are demonstrably more effective than others. Indeed, if the research has shown anything at all, it as that as far as treatment models are concerned, "the model of therapy [a mental health professional uses] simply does not make much difference in therapy outcome" (p. 7, Miller, Duncan, and Hubble, 1997, emphasis in original). For example, early claims that cognitive-behavioral therapy (CBT) was demonstrably more effective than other approaches in the treatment of anxiety-based problems have, upon later and more sophisticated analysis, largely proven to be the result of the highly reactive nature of the outcome measures employed in such studies and the allegiance of the experimenters to the methods being employed (Lambert and Bergin, 1994). Moreover, as veteran psychotherapy researcher Wampold recently pointed out in the prestigious journal, Psychotherapy Research, "given the ambiguity inherent in [such] research, delineating conditions under which treatments are classified as empirically validated is difficult, if not impossible" (p. 36, Wampold, 1997).

We agree with members of Division 12 that existing ethical codes should be changed to require that professionals practice effectively rather than, as the APA code of ethics requires, "within the boundaries of their competence" (p. 1600, APA, 1992). As contradictory as it may seem on the surface, ineffective therapy can be practiced competently. The real issue confronting treatment professionals, however, is not determining a priori "what treatment works for which client" but rather "Is this treatment working for this client at this time?" As evidence of this, consider that research has consistently found that the influence of treatment models on psychotherapy outcome pales in comparison to the personal qualities of the individual therapist--in some studies being three times more important than the model or theoretical orientation of the therapist (Luborsky et al., 1986)! Based on this and other related evidence, our professional organizations should not be dictating what methods should be practiced but rather requiring therapists to determine empirically whether the treatment they are administering to a given client is helpful or not.

Several researchers and clinicians have developed simple, straightforward (and empirically valid) methods for evaluating the progress and overall effectiveness any given treatment (c.f., Howard et al., 1996; Johnson and Shaha, 1996). These methods focus on assessing the factors which research has shown really do make a significant contribution to outcome (e.g., incorporation of client strengths, the development of a strong therapeutic alliance, the creation of hope and expectancy, etc. [Miller, Duncan, and Hubble, 1997]). If our professions are going to successfully confront the challenges of clinical practice in the next millennium, then we must abandon the "search for the winner" mind set that has characterized the first 100 years of psychotherapy practice and instead focus on these factors--in other words, the factors that really work.

American Psychological Association (1992). Ethical principles of psychologists and codes of conduct. American Psychologist, 47(12), 1597-1611.

Howard, K.I., Moras, K., Brill, P.L., Martinovich, Z., and Lutz, W. (1996). The evaluation of psychotherapy: Efficacy, effectiveness, patient progress.

Johnson, L., and Shaha, S. (1996). Improving quality in psychotherapy. Psychotherapy, 33(2), 225-236.

Lambert, M.J. and Bergin, A.E. (1994). The effectiveness of psychotherapy. In A.E. Bergin, and S.L. Garfield (eds.). Handbook of Psychotherapy and Behavior Change (4th Ed.). New York: Wiley.

Luborsky, L., Crits-Cristoph, P., McLellan, T., Woody, G., Piper, W., Liberman, B., Imber, S., and Pilkonis, P. (1986). Do therapists vary much in their success. Findings from four outcome studies. American Journal of Orthopsychiatry, 56, 501-512.

Miller, S.D., Duncan, B.L., and Hubble, M.A. (1997). Escape from Babel: Toward a Unifying Language for Psychotherapy Practice. New York: Norton.

Wampold, B. (1997). Methodological problems in identifying efficacious psychotherapies. Psychotherapy Research, 7(1), 21-44.

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General Research on Common Versus Specific Factors

Characteristics of "Proven Therapies."
O'Donohue and colleagues investigated the qualities of therapies identified by the APA as "empirically valid." Questionnaires were sent researchers in the field. Their responses indicated that effective therapies:

	Involved skill building rather than insight or catharsis;
	Had a specific rather than general focus;
	Included regular, ongoing assessment of progress;
	Were relatively brief in duration (20 visits or less).

According to the researchers studied:

	54% felt that knowing a person's history was unimportant;
	61% felt diagnosis was not essential for making treatment decisions; and
	Only 38% felt that a DSM diagnosis was important.

While the study may elicit a collective, "well, duh" reaction from most practicing clinicians, it is a relief to see serious researcher types identifying common rather than specific factors as the relevant variables to consider in the evaluation of so-called empirically supported treatments. O'Donohue, W. et al. (2000). Characteristics of empirically supported treatments. Journal of Psychotherapy Practice and Research, 9, 69-74.

What is the best way to insure therapists' multi-cultural competency? TRAIN THEM IN A COMMON FACTORS PERSPECTIVE!
For most of the history of the field, the face of therapy--both clients and therapists-- was largely the same: white people or European ancestry. With a changing clinical population and entry of marginalized cultures into the field, awareness of the cultural boundedness of most therapeutic approaches has grown. This, in turn, has led to calls for new approaches to treatment and for training therapists to be aware of cultural biases in their clinical work. In a series of recent articles in The Journal of Counseling Psychology various researchers and authors discussed recent developments in multi-cultural competency and argued against the development of new models of therapy since all approaches are a function of the culture which sustains it. Instead, they suggested that therapists should be trained in the healing factors all models of therapy share--the common factors--so that treatment can be maximally tailored to the culture in which it is being delivered!

Fischer, A. R., Jome, L. M., & Atkinson, D. R. (1998). Reconceptualizing multicultural counseling: Universal healing conditions in a culturally-specific context. The Counseling Psychologist, 26, 525-588.

Does Cognitive Therapy Work by being Cognitive?
You've heard it! The APA stands behind it! Cognitive and cognitive behavioral approaches are the "validated" approaches for the treatment of depression and anxiety approaches. But how do they work? Do they actually change the cognitive functioning of those who are treated with the method? A recent study by Spangler et al. found that, while effective, cognitive therapy did not alter the cognitive functioning of those treated with the approach! Apparently, the effectiveness of the approach MUST be due to something other than the specific qualities of the method--namely, the common factors.

Spangler et al. (1997). Response to cognitive-behavioral therapy in depression: Effects of pretreatment cognitive dysfunction and life stress. Journal of Consulting and Clinical Psychology, 65, 568-575.

In another study of CBT in the treatment of depressed children and adolescents, researchers Vostanis, Feehan, Grattan, and Bickerton found no difference in effectiveness between the focused approach and a non-focused treatment alternative.  Here again, common factors were likely responsible for the improvements which the researchers found in both treatment groups.

Vostanis, P., Feehan, C., Grattan, E., and Bickerton, W.L. (1997).

Which Treatment is Best for Panic Disorder? The Answer is not what you've been told!
There is a widely held belief that cognitive and cognitive-behavioral treatment methods are the "treatments of choice" for people with anxiety related problems. In this comprehensive review of the literature, researchers Milrod and Busch (1996) examined the long-term outcome data from treatment studies for panic disorder in the hopes of ascertaining the differential efficacy of the available treatments. In contrast to what has come to be expected, these researchers found that the available literature suffered from a wide variety of serious methodological problems which make it nearly impossible to identify which, if any, treatments are differentially effective and which have superior long-term outcome. In particular, studies that are widely cited as evidence for superior outcomes frequently: (1) failed to use DSM criteria or state whether those being studied suffered from panic and agoraphobia; (2) lacked clarity about the treatment that was administered or the qualifications of those who administered the treatment; (3) were confounded by concurrent nonstudy treatments that were being administered at the same time the study was being conducted; and (4) were confounded by treatments that were received between the study and follow-up period. Two examples can be used to illustrate these points. In a widely cited study by Beck et al (1992) which concluded that "cognitive therapy has a much higher success rate in the treatment of panic disorder than supportive psychotherapy" (p. 725), the cognitive condition was conducted by experienced therapists using a treatment manual while supportive psychotherapy condition was performed by therapists who the researchers recognized had doubts about the efficacy of the treatment they were offering! In a study that is usually cited as a benchmark in the research on the treatment of panic disorder, as many as 63% of the study sample sought and received treatment in between the termination of the study and 24-month follow-up. At the same time, however, Barlow et al. (1989) make no mention of nor give any clarification about the type or intensity nor the effect that such treatment may have had on their ability to attribute change to the interventions under study in their research.

In contrast to the current emphasis on brief, intensive, and cognitive-behavioral interventions, the reviewers conclude that, "questions remain as to what is the best type of initial treatment for panic disorder . . . and what types of interventions may be most useful to reduce symptoms in patients whose symptoms are persistent or recurring" (p. 729). They note that while current research notes that a majority of people are responsive to treatment, many continue to experience symptoms and may require ongoing intervention.

Milrod, B., and Busch, F. (1996). Long-term outcome of panic disorder treatment: A review of the literature. Journal of Nervous and Mental Disease, 184(12), 723-730.

"All have won, therefore all deserve prizes": Cognitive and Exposure Therapies equally effective in the treatment of OCD
Exposure therapies have long been considered the "treatment of choice" for people with obsessive-compulsive disorder. In his review of the quantitative literature on the treatment of obsessive-compulsive disorder, however, researcher Jonathan Abramowitz found that both exposure and cognitive therapies were highly and equally effective in reducing the symptoms of this debilitating problem.. In spite of the apparent differences in theory and technique, Abramowitz concludes that there is "no support for the notion that cognitive therapy and ERP work by separate mechanisms" (p. 49). This paper also reviews the literature on pharmacological intervention and finds, in general, that serotonergic medication is more effective than nonserotonergic medication in reducing symptomatology. However, in his sample, Abramowitz also found that the difference in side effect profiles successfully predicted pharmacological treatment effectiveness, suggesting strongly that, "when two groups have markedly different side-effect profiles, such as in a placebo-controlled trail, there is a potential loss of blindedness, which could give way to biases in favor of the active medication" (p. 50).

Abramowitz, J.S. (1997). Effectiveness of psychological and pharmacological treatments for obsessive compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology, 65(1), 44-52.

Are Common or Specific Factors Responsible for Outcome in Cognitive Therapy?
For the last 40 years, "psychotherapy" has been busily dividing into hundreds of different models and theoretical camps. In spite of 40 years of research evidence to the contrary, the proponents of each new model to enter the "therapy model marketplace"--without fail--argue that they have discovered some unique process or technique responsible for human change. One of the most recent models to gain popular and professional interest is Cognitive Therapy. Proponents of the approach have long argued that symptomatology is a result of distorted thinking and that successful treatment uses various techniques to address that supposed linkage. Once again, the research indicates otherwise. In this study, researchers found that only common factors (e.g., the quality of the therapeutic alliance and the client's emotional involvement in the therapeutic process) predicted improvement on the outcome measures. Even more damning, however, was that therapists' emphasis on linkages between distorted thoughts and the client symptomatology was negatively related to outcome.

Castonguay, L.G. et al. (1996). Predicting the effect of cognitive therapy for depression: A study of unique and common factors. Journal of Consulting and Clinical Psychology, 64 (3), 497-504.

Clients' Perceptions of Successful Treatment of Depression Highlight the Common Factors
In this study, the clients' perceptions of the helpful aspects of treatment were examined using post-treatment data from the massive and influential NIMH Treatment of Depression Collaborative Research Study (TDCRP). Already having shown that the much-touted Cognitive-Behavioral therapy fared no better than either interpersonal psychotherapy or placebo plus clinical management in the treatment of depression, this study found that clients most frequently identified the common aspects of the various treatment modalities as helpful (e.g., symptom relief, therapist caring and support, new insight or learning, etc.).

Gershefksi, J.J., Arnoff, D.B., and Glass, C.R. (1996). Clients' perceptions of treatment for depression: I. Helpful aspects. Psychotherapy Research, 6(4), 233-247.