Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: July 2015
At the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.
About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.
Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.
At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.
If you have ideas for an article to review or a topic you would like to see covered, please send me an email at email@example.com.
Giorgio A. Tasca
In this chapter, Wampold and Imel contrast the Medical Model to a Contextual Model of psychotherapy. The Medical Model argues that there is a biological explanation for a disorder and that the basis for treatment is to address the biological system causing the disorder. Understanding the cause of the disorder (e.g., excess stomach acid) leads to an explanation of the mechanism of the disorder and of change (e.g., reduce stomach acid), which in turn leads to specific interventions (e.g., administer an antacid). Key to this model is specificity: that is, a specific disorder can be explained by a specific mechanism, and a specific treatment based on this explanation will result in alleviation of the disorder. In psychotherapy, for example, one could argue that PTSD symptoms are caused by maladaptive avoidance of traumatic memories, which can be successfully treated by repeated exposure to the traumatic memories to reduce symptoms. Exposure is the specific intervention indicated by the purported mechanism or cause of PTSD. By contrast, Wampold and Imel discuss a Contextual Model of psychotherapy. This model combines the elements of common factors in psychotherapy (e.g., the bond, real relationship, therapeutic alliance) with specific factors of interventions. The Contextual Model indicates that people are fundamentally social animals that require relationships with others to survive and to heal. That is, the initial therapeutic bond between client and therapist is the basis of psychotherapeutic practice. There are three elements to the Contextual Model. (1) The real relationship – which is based on genuineness [openness and honesty] and therapist empathy. Both genuineness and empathy are related to client outcomes. (2) Expectations – which, like the placebo effect, increases one’s readiness to benefit from treatment, is related to greater hope of improvement, and belief in the treatment. The placebo effect is associated with improvements in a pharmacological treatments of depression, and client expectations are related to psychotherapy outcomes. (3) Specific ingredients – as indicated in the Medical Model refers to psychotherapeutic interventions based on a psychological theory of a disorder. But unlike in the Medical Model, the Contextual Model sees the key element of specific ingredients as the agreement between client and therapist on the explanation for the disorder and on the treatment. In other words, a therapeutic alliance in part depends on clients and therapists agreeing on the specific tasks and goals of therapy.
Patient outcomes are enhanced by a positive therapeutic bond, genuineness and congruence in the way a therapist interacts with a client, and a therapeutic alliance in which clients and therapists agree on tasks and goals of therapy. Typically, these occur within a context in which therapists use some specific techniques of therapy to which he or she feels an allegiance. It is also important that the client agree with the explanation for their disorder provided by this specific treatment model and that the client expects that this treatment will provide them with relief. Although common and specific factors of psychotherapy have been seen as having entirely separate roles in client outcomes, Wampold and Imel argue that within the Contextual Model, they are intimately tied to each other.
Kivlighan, D.M., Goldberg, S.B., Abbas, M., Pace, B.T., …Wampold, B.E. (2015). The enduring effects of psychodynamic treatments vis-à-vis alternative treatments: A multilevel longitudinal meta-analysis. Clinical Psychology Review, 40, 1-14.
There is a great deal of evidence that indicates uniform efficacy of a variety of psychotherapies for many common disorders. For example, in the July 2014 PPRNet Blog, I reviewed a meta-analysis comparing 7 psychotherapies for depression indicating no differences between the various treatments in terms of patient outcomes. Nevertheless proponents of cognitive behavioural therapy have claimed superiority to alternative treatments for decades. On the other hand proponents of psychodynamic therapies have argued that these treatments focus on personality change rather than symptoms, and so benefits of psychodynamic therapies will be longer lasting. In this meta analysis, Kivlighan and colleagues put these claims to the test. They selected studies in which a psychodynamic therapy was compared to one or more alternative treatment. Both the psychodynamic therapy and the alternative (most often CBT) had to be judged as "bona fide" therapies by independent raters (i.e., they had to be therapies that were delivered in a manner in which they could be expected to be effective by clients and therapists). Outcomes not only included specific symptoms (e.g., depression), but also non-targeted outcomes (e.g., improved self esteem in a study of treatment of anxiety), and personality outcomes. Effect sizes for outcomes were assessed at post-treatment and also at follow-ups. Twenty five studies directly comparing psychodynamic and non-psychodynamic therapies were included, representing 1690 patients. At post treatment, no significant differences were found between psychodynamic and non-psychodynamic treatments on targeted outcomes, non-targeted outcomes, and personality measures (all gs < .10). There was also no significant or meaningful effect of time to follow up on outcomes, indicating no differences between treatment types at any of the follow up periods.
Psychodynamic and non-psychodynamic treatments were equally effective at post treatment and at follow ups for all outcomes, including personality variables. This challenges the belief that psychodynamic treatments uniquely affect personality and have longer lasting effects compared to other treatments. It also challenges the notion that CBT (by far the most common comparison treatment) is a superior therapy for patient outcomes. Pan-theoretical psychotherapy factors (client contributions, expectations, therapeutic alliance) may be more promising factors in understanding the long term benefits of psychotherapy.
Mallinckrodt, B. & Jeong, J. (2015). Meta-analysis of client attachment to therapist: Associations with working alliance and pre-therapy attachment. Psychotherapy, 52, 134-139.
Attachment theory has become one of the most important conceptualizations of affect regulation and interpersonal relationships. John Bowlby and others suggested that attachment behaviour is hard wired so that infants can gain proximity to caregivers which is necessary for infant survival. Repeated interactions with caregivers coupled with the variety of caregiver responses (i.e., available, unavailable, or inconsistently available) lead to children and adults developing internal working models of attachment. These models become the basis for attachment styles in adulthood. Attachment security in adults is associated with the ability to give and receive caring and love, and to adaptively regulate emotions. Attachment avoidance is associated with a tendency to dismiss relationships as important, and to downregulate emotional experiences. Attachment anxiety is associated with a preoccupation with relationships, and to unregulated emotional experiences. In a previous meta analysis, client general attachment security was modestly but significantly associated with higher levels of therapeutic alliance (r = .17). In another meta analysis, higher client general attachment anxiety was associated with poorer client outcomes (r = -.22). In this meta analysis Mallickrodt and Jeong assessed whether client attachment to the therapist was associated with client general attachment style and with the therapeutic alliance with the therapist. They included 13 studies representing 1051 client-therapist dyads. Client general pre-therapy attachment avoidance and anxiety were negatively associated with client-therapist attachment security, and the effects were modest but significant (r = -.12, r = -.13). Client-therapist attachment security (r = .76) and client-therapist attachment avoidance (r = -.63) were significantly associated with therapeutic alliance, and these effects were large.
Client pre-therapy attachment styles appear to have an impact on their attachment to the therapist. A client pre-therapy attachment style characterized by preoccupation with relationships and an over-emphasis on emotions (i.e., attachment anxiety) will likely lead to similar behaviors and pre-occupations in the relationship with the therapist. Mallickrodt and Jeong suggest that this might be the basis for transference-related phenomenon that therapists and clients experience in the therapeutic relationship. That is, client attachment anxiety and avoidance likely interfere with developing a secure attachment to the therapist. Further, client attachment avoidance with regard to the therapist will interfere with developing a therapeutic alliance, which is key to achieve improved patient outcomes. Despite these challenges, therapists who can facilitate a secure psychotherapy attachment experience for their clients are more likely to see improvements in their clients’ functioning.