The common factors, empirically validated treatments, and recovery models of therapeutic change.
One might surmise that when differences of opinion arise between shamen, they would settle them by asserting their powers of magic, whereas, our debating therapists and modern scholars would lay claim to the power of science. As it happens, individuals with opposing views on what helps people to change are currently laying claim to the scientific high ground while engaging in a scholarly dispute.
Three different views will be discussed: the Empirically Validated Therapy Model, the Common Factors Model, and the Recovery Model. Proponents of the Empirically Validated Therapy (EVT) model suggest that for psychotherapy to have continuing credibility and to compete successfully with psychopharmacology and psychiatry for third party reimbursement, we must establish which psychotherapies for given disorders have met high scientific standards of efficacy and use those therapies preferentially (Barlow, 1996; Chambless, 1996; Chambless et al., 1998; Task Force on Promotion and Dissemination of Psychological Procedures [Task Force], 1995). One group of authors suggests that we not only continue to identify empirically supported treatments, but that we should also identify treatments that have no scientific merit, and impose professional sanctions on those who "use therapeutic and assessment practices that are devoid of scientific support" (Lohr, Fowler, & Lilienfeld, 2002, p. 8). Proponents of the Common Factors Model, however, suggest that science has established psychotherapy as generally effective, that all therapies are basically equal in effectiveness, and that factors common among all therapies are what account for patient improvement, rather than the specific techniques used by a given school of therapy (Beutler, 2000; Hubble, Duncan, & Miller, 1999; Lambert & Bergin, 1994; Luborsky, McLellan, Woody, O'Brien, & Aurbach, 1985; Najavits & Strupp, 1994; Seligman, 1995; Smith, Glass, & Miller, 1980; Wampold, Mondin, Moody, Stich, Benson, & Ahn, 1997; Weinberger, 1995). Proponents of the Recovery Model suggest that patients (consumers) should, unless their judgment is grossly impaired, have greater freedom to choose their treatments (Frese, Stanley, Kress, & Vogel-Scibilia, 2001) and to participate in, and contribute to, the mental health system (Frese & Davis, 1997). It is thought that when consumers are empowered within the mental health system that internal locus of control is increased, which may, in turn, improve mental health (Frese et al., 2001).
Common Factors and the "Dodo Bird Verdict"
Rosenzweig (1936) is credited with originating the Common Factors Model. In his seminal article he introduced this notion with a quote from Lewis Carroll's (1865/1993, p. 16) Alice in Wonderland: "At last the Dodo said, 'Everybody has won, and all must have prizes.'" Rosenzweig (1936) suggested that all therapies are effective and may produce positive results as the consequence of factors common to all therapies. He asserts that when a given therapy obtains positive results, this success does not prove the correctness of the therapy's underlying theory. He did acknowledge, however, the possibility that certain therapies may be clinically preferable in some situations. Empirical research has supported the notion of the relative equality of therapies in terms of effectiveness, and this effect was labeled "the Dodo Bird Verdict" (Luborsky, Singer, & Luborsky, 1975). A meta-analysis demonstrated the equality of therapies, but revealed some areas wherein behavioral therapies appeared marginally more effective (Smith et al., 1980). A subsequent meta-analysis also upheld the Dodo Bird Verdict (Wampold et al., 1997). Although hampered by small sample size, a recent survey of prominent psychotherapy researchers found that "There was strong expert agreement that therapies achieve similar outcomes and that problems, in general, do not necessarily respond better to specific as opposed to nonspecific therapy techniques" (Boisvert & Faust, 2003, p. 511).
Although many studies have shown the superiority of one form of therapy over another, bias due to experimenter allegiance to a given therapy may account for these results (Lambert, 1998; Luborsky, 1995; Luborsky et al., 1999; Messer & Wampold, 2002; Silverman, 1996; Smith et al., 1980). In completing an extensive meta-analysis, one set of authors indicated that experimenters who support one type of therapy would often treat the comparison therapy "with obvious disdain," and the comparison therapy "would not be given much opportunity for success." (Smith et al., 1980, p. 119). Research suggests that in psychotherapy outcome research, experimenter allegiance accounts for approximately 70% of the variance (Luborsky et al., 1999; Messer & Wampold, 2002). It has further been suggested that meta-analyses generally find a relative equality between therapies because the various and opposing experimenter biases tend to cancel each other out (Luborsky, 1995). Seligman (1995) pointed out that a major Consumer Reports survey failed to find superiority of any one type of therapy perhaps because of the neutrality of the people who conducted the survey.
A number of common factors may bring about therapeutic change independent of the therapist's specific techniques. The personality of the therapist has been found to be a significant factor in therapy outcome (Luborsky, McLellan, Diguer, Woody, & Seligman, 1997; Messer & Wampold, 2002; Najavits & Strupp, 1994; Silverman, 1996), particularly with regard to his or her ability to form a working alliance with the patient (Asay & Lambert, 1999; Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Lambert & Barley, 2001; Luborsky et al., 1986). A review found that therapist characteristics and behaviors associated with formation of a positive therapeutic alliance include being "flexible, experienced, honest, respectful, trustworthy, confident, interested, alert, friendly, warm, and open" (Ackerman & Hilsenroth, 2003, p. 28). Messer and Wampold (2002) suggest that because therapist factors account for more variance than therapy technique, potential consumers should seek out the most competent therapist rather than a therapist who practices a specific Empirically Validated Therapy. A Task Force of the APA Division of Psychotherapy, in fact, has worked toward identifying "empirically supported therapy relationships," as opposed to empirically validated therapies (Norcross, 2001, p. 345). One study found therapist warmth, understanding, and affirmation to be positively associated with therapy outcome, whereas, belittling, blaming, neglecting, attacking, and rejecting were found to be negatively related to outcome (Najavits & Strupp, 1994). In another study, the more effective therapists displayed more self-criticism, and tended to rate the therapy as going less well than did the less effective therapists (Najavits & Strupp, 1994). The psychological health and skill of the therapist, as well as his or her interest in helping the patient, have been found to be positively associated with therapy outcome (Luborsky et al., 1997).
Weinberger (1995) provides an excellent analysis of how different schools of therapy use common factors to bring about positive change. According to Weinberger (1995) patients benefit when therapists help them to attribute improvement to themselves, thus increasing the patients' sense of self-efficacy. Self-efficacy is positively associated with measures of mental health (Bandura, 1989). Increasing self-efficacy, thus, may be one common factor in successful therapies. Other common factors involve various schools of therapy helping the patients to develop mastery through teaching skills, or helping the patients to expose themselves to threatening situations, thoughts, or feelings. Different therapies employ the common factor of helping to bring about corrective emotional experiences. The therapy relationship itself is an important common factor leading to patient improvement, as is the therapist helping the patient to increase expectations of improvement. Frank (1995), in fact, suggests that the therapist's ability to create positive expectations regarding the therapist's techniques is more important than the techniques themselves. Indeed, the generation of placebo effects plays an important role in all forms of medical care (Scovern, 1999). Weinberger (1995) suggests that while different schools of therapy emphasize different common factors, all therapies--knowingly or unknowingly--make use of them.
Contrary to Eysenck's (1952) past assertion, evidence from research indicates that psychotherapy generally is effective (Asay & Lambert, 1999; Lambert & Bergin, 1994; Luborsky et al., 1975; Seligman, 1995; Smith et al., 1980). One meta-analysis found that "the average person who receives therapy is better off at the end of it than 80% of the persons who do not" (Smith et al., 1980, p. 87). In meta-analyses, an effect size of .20 is considered small, .50 medium, and .80 large (Crits-Christoph, 1992). Based on 475 controlled studies and obtaining an average effect size of .85 in their meta-analysis, the authors proclaimed psychotherapy clearly effective (Smith et al., 1980). They also noted that psychotherapy studies judged to demonstrate more experimental rigor were more likely to demonstrate positive effects than were less rigorously controlled studies (Smith et al., 1980). Results from another meta-analysis yielded an effect size of .82 for psychotherapy vs. no treatment, and .48 for psychotherapy vs. placebo (Wampold et al., 1997). Interestingly, the effect size for placebo vs. no treatment was .42 (Wampold et al., 1997), suggesting a substantial contribution of placebo effects in psychotherapy, yet the study also clearly demonstrates the effectiveness of psychotherapy above and beyond that of placebo control. The Consumer Reports survey (Seligman, 1995) found that of 426 respondents who reported feeling "very poor" when their psychotherapy began, 87% reported improvement; and 92% of the 787 respondents who initially reported feeling "fairly poor" reported improvement.
One literature review concluded that effective therapies exist for all of the disorders they studied, including major depression, generalized anxiety disorder (GAD), social phobia, obsessive compulsive disorder (OCD), agoraphobia, panic disorder, post traumatic stress disorder (PTSD), schizophrenia, and drug and alcohol abuse. Most of these effective treatments, however, were either behavioral or cognitive behavioral (DeRubeis & Crits-Christoph, 1998). This finding tends to run counter to the hypothesis that all therapies are approximately equal in effectiveness (the Dodo Bird Verdict). The authors noted that many studies were excluded from their analysis due to imprecise descriptions of patients, or in some cases, because the therapy was not manualized (DeRubeis & Crits-Christoph, 1998). It is likely that different literature reviews or meta-analyses will obtain different results based on exclusion criteria for the studies to be examined.
Some studies reputedly demonstrating the equivalence of therapies warrant reconsideration. In the Luborsky (1975) meta-analysis, psychotherapy was not found superior to behavior therapy in any of the experimental studies; yet behavior therapy was found superior to psychotherapy in 6 studies, and both were equivalent in 13 studies. Although the authors generally concluded that all forms of therapy were equivalent in effectiveness (Luborsky et al., 1975), some might wonder why some studies found behavior therapy superior, whereas no studies found psychotherapy superior. Another study using anxiety disorder and personality disorder patients compared behavior therapy to short term analytically oriented psychotherapy to a waiting list control (Sloane, Staples, Cristol, Yorkston, & Whipple, 1975). Both therapies outperformed waiting list controls with regard to improvement in target symptoms, however, behavior therapy proved superior to psychotherapy on a measure of overall adjustment, and, in some comparisons, in improving work and social adjustment as well. Although tempted to argue that behavior therapy was superior to psychotherapy, the authors settled on a seemingly more conservative conclusion that the two therapies were essentially equally effective (Sloane et al., 1975). Also, in the Smith et al. (1980) meta-analysis, the overall results initially favored behavior therapy. It was only after the results were corrected (post hoc) for reactivity of dependent measures that the overall differences between behavior therapy and psychotherapy disappeared. Although this correction appeared appropriate, in light of a finding that reactivity of dependent measures correlated highly with effect size of the therapy, this example highlights the impact of statistical choices on overall results. This meta-analysis still seemed to indicate a superiority of behavioral therapies with regard to treating fear-anxiety symptoms (Smith et al., 1980). Some trends toward behavior therapy outperforming psychotherapy may have been minimized in the above studies. It has been suggested, in fact, that the pronouncements of the equivalence of therapies based on early comparative outcome research may have been inconsistent with the experimental data (Dennis J. Delprato, personal communication, January 30, 2004).
Chambless (2002, p. 15) proclaims that we should "Beware the dodo bird and shun overgeneralization." She makes the point that it is necessary to be cautious regarding conclusions from meta-analyses proclaiming the equivalence of all therapies; and she argues that it is inappropriate to conclude that any given therapy is equivalent to any other therapy, for any disorder. Patients might be harmed by being deprived of effective treatments, especially with regard to deprivation of behavior therapy for certain anxiety disorders (Chambless, 2002).
For the Common Factors Model to be credible, common factors must be differentiated from placebos. Common factors or nonspecific factors in psychotherapy have, in the past, been considered to be placebo factors or "nuisance variables," partly because they were unrelated to the given researcher's theories of therapeutic change (Critelli & Neumann, 1984). It has been said, though, that one researcher's "psychotherapy placebo is likely to be another's active alternative treatment approach" (Parloff, 1986, p. 525). The Common Factors Model appears to have preserved the credibility of psychotherapy, though, by the scientific feat of transforming nuisance variables into legitimate treatment variables. If these common factors variables, however, included only "attention," "suggestion," and "common sense advice," it would detract from psychotherapy's credibility by creating the appearance of a placebo cure (Parloff, 1986, p. 524). Citing Frank's conceptualization, however, Parloff (1986) suggests that the efficacious common factors in psychotherapy include establishing a credible, trusting, therapeutic relationship, helping the patient to test reality and overcome fears, to learn new ways to conceptualize and solve problems, and to increase a sense of mastery and self-esteem. These common factors are not mere placebos or nuisance variables. It must be acknowledged, though, that the common factor of mobilizing positive expectations (hope) is the quintessential placebo. Common factors, on the whole, though, can be considered to be powerful and legitimate mechanisms of psychotherapeutic change.
As most common psychotherapy factors are not mere placebos, it is not necessary that one therapy prove its efficacy above and beyond the efficacy of common factors ("incremental effectiveness"), as has been suggested elsewhere (Critelli & Neuman, 1984). It would certainly be a major accomplishment, though, if a therapy could meet this difficult criterion. It is necessary, though, for therapies to demonstrate superiority to some type of placebo or control condition (despite the conceptual ambiguities of the concept of psychotherapy placebos as explicated by Parloff, 1986, and Critelli & Neuman, 1984). One of the previously mentioned meta-analyses did, in fact, demonstrate the superiority of psychotherapy to placebo control (Wampold et al., 1997). Thus, there is more to psychotherapy than mobilizing hope and positive expectations. Psychotherapy is not merely a placebo cure.
The Empirically Validated Therapy (EVT) Model
For several reasons the American Psychological Association's Society of Clinical Psychology (Div. 12) formed a task force to identify empirically supported treatments (Task Force, 1995):
1. To compete with psychopharmacology which is supported by placebo controlled research (Chambless, 1996).
2. To supply third party payers with information concerning the most effective treatments (Task Force, 1995).
3. To help guide clinical training such that effective treatments would be taught (Task Force, 1995).
For a therapy to earn a "well-established" rating it needs support by two group design studies conducted by different investigators, demonstrating superiority to a placebo, or demonstrating equivalency to an established treatment. Alternately, the therapy must be supported by "a large series of single case design studies demonstrating efficacy" (Task Force, 1995, p. 21). The studies must employ treatment manuals and have clearly specified client samples. To earn the classification "probably efficacious," the therapy must be supported by two studies demonstrating superiority to waiting list controls. These two studies can come from the same experimenter, although one "good study" may suffice to meet the criteria. Also, two good studies even if flawed by client heterogeneity would suffice, as would a series of good single case designs (Task Force, 1995).
Therapies meeting the full criteria for "well-established" treatments are (Task Force, 1995):
1. Beck's cognitive therapy for depression 2. behavior modification for the developmentally disabled 3. behavior modification for enuresis and encopresis 4. behavior therapy for headache and irritable bowel syndrome 5. behavior therapy for male and female sexual dysfunction 6. behavioral marital therapy 7. cognitive therapy for chronic pain 8. cognitive therapy for panic disorder (with or without agoraphobia) 9. cognitive behavioral therapy for generalized anxiety disorder 10. exposure treatment for phobias (agoraphobia, social phobia, simple phobia, and PTSD) 11. exposure and response prevention for OCD 12. family therapy for schizophrenia per Hogarty or Falloon 13. group cognitive behavior therapy for social phobia 14. interpersonal therapy for bulimia 15. Klerman and Weissman's interpersonal therapy for depression 16. parent training for oppositional defiant disorder 17. systematic desensitization for simple phobias 18. token economy programs.
Therapies meeting criteria for categorization as "probably efficacious" are (Task Force, 1995):
1. applied relaxation for panic disorder
2. brief psychodynamic therapies
3. behavior modification for sex offenders
4. dialectical behavior therapy for borderline personality disorder
5. emotionally focused couples therapy
6. habit reversal and control techniques
7. Lewinsohn's psychoeducational treatment for depression
Additional therapies were added to the list of efficacious treatments in an Update on Empirically Validated Therapies (Chambless et al., 1998).
As one can see, cognitive behavioral and behavioral therapies are heavily represented among well-established and probably efficacious treatments. Psychodynamic and experiential therapies, in contrast, are poorly represented. It is lamented that "The dearth of information on the efficacy of psychodynamic and experiential therapies is of particular concern for those who aspire to a science-based practice" (Chambless, 1996, p. 2). The problem with these therapies reportedly involves a lack of evidence regarding efficacy, rather than negative results regarding efficacy (Chambless, 1996). A number of other researchers, however, have identified studies supporting the use of psychodynamic therapy for various disorders (Brom, Kleber, & Defares, 1989; DeRubeis & Crits-Christoph, 1998; Karon & VandenBos, 1970, 1972; Leichsenring & Leibing, 2003; Weinberger, 1995; Westen & Morrison, 2001). The Task Force (1995) indicates that a therapy failing to be on the list does not necessarily indicate that the therapy is ineffective, but rather that there is insufficient evidence to endorse the treatment.
The findings of the Task Force have been criticized on several grounds: a bias toward cognitive behavioral therapies, recommendations based on a less-than-thorough literature review, an allegedly inadequate sampling of studies, and the lack of consideration of studies based on nonmanualized therapies (Silverman, 1996). Further, critics have expressed concern regarding one American Psychological Association division claiming the right and authority to publish a list of treatments that might lead to restrictions on therapies taught to graduate students and used by practitioners (Silverman, 1996). The Task Force (1995) conceded that instead of doing an exhaustive literature review, they investigated therapies that they thought effective. In their own defense, the Task Force (1995) noted that they are not exclusively cognitive behaviorists; further, because many therapies other than the behavioral varieties use manuals, they merited investigation in their review. The APA Division 12 Task Force (1995, p. 16) additionally claimed that the meta-analytic studies demonstrating the equality of all therapies have been "superceded by more recent evidence," citing three studies (two from the 1970s) wherein exposure therapies for anxiety disorders outperform other methods. They criticized the Smith, Glass, and Miller (1980) meta-analytic study because many of the subjects in the various studies never sought treatment for clinical problems, and the studies used no therapy manuals (Task Force, 1995). One could just as easily argue, however, that a much more recent meta-analysis, which found relative equality between bona-fide psychotherapies (Wampold et al., 1997), supercedes the findings of the Task Force (1995). It has also been suggested that the reliance on an "efficacy" model of psychotherapy research (which emphasizes internal validity) as opposed to an "effectiveness model" (which stresses external validity) fails to adequately test longer term therapies, thus allowing managed care companies to unfairly restrict access to such treatments (Seligman & Levant, 1998).
The use of therapy manuals tends to be associated with the Empirically Validated Therapy Model, given the need to deliver pure forms of the therapies that have been empirically supported (Wilson, 1998). Although it is generally agreed that therapy manuals are important in conducting psychotherapy outcome research (Lambert & Bergin, 1994; Strupp & Anderson, 1997; Wilson, 1998), opinions and research findings are mixed as to whether therapy manuals help the therapeutic process or hinder it (Ogles, Anderson, & Lunnen, 1999). Some research suggests that therapy outcome is enhanced by adherence to a manual (Luborsky et al., 1985, 1997; Rounsaville, O'Malley, Foley, & Weissman, 1988); yet other studies find that manual use may detract from therapist warmth, spontaneity, and creativity, thus hindering the therapeutic process (Castonguay et al., 1996; Henry, Strupp, Butler, Schacht, & Binder, 1993; Strupp & Anderson, 1997). Beutler (2000) suggests that most clinicians are eclectic and dislike manuals as they prevent the clinician from using the methods with which they are most comfortable. One strong critic of therapy manual use went so far as to liken the practice to "painting by numbers" (Silverman, 1996). Similar to the views of Hubble et al. (1999), Beutler (2000, p. 1006) suggests that therapists should make use of principles of change established in the scientific literature rather than following manuals, and he suggests that "only an artist can apply these scientific principles to the complexities of lives and can find creative and new ways of making them relevant and workable in complex environments." More research is needed to resolve these issues.
Effectiveness of Specific Treatments
Research has shown various therapies and techniques to be effective for a wide variety of disorders. The NIMH project demonstrated that both interpersonal therapy and cognitive behavioral therapy were effective with depression, and that these therapies were not inferior to medication treatment (Elkin et al., 1989). One review cited evidence that cognitive behavior therapy was more effective with major depression than was brief psychodynamic therapy (Lambert & Bergin, 1994). Another review found behavior therapy, interpersonal therapy, and psychodynamic interpersonal therapy to be empirically supported for the treatment of depression; and it suggested that problem-solving therapy is "possibly efficacious" (DeRubeis & Crits-Christoph, 1998).
Studies generally find that programs effective in treating schizophrenia tend to emphasize medication compliance (Aronson, 2002). Such programs also make use of families as allies, improve family communication and coping, and provide patient support and stress reduction (Aronson, 2002). When combined with traditional medication, "personal therapy"--an intensive long-term supportive psychotherapeutic and psychoeducational program--has been found effective for schizophrenia (Hogarty, 2002). Social skills training is thought to be "possibly efficacious" in preventing relapse, although studies obtained mixed results (DeRubeis & Crits-Christoph, 1998). Experimental support exists for the use of cognitive therapy with schizophrenia, as it may reduce distress and positive symptoms when used in combination with medication (Hagesfeld, 2002; Rector & Beck, 2001; Sensky et al., 2000). Family educational programs have also been found efficacious in reducing relapse rate (Chambless et al., 1998; Gingerich & Bellack, 1995). One study found psychoanalytic psychotherapy to be effective with schizophrenia (Karon & VandenBos, 1970, 1972), although the study was criticized on methodological grounds (May & Tuma, 1970; Tuma & May, 1975), but later was defended (Karon & VandenBos, 1981).
A number of therapies are effective with anxiety disorders such as generalized anxiety disorder (DeRubeis & Crits-Christoph, 1998; Westen & Morrison, 2001), panic disorder (Barlow, Craske, Cerny, & Klosko, 1998; DeRubeis & Crits-Christoph, 1998; Westen & Morrison, 2001), post traumatic stress disorder (PTSD) (Foa & Meadows, 1997; Ironson, Freund, Strauss, & Williams, 2002; Solomon, Gerrity, & Muff, 1992; VanEtten & Taylor, 1998), obsessive compulsive disorder (DeRubeis & Crits-Christoph, 1998), and simple phobias (Ost, 1989). Cognitive and behavioral treatments appear quite prominently among effective treatments for all of these anxiety disorders (Barlow et al., 1998; DeRubeis & Crits-Christoph, 1998; Foa & Meadows, 1997; Ost, 1989; Solomon et al., 1992; VanEtten & Taylor, 1998). Research suggests that behavioral therapies effective with anxiety disorders include systematic desensitization, exposure, stress inoculation, eye movement desensitization and reprocessing (EMDR), and relaxation training (Kennedy, 2002). Eye movement's importance in EMDR (for PTSD), however, has been controversial (DeRubeis & Crits-Christoph, 1998; Foa & Meadows, 1997; Lohr et al., 2002; Perkins & Rouanzoin, 2002; Pitman, Orr, Altman, Longpre, Poire, & Mecklin, 1996), and it has been suggested that some of the claims of this therapy may have, at times, been exaggerated (Lohr et al., 2002). One review found mixed results for EMDR and stated that "The vast majority of the studies examining EMDR are inundated with methodological flaws" (Foa & Meadows, 1997, p. 474). This review of the PTSD literature tended to find the most supporting evidence for cognitive behavioral therapies, especially prolonged exposure techniques and stress inoculation training (Foa & Meadows, 1997). A pilot study found EMDR and prolonged exposure to be equally effective for PTSD, but EMDR produced fewer dropouts and less subjective distress (Ironson et al., 2002). One controlled study found trauma desensitization, hypnotherapy, and brief psychodynamic therapy effective with PTSD (Brom et al., 1989). Also, one process study demonstrated that psychodynamic techniques were specifically linked to therapeutic progress in PTSD or other "stress response syndromes," and they achieved good effect sizes on the before and after measures (Jones, Cumming, & Horowitz, 1988). No control groups were employed (Jones et al., 1988), however, thus limiting the ability to directly compare effectiveness of this treatment to other specific treatments or no treatment. The authors stated that the effect sizes obtained were similar to those found for psychotherapy in general (Jones et al., 1988). A review found that psychodynamic therapy has some empirical support in the treatment of generalized anxiety disorder (Westen & Morrison, 2001).
Dialectical behavior therapy (DBT) has received empirical support for the treatment of borderline personality disorder (BPD) (Koerner & Linehan, 2000; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). One reviewer not associated with Linehan's research group, however, suggests that DBT is a promising treatment for BPD which has more empirical support than other therapies for this disorder; but the reviewer still questions proof of its efficacy (Scheel, 2000). A recent meta-analysis found that both cognitive behavioral (including DBT) and psychodynamic treatments for borderline personality disorder (and other personality disorders) are effective (Leichsenring & Leibing, 2003). The meta-analysis included eight studies involving psychodynamic therapy for BPD and four involving cognitive behavioral therapy (three of which apparently involved DBT). Psychodynamic therapy achieved an effect size of 1.31 and cognitive behavioral therapy achieved an effect size of .95 (Leichsenring & Leibing, 2003), both very respectable figures. Although DBT has received much attention in recent years, it is not the only therapy potentially effective with borderline personality disorder.
Other techniques and treatments have been found effective. One review observed that 100% of 13 studies found paradoxical intention an effective technique (Ogles et al., 1999). A meta-analysis found 12 studies wherein brief psychodynamic therapy was effective with various disorders; the therapy obtained effect sizes on par with other forms of psychotherapy (Crits-Christoph, 1992). Weinberger (1995) cites five studies demonstrating the efficacy of long-term psychoanalytic treatment with various disorders.
Although it is the author's contention that psychotherapy in general is effective, and that common factors may account for most of the change, there are areas wherein one therapy may have received more scientific study than another, or it may have demonstrated greater effectiveness in circumscribed areas. When one therapy proves superior to another for a given condition, it should be used preferentially.
Negative Therapy Outcome
Although psychotherapy is generally effective, research has found that all therapies are associated with some risk of negative outcome (Lambert & Bergin, 1994; Mohr, 1995). One meta-analysis consisting of 475 studies, however, found only "scant evidence of negative or deterioration effects of psychotherapy" (Smith et al., 1980, p. 124). This meta-analysis found that when therapy groups were compared to control groups, only on 9% of the measures employed did the therapy groups underperform the control groups (Smith et al., 1980). Mohr, however, (1995, p. 2) contends, "That psychotherapy can have negative outcomes is hardly surprising--indeed this places it in the company of almost all other therapeutic interventions with human beings, from aspirin to laser surgery."
At times the use of flooding (prolonged exposure) in PTSD cases can bring about unwanted effects such as alcohol relapse (Pitman et al., 1991; Solomon et al., 1992), intensified guilt or shame (Pitman et al., 1991), poor sleep, or even psychotic-like symptoms (Solomon et al., 1992). It has been suggested that PTSD patients with low ego strength (Gaston, 2003) or co-morbid conditions (Pitman, 1991) may experience psychiatric complications with prolonged exposure techniques. Many studies successfully using prolonged exposure reportedly exclude patients with co-morbid conditions that are often seen in clinical practice (Louise Gaston, personal communication, December 8, 2003). One study found that a small minority of PTSD patients introduced to prolonged exposure had temporary increases in distress which did not affect the likelihood of ultimate improvement (Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002). This study, however, excluded patients with many co-morbid conditions (Foa et al., 2002).
Other therapies also present potential risks. Gestalt and experiential therapies (perhaps especially extended encounter groups) may exhibit a higher rate of patient deterioration than do most therapies (Mohr, 1995). With psychodynamic therapies, excessive use of transference interpretations has been associated with problems in the therapeutic alliance (Ackerman & Hilsenroth, 2001) and with negative outcome (Mohr, 1995). Even relaxation therapy can produce paradoxical anxiety increases in a significant percentage of patients (Mohr, 1995). It has been found in an acute short-term inpatient program that therapy groups that "emphasized emotional expression, breaking down defenses, and emotional release" can often produce negative results (Lambert & Bergin, 1994, p. 177).
Some patient types may be more vulnerable to deterioration in therapy than others. Particularly vulnerable to negative outcome are psychotic and borderline patients subjected to therapies that break down their normal defenses or coping mechanisms (Lambert & Bergin, 1994; Mohr, 1995). Obsessive compulsive patients have also been known to deteriorate in therapy or experience symptom substitution (Mohr, 1995).
Certain therapist characteristics have been associated with increased rates of negative outcome. Poor group leaders were found to be more authoritarian, impatient, and they insisted on immediate self-disclosure and emotional expression (Lambert & Bergin, 1994). Therapists who lack empathy, underestimate psychopathology, or sexually exploit their patients are more likely than other therapists to obtain negative results (Mohr, 1995). The therapeutic alliance has been associated with positive therapy outcome (Ackerman & Hilsenroth, 2003; Asay & Lambert, 1999; Castonguay et al., 1996; Luborsky et al., 1986), but therapist attributes such as being "rigid, uncertain, exploitative, critical, distant, tense, aloof, and distracted" have been associated with problems in the therapy alliance (Ackerman & Hilsenroth, 2001, p. 182). Therapists judged to be low in competence have more negative therapy outcome than do other therapists (Mohr, 1995).
The Recovery Model
The Recovery Model is a framework for change encompassing the need for consumers to learn to cope with the effects of their mental illness and to reach their highest possible level of functioning, while developing new meanings for their lives (Anthony, 1993). The Recovery Model has its roots in a "Consumer-Survivor movement" (Anthony, 1993; Frese & Davis, 1997), however, many concepts are borrowed from rehabilitation and community support systems models (Anthony, 1993). In fact, building upon a community support system, a recovery-oriented mental health system may attempt to provide multifaceted mental health services and support to severely mentally ill persons in the community, which have been shown to reduce the use of psychiatric hospitalization (Anthony, 1993). Services may include treatment, crisis intervention, case management, skill and role development, activities, rights protection, enhanced self-help skills, shelter, and food (Anthony, 1993). Going beyond rehabilitation and community support models, however, recovery models stress empowerment, destigmatization, and inclusion of the consumers at all levels of the mental health system (Anthony, 1993; Frese & Davis, 1997; Jacobson & Greenley, 2001).
At least two states thus far, Wisconsin and Ohio, are making a transition toward recovery models in their mental health systems (Jacobson & Greenley, 2001). Ohio also endorses the need for evidence-supported clinical practices. Part of the philosophy behind Wisconsin's recovery-oriented program involves mobilizing hope, empowerment, respect for the rights of the mentally ill, and increased interpersonal connection (Jacobson & Greenley, 2001). The Ohio Department of Mental Health [ODMH] lists nine components in their recovery model including: clinical care, family support, peer support and relationships, work/meaningful activity, increased power and control for the consumer, decreased stigma for the mentally ill, community involvement, access to resources, and education (ODMH, 2002). Using current knowledge and the consensus of a work group consisting of mental health professionals, consumers, and family members of consumers, the Ohio Department of Mental Health adopted a set of emerging best practices which recommend interventions for severely mentally ill patients at differing stages of awareness and independence (ODMH, 2002; Townsend, Boyd, Griffin, Hicks, Hogan, & Martin, 2000).
The Recovery Model, in general, emphasizes a stage model of change similar to the empirically supported model of Prochaska, DiClemente, and Norcross (1992). Patients in different stages of change readiness require different therapeutic approaches (Prochaska et al., 1992). More active and behavioral techniques may work best with patients ready to change, whereas patients lacking insight will need help in identifying their problems (Prochaska et al., 1992). Thus, with regard to choice of therapy, the stage of readiness for change may be more important than diagnosis.
It has been suggested that there are both consistencies and inconsistencies between the use of evidence-based practices and the Recovery Model, a model that seeks to empower mental-health-services consumers (Frese et al., 2001). According to this view, consumers with decision-making ability severely impaired by mental illness may benefit from mental health professionals choosing evidence-based treatments on their behalf. It is also acknowledged that even in a recovery model there are times when psychotic patients who lack insight must be treated on an involuntary basis (Munetz & Frese, 2001; Munetz, Galon, & Frese, 2003). However, consumers better established in their recovery may benefit from the empowering effects of choosing their own therapy, even if this means rejecting an empirically based treatment. Accepting and respecting the consumer's ultimate choice concerning treatment options may increase the consumer's internal locus of control and decrease the potentially negative effects of a paternalistic mental health system based on the medical model (Frese et al., 2001). This consumer empowerment, in turn, may compensate for the possible rejection of an empirically based treatment (Frese et al., 2001). Indeed, research suggests that internal locus of control and self-efficacy may reflect similar underlying constructs (Judge, Erez, Bono, & Thoresen, 2002), and both tend to correlate with measures of mental health (Bandura, 1989; Judge et al., 2002). Perhaps a study could be conducted to determine whether well-informed patients who select their own psychotherapy modality fare better than matched patients whose empirically supported treatment is selected on an actuarial basis. In their view, evidence-based practice is seen in a positive light, yet at times consumer choice may take precedence (Frese et al., 2001).
The President's New Freedom Commission on Mental Health (2003) endorses recovery values, including mobilizing hope and increasing consumer self-determination. Consistent with a recovery model, the New Freedom Commission Report (2003, p. 28) states: "In a consumer- and family-driven system, consumers choose their own programs and the providers that will help them most. Their needs and preferences drive the policy and financing decisions that affect them. Care is consumer-centered, with providers working in full partnership with the consumers they serve to develop individualized plans of care." The report also, however, strongly endorses the development and dissemination of evidence-based practices in the mental health field.
The Recovery Model is more an overarching philosophy of treatment than an empirically validated treatment in and of itself. The limited scientific research pertaining to the effectiveness of this model has been cause for concern (Peyser, 2001), and even a strong advocate of the Recovery Model acknowledges the need for more research (Anthony, 1993). Yet the Recovery Model seems to encompass many basic long-accepted principles, such as respect for consumers, mobilizing of hope, the need for multifaceted rehabilitation, and the need for alliances of mental health professionals, consumers, and families of the mentally ill. The body of research concerning the association between internal locus of control, self-efficacy, and mental health (Bandura, 1989; Judge et al., 2002) is consistent with the Recovery Model's claim that consumer empowerment, choice, and inclusion may be beneficial. Self-efficacy is also considered to be an efficacious common factor in successful therapies (Weinberger, 1995). The notion that people in different stages of readiness for change require different interventions has empirical support (Prochaska et al., 1992), as does the notion of the importance of the working alliance (Ackerman & Hilsenroth, 2001, 2003; Asay & Lambert, 1999; Castonguay et al., 1996; Luborsky et al., 1986). The mobilizing of hope is empirically supported for both psychological and medical interventions (Scovern, 1999). Although empirically validated therapies can be used within a recovery model, the Recovery Model itself appears conceptually closer to a common factors model than to an empirically validated treatment model. It is guided by general principles that have empirical and clinical support, but can also employ specific empirically validated treatments.
It was earlier noted that modes of treatment need to be consistent with the assumptive system of the culture in which it is employed (Frank, 1974). Although our culture tends to be scientifically oriented, there are also certain core values such as respect for autonomy and the rights of individuals which may favor acceptance of recovery models. It is noted that "These models also appeal to the general public and policy makers in a nation where individual rights are given the highest of priorities" (Munetz & Frese, 2001, p. 36). Our cultural respect and valuing of autonomy may also favor models wherein both patients and clinicians have input into the therapy modalities ultimately chosen.
Summary and Conclusions
Ample evidence exists that psychotherapy, in general, is effective; and for the most part, therapies are equally effective. There are some areas, however, wherein cognitive and behavioral therapies appear more effective--or at least are overrepresented among successful therapies in the research literature. Cognitive and behavioral therapies seem more effective than other forms of psychotherapy in treating anxiety disorders, or, at least are better represented among effective treatments in the research literature (Barlow et al., 1998; DeRubeis & Crits-Christoph, 1998; Ogles et al., 1999; Smith et al., 1980; Solomon et al., 1992; VanEtten & Taylor, 1998). Weinberger (1995) points out one factor common to all therapies: helping patients to confront or face problems, including their fears. He notes that although all therapies do this, behavioral therapies seem stronger in this area. In fact, exposure techniques appear to be a commonality with regard to cognitive behavioral treatment of anxiety disorders such as simple phobias, OCD, PTSD, agoraphobia, and panic disorders. It is important, though, to consider the possibility of a negative outcome if prolonged exposure is used in PTSD patients with low ego strength or co-morbid conditions. There is thought to be more research supporting dialectical behavior therapy for borderline personality disorder, as compared to other therapies (Scheel, 2000). However, a recent meta-analysis suggests that psychodynamic psychotherapy is also effective (Leichsenring & Leibing, 2003). The cognitive and behavioral schools have had a greater tradition of research than do other schools of therapy, thus also contributing to the overrepresentation of cognitive and behavioral therapies among empirically supported treatments. It has been suggested, though, that cognitive and behavioral researchers may find it easier to obtain external research funding as compared to psychodynamic researchers, thus partially accounting for the apparent disparity in amounts of research produced by the two schools (Louise Gaston, personal communication, December 8, 2003).
Regardless of school of therapy or techniques used, ample evidence indicates that the therapist, himself or herself, is a powerful factor in the outcome of the therapy. Forging a strong therapy alliance and fostering an expectation of improvement is crucial in psychotherapy. Common factors in therapy may, indeed, account for more of the variance in therapy outcome, as compared to specific techniques. Although much can be said for actuarial decision making, it is the therapist who decides, moment to moment, when to talk and when to listen, what technique to use and why, and as Linehan (1993) discusses, when to accept and when to encourage change. A technique or set of techniques cannot substitute for a therapist's judgment or make the therapist more empathic or caring.
Consumers, clinicians, researchers, and third-party payers are all vying for the power to decide what is best for the patient. The Recovery Model calls for more input by the consumer. The Common Factors Model favors the clinician as the decision maker, perhaps with input from the consumer. The Empirically Validated Treatment Model allows for the possibility of treatment modality decisions being made actuarially, administratively, or by third party payers. Clinicians and consumers, of course, could also make decisions to choose a given empirically validated treatment. Each perspective has its merits.
Psychotherapy in general is effective, yet on occasions research points to therapies for certain conditions that are more efficacious than others. In Orwell's (1946, p. 133) Animal Farm, it was proclaimed that "All animals are equal, but some animals are more equal than others." Similarly, in the field of psychotherapy outcome research, all therapies are generally equal, but some therapies for some conditions may be more equal than others. It is incumbent on clinicians to make reasonable, scientifically informed choices regarding therapy selection, while
seeking input from, and respecting the autonomy of, the consumer. Because psychotherapy is generally effective, it does not make sense to eliminate therapies (or not fund therapies) that do not prove superior to other therapies. However, the equivalence of all therapies is not as clearly established as it once appeared to be. The likelihood that some therapies for some conditions will prove more efficacious than others justifies the continued search to identify those therapies that are more equal than others.
The phrases "evidence-based practices," "empirically supported treatments," and "empirically validated treatments" have tended to be used synonymously, but the first phrase is gaining ascendancy (Levant, 2003). Levant (2003, p. 4) suggests that the Institute of Medicine's (2001) definition of evidence-based practice, which includes the "best research evidence, clinical expertise and patient values," should be adopted in the mental health field. The current author agrees with this, as this definition would allow for the strengths of the EVT, Common Factors, and Recovery Models to be used in clinical practice, while potentially reducing divisive power struggles. An unhealthy imbalance might be created if clinical expertise alone, research findings alone, or patient preference alone dictated the treatments that patients receive. All three components have potential biases as well as strengths.
The Recovery Model is a model of change which is largely theoretically based, yet some of its features are consistent with research findings. Its emphasis on mobilizing hope, on promoting change according to the consumer's stage of readiness, and on increasing internal locus of control (or self-efficacy) in seriously mentally ill people connects it to bodies of research. This model is already in use in some mental health systems. It would be helpful to determine whether mental health systems using this model actually produce better clinical results than systems that do not. The Recovery Model has the potential to incorporate empirically validated treatments (or to reject them), and it may also benefit from a number of common therapeutic factors. It remains to be seen as to what effect the greater empowerment and inclusion of the consumer will have on individual consumer's treatment, and on mental health systems in general. Measuring the effects of consumer empowerment represents a new challenge and opportunity for researchers. Recovery is a new frontier.
Although the views expressed in this article are solely mine, I thank Denise Kohler, Ph.D., and Thomas Hagesfeld, Ph.D., for their review of an earlier draft. I also thank Sandy Gekosky, Librarian, Appalachian Behavioral Heathcare, for acquiring articles, and Rebecca Reisner, B.A., for help with editing. I also thank journal reviewers for their helpful comments.
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ANDREW D. REISNER
Appalachian Behavioral Healthcare: Cambridge Campus
Correspondence concerning this article should be sent to Andrew D. Reisner, Psy.D., Cambridge Psychiatric Hospital, 66737 Old 21 Road, Cambridge, OH 43725. (E-mail: Reisnera@mh.state.oh.us).
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|Author:||Reisner, Andrew D.|
|Publication:||The Psychological Record|
|Date:||Jun 22, 2005|
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