http://www.talkingcure.com/archive/Whatworksarchive.htm(This is Long But Worth the Read), as it provides evidence against involuntary treatment in Behavioral Boarding Schools
I'm a Therapist Critical of My Profession - this is why I endorse the below against the beliefs of many of my collegues.
What Works Archive
This page contains reviews of research on "what works" in therapy once reviewed on the I.S.T.C. (Institute for the The Study of Therapuitic Change) website. As with the general "what works" page, this page of archived studies is categorized according to the four common factors.
Extratherapeutic Factors / Relationship
Factors / Model and Technique Factors / Placebo Factors / General Research on Common versus Specific Factors
What Makes Therapy Work? It's the Client,
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.
THIS IS CRUCIAL
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 (wants and needs) 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?
(This is why boarding schools decrease progress - words mine)
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.
What Works in Therapy? A controversy about the alliance is resolved...
A running controversy in outcome research has been whether the alliance leads to change or changes early in treatment lead to a strong alliance. Of course, the proponents of various models and techniques--lead chiefly by the First Church of Cognitive Behavioral Therapy--have argued the latter. Alas, research has once again resolved the battle between ideology and practice. Briefly, Barber (2000) followed the treatment of 88 individuals receiving treatment for specific DSM diagnoses (e.g., depression, anxiety, personality disorders, OCD). By carefully tracking the alliance and amount of change from visit to visit, he was able to show that
the strength of the alliance predicted subsequent improvement even when prior change was partialed out.
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. (Cognitive Behavioral Therpy) 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.
Keijsers et al. (2000). The impact of interpersonal patient and therapist behavior on outcome in cognitive behavior: A review of empirical studies. Behavior Modification, 24(2), 264-97.
How to Prevent Drop Out? Give Clients Choices!
(Do Boarding Schools Give Chioces?) - words in parenthises mine).
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?
In 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/ ... 2140e.htmlWhich 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),
