The Great Psychotherapy Debate The Evidence for What Makes Psychotherapy Work
Preface
There is more evidence now for the effectiveness of psychotherapy than ever before. (Location 62)
Something in the core of human connection and interaction has the power to heal. Ironically, the unavoidable complexity of unstructured, emotional dialogue poses an immense challenge to scientists who wish to know why it is that conversations with certain characteristics lead to improvements in psychological well-being, decreases in distress, and recovery from profoundly disabling mental health problems—while other conversations do not. (Location 96)
Patients prefer psychotherapy as a first-line treatment for many problems, but psychotherapy continues to decrease as an overall percentage of mental health care. (Location 101)
Technology has revolutionized almost every aspect of human life, transforming science, medicine, entertainment, journalism, and social interaction. However, our current gold standard for evaluating the process of change in psychotherapy—human behavioral coding of patient–provider interactions—is based on 70-year old technology first used by Carl Rogers and his students. (Location 103)
psicoterapia investigación crítica
Chapter 1 History of Medicine, Methods, and Psychotherapy Progress and Omissions
Medicine
Although the origins of Western scientific medicine can be traced to the ancient Greeks, the preponderance of the treatments in Europe and the United States remained ineffective, by modern standards of medicine, until at least the nineteenth century. The introduction of the twined concepts of materialism and specificity, arising in the Renaissance era, along with the concept of the placebo, allowed modern medicine to ride the crest of the wave created by science and the scientific method. (Location 180)
It was René Descartes, in the early seventeenth century, who made the distinction between mind and body, although it was not his purpose to be at the service of the development of medicine, as he was interested in the mind in an ontological sense. Nevertheless, the distinction placed anatomy and physiology, which were now subject to observation, on an empirical track; the mind remained in the metaphysical realm and, in a manner of speaking, became the province of psychology. (Location 201)
In 1785 the term placebo entered the medical lexicon and was applied to treatments that were known to be ineffective physiochemically but satisfied the patient’s desire to be treated (Shapiro & Shapiro, 1997b). The term, according to Walach (2003), originated from the Latin psalm verse, “Placebo Domino in regione vivorum” (“I shall please the Lord in the land of the living”), which was sung in the Middle Ages as a prayer at the deathbed. (Location 209)
As will become apparent in subsequent discussions, placebo and the effects that are derived from them are deeply imbedded in several controversies in medicine and in psychotherapy; from the perspective of this volume, an understanding of the placebo effect is critical to an understanding of psychotherapy. Nevertheless, the term placebo, from its origin, has retained a tainted connotation—administration of a substance simply to please the patient became repugnant and claims that a “placebo” was curative would risk being labeled a charlatan, as Franz Anton Mesmer was soon to find out. (Location 214)
King Louis XVI of France established in 1784 a Royal Commission, chaired by Benjamin Franklin, to investigate mesmerism (Gould, 1991). Some of the experiments designed by the commission involved patients being split into two groups, with one group coming into contact with “magnetized” objects and the other group coming into contact with what they believed were “magnetized” objects (i.e., according to modern terminology, a placebo). Care was taken to ensure that the patients did not know whether they were receiving a magnetized object or not, creating one of the first, if the not the first, rigorous blinding in a study (here, a single blind). This design enabled the Royal Commission to demonstrate, as there were no differences in the cures produced by the two groups, that Mesmer’s cures did not occur through treatment-specific ingredients. (Location 225)
The noted natural historian Stephen Jay Gould (1989) heralded the testing and discrediting of Mesmer as one of the earliest and exemplary demonstrations of the use of the scientific method to expose pseudoscience and charlatanism. (Location 231)
Pasteur hypothesized that living microorganisms were responsible for fermentation, rather than being created spontaneously as a result of the process. This discovery led to other conclusions, including the conjecture that disease was caused by microorganisms, which constituted the origins of the germ theory of disease. The pairing of theory and experimentation resulted in medical practices with demonstrable benefits—vaccines using compromised organisms, sterilization of medical environments, and sterilization of foods by heat (i.e., “pasteurization”). (Location 250)
What constitutes knowledge in a given field depends, in part, on the people who conduct the research, create the theories, and influence the scientific community, particularly in the social sciences. Knowledge at any given time, as we will argue in this volume, is tenuous—the nature of psychotherapy makes itself known in response to our inquiries, but the nature of those inquiries shapes what we accept as knowledge. We, as researchers, clinicians, and policymakers, influence what is said to be knowledge. (Location 269)
epistemología psicoterapia investigación conocimiento
The second means to establish specificity is to establish that the medical treatment operates through its intended mechanism. Administration of antibiotics leads to a decrease in H. Pylori, which subsequently leads to healing of the ulcer, lending support for the explanation and the mechanism of change and thus lending support for specificity—the antibiotic works through the intended mechanism (see Hentschel et al., 1993). (Location 313)
Adaptation of the Medical Model to psychotherapy is a controversial project, which in many ways is the subject of this volume. As we will see, the development of psychotherapy as a treatment for mental disorders is entwined with the development of medicine. Medicine, of course, is the predominant force and psychotherapy is subordinate. (Location 320)
it was not until the 1950s that the randomized placebo control group design was developed, and it was not until 1980 that the Food and Drug Administration (FDA) required such designs be used to approve drugs in the United States, as discussed in the next section. (Location 335)
investigación historia psicoterapia
The streptokinase example is one of many that led to the initiation of a movement to ensure that research evidence was translated into practice. This movement, called evidence-based medicine, initiated in the United Kingdom and Canada, emphasizes systematic and analytic reviews of evidence and the use of that evidence by clinicians. (Location 348)
Intimately tied to the evolution of modern medicine is the development of methods that could establish specificity, most importantly the randomized double-blind placebo control group design. (Location 357)
investigación método causalidad
Randomized Designs as the “Gold Standard”
The British statistical approach contributed the critical concepts of measurement of unobservable characteristics (in this case, mental abilities) and statistical distributions of such characteristics, critical components of analysis of the observation in randomized control group designs. (Location 391)
Wundt introduced laboratory methods in psychology and attempted to extract general rules. The French researchers devised designs in which the experimenter subjected research participants to various conditions and compared abnormal to normal persons. The British social statisticians provided the statistical theory related to deviations from the mean. These were all critical components of clinical trials in medicine and psychotherapy, but the missing component to this mix was randomization. The impetus for that critical component came, in part, from the desire to provide pragmatic knowledge to various consumer groups. Academic psychologists deemed education an apt context to demonstrate the utility of their nascent discipline. In the early 1920s, the treatment group methodology was “being sold to American school superintendents as the ‘control experiment’ and touted as a key element in comparing the ‘efficiency’ of various administrative measures” (Danziger, 1990, p. 114). Shortly thereafter, McCall (1923) published How to Experiment in Education, which introduced control group experimentation in education and discussed the notion of randomization. At about the same time, Sir Ronald Fisher took a position at an agricultural station where he developed the analysis of variance and various other procedures for comparing crop yields (Gehan & Lemak, 1994). Fisher’s work in randomized experimental designs and the analysis of data derived from such designs was absolutely stunning—arguably the design and analysis of every clinical trial in medicine, psychology, and education is based on methods developed by Fisher (Danziger, 1990; Shapiro & Shapiro, 1997b) or derived from his work. Fisher’s publications, most prominently The Design of Experiments, which appeared in 1935, became particularly useful to medical researchers eager to show the efficacy of various medications, although one additional component, the placebo control, was needed (Gehan & Lemak, 1994). (Location 396)
researchers in the late 1930s began to use double-blind placebo studies in the United States and the United Kingdom, but the method did not take root, apparently because placebo carried a negative connotation (Location 415)
The importance of the randomized double-blind placebo control group design methodologically and conceptually should not be underestimated. It took more than 300 years from Descartes’ dualism of mind and body and nearly 200 years from the time that Mesmer was discredited on specificity claims to the institutionalization of a design that could rule out psychological threats to the establishment of the specific effects of substances on the body (Location 428)
The Emergence of Psychotherapy as a Healing Practice
According to Caplan (1998), several events in the United States conspired to challenge the emphasis on physiochemical explanations. First, the train as a means of transportation emerged. Trains, of course, differed in many ways from previous forms of transportation, but for purposes of the development of psychotherapy, the important aspect was that trains, when things went awry, created catastrophic collisions, which produced a multitude of various injuries. A frequent complaint of those in the collisions involved a diffuse constellation of symptoms, which usually included back pain, and led to the diagnosis of “railway spine.” What was troubling for medicine was that witnesses on the platforms near the collisions reported many of the same symptoms even though they had not been involved in the physical trauma, a phenomenon that cast doubt on a physiochemical cause of reported symptoms and introduced the notion that the mind has a role in symptoms. (Location 455)
The Boston School of Psychopathology, initiated in 1859, which was an informal group of investigators, including the psychologists William James and G. Stanley Hall as well as neurologists and psychiatrists, was to become the epicenter of the new talk therapy. (Location 481)
The manifestation of physical symptoms in the absence of physical cause, the efficacy of various incompatible treatments for a prevalent disorder, and the increasing popularity and legitimacy of talk therapies for physical and mental disorders were problematic for the emerging modern medical profession. And thus a dilemma for medicine: reject the emerging psychotherapeutics because it treated psychic disorders with non-medical means (viz., talk) or absorb the lucrative professional practice of mental therapeutics. (Location 486)
política psicoterapia psiquiatría medicina
“As early as 1894, [William] James publicly assailed a proposal to proscribe the practice of mental healing, ‘What the real interest of medicine requires,’ James proclaimed, ‘is that mental therapeutics should not be stamped out, but studied, and its laws ascertained’” (Location 493)
What was missing was a cogent theory of mental disorder and that would soon be provided. (Location 499)
When Sigmund Freud gave his lectures at Clark University in 1909, talk therapy was established as a legitimate medical practice in the United States, but he provided the missing theoretical coherence and all the better that it was provided by a physician and in the medical context. Within six years, psychoanalysis had become the predominant form of psychotherapy in the United States: “Psychoanalysis appeared to be more proper and civilized than mind cure, more scientific than Christian Science and positive thinking, and more medical than advertising” (Location 502)
psicoanálisis historia psicoterapia
From these early origins of psychoanalysis, the components of the Medical Model were apparent: a disorder (hysteria), a scientifically based explanation of the disorder (repressed traumatic events), a mechanism of change (insight into unconscious), and specific therapeutic actions (free association). (Location 511)
Regardless of the debates about the scientific merit of psychodynamic concepts, it should be realized that Freud’s complex theories were introduced prior to Flexner’s report and the reformation of medicine that resulted; that is, the substance and bases for Freud’s claims were suitable for the period in which they occurred. (Location 520)
One critical point for our history of psychotherapy is related to the degree to which psychotherapy for the first half of the twentieth century was the province of medicine. As we have seen, psychotherapy was already incorporated into medicine at the turn of the century and Freud, a physician, provided an explanation acceptable to the medical profession. Moreover, admittance to psychoanalytic institutes and the practice of psychoanalysis was limited primarily to physicians, further defining psychotherapy as a medical practice. (Location 522)
until mid-century, in the research context particularly, “The division of labor by discipline was unquestioned: Psychologists did intelligence testing and assessment of personality, usually the Rorschach test; social workers did the interviewing; and psychiatrists conducted therapy” (Location 529)
A major impetus to behavioral therapy was provided by Joseph Wolpe’s development of systematic desensitization. Wolpe, who like Freud was a medical doctor, became disenchanted with psychoanalysis as a method to treat his patients. Based on the work of Pavlov, Watson, Rayner, and Jones, Wolpe studied how eating, an incompatible response to fear, could be used to reduce phobic reactions of cats, which he had previously conditioned. After studying the work on progressive relaxation by physiologist Edmund Jacobson, Wolpe recognized that the incompatibility of relaxation and anxiety could be used to treat anxious patients. His technique, which was called systematic desensitization, involves the creation of a hierarchy consisting of progressively anxiety-provoking stimuli, which are then imagined by patients, under a relaxed state, from least to most feared. His seminal book Psychotherapy by Reciprocal Inhibition, in which he explicated how classical conditioning could be used as a psychological treatment, was published in 1958—at about the same time the medical barrier was lowered and psychologists began to practice psychotherapy more prevalently. (Location 541)
although the psychoanalytic paradigm is saturated with mentalistic constructs whereas the behavioral paradigm generally eschews intervening mentalistic explanations, they are both systems that explain mal-adaptive behavior and offer therapeutic protocols for reducing distress and promoting more adaptive functioning. (Location 552)
In the context of post–World War II modernism and attempts to make meaning of life given the ravages of war and the Holocaust, psychotherapy developed a third force (after psychoanalysis and behavioral therapy) derived from the humanistic philosophers (e.g., Kierkegaard, Husserl, and Heidegger). Humanistic approaches have in common a) a phenomenological perspective (i.e., therapy must involve understanding the client’s world); b) an assumption that humans seek growth and actualization; c) a belief that humans are self-determining; and d) a respect for every individual, regardless of their role or actions (Location 574)
Humanistic approaches emanated from distinctly non-medical origins and non-experimental traditions, having roots more in philosophy than in science and medicine. (Location 581)
The types of treatments delivered by therapists constitute another indicator of the status of psychotherapies. Every 10 years, Norcross and colleagues survey psychologists with regard to a number of practices, including type of treatment provided (see Norcross & Karpiak, 2012; Norcross, Karpiak, & Santoro, 2005, for the most recent surveys of clinical psychologists). The results of the survey show a remarkable rise in the proportion of clinical psychologists who report that their orientation was cognitive: in the 1960s and 1970, virtually no clinical psychologist reported that they were cognitively oriented, whereas in the most recent survey (viz., 2010), about one-third do so. If one combines cognitive with behavioral, which has been steadily rising from 8 percent in 1960 to 15 percent in 2010, then 45 percent of clinical psychologists in the United States report that their primary orientation is either cognitive or behavioral (Norcross et al., 2012). On the other hand, the proportion that report a dynamic or eclectic/intregrative orientation has decreased from 35 percent and 36 percent, respectively, in 1960 to 18 percent and 22 percent in 2010, respectively. All other orientations, including Rogerian, humanistic, systems, and interpersonal, among others, were only endorsed by 14 percent of the clinical psychologists responding in the 2010 survey. Of course, psychotherapy is not solely practiced by clinical psychologists, but it appears, nevertheless, that not only have humanistic approaches been abandoned (or perhaps have abandoned) mainstream theoretical psychology, as Rice and Greenberg (1992) suggested, but psychotherapists (at least psychologists) have abandoned these approaches as well. (Location 594)
Research Methods, Psychotherapy Efficacy, and the Ascendancy of Treatments for Disorders
The case methods used by Freud and colleagues documented that their treatments were remarkably successful but created much doubt by those outside of the psychoanalytic community (Strupp & Howard, 1992). Indeed, one of the continuing criticisms of psychoanalytic approaches has been the lack of objective verification of outcomes. (Location 618)
The first direct observation of psychotherapy emanated from the humanistic tradition, which is somewhat surprising given the phenomenological bent of this school. While advocates of other approaches, particularly the psychoanalysts, were loathe to invade the sanctity of the interview room, in the 1940s Carl Rogers and his group prepared transcripts of sessions from audio tapes, a technology that was evolving at the time (Rice & Greenberg, 1992). From this source material, Rogers and his research group generated hypotheses that were to be tested by the evolving research methods being developed in education and psychology (see, e.g., Rogers, 1951b). (Location 620)
Although the use of placebo control groups in psychotherapy research is problematic (see Chapter 8), historically Rosenthal and Frank’s recommendation was emblematic of psychotherapy’s close connection with medicine. Psychotherapy was adopting models of research that were used by medicine to demonstrate the effects of medications, thereby conceptualizing psychotherapy as a medical treatment. This is a trend that has increased over the decades such that beginning in the 1980s psychotherapy began to label its outcome research as clinical trials as it sought to establish the viability of particular treatments for particular disorders. The use of placebo-type control groups in psychotherapy research was an attempt to show that psychotherapies, like drugs, were specific, which as we have seen, is a distinguishing feature of modern medicine. Purportedly, the superiority of a particular psychotherapy to a placebo establishes the specificity of the treatment but also established the legitimacy of the psychotherapy enterprise. (Location 644)
Mary Lee Smith and Gene Glass, in 1977, published a meta-analysis of all studies that compared a psychotherapeutic approach to some type of control group, thereby demonstrating the utility of the method of meta-analysis, which will be described more completely in Chapter 3. Subsequently, meta-analysis has become the standard method of aggregating research results in education, psychology, and medicine. Importantly for psychotherapy, Smith and Glass (1977; Smith, Glass, & Miller, 1980) found that psychotherapy was indeed efficacious, a conclusion that will be examined fully in Chapter 4. (Location 656)
meta_análisis psicoterapia evidencia efectos
To address this issue, first treatments were to be standardized, accomplished with treatment manuals, after which the standardized treatments could be tested and compared. (Location 664)
psicoterapia mecanismo investigación
The purpose of the treatment manual is to create standardization of treatments, thereby reducing variability in the independent variable in clinical trials, and to ensure that therapists deliver correctly the specific ingredients that are characteristic of the theoretical approach. With regard to the latter point, manuals enable “researchers to demonstrate the theoretically required procedural differences between alternative treatments in comparative outcome studies” (Wilson, 1996, p. 295). Credit for the first treatment manual usually is attributed to Beck, Rush, Shaw, and Emery (1979), who delineated cognitive-behavioral treatment for depression. The proliferation of treatment manuals since the Beck et al. manual in 1979 has been described as a “small revolution” (Location 668)
The criteria essentially stipulated that a treatment would be designated as empirically validated for a particular disorder provided that at least two studies showed superiority to groups that attempted to control for general effects and were administered to a well-defined population of clients (including importantly the clients’ disorder, problem, or complaint) using a treatment manual. (Location 691)
The requirement that only treatments administered with a manual are certifiable as an EST further demonstrates a connection between ESTs and the Medical Model because, as discussed above, manuals are intimately tied to the Medical Model. The lists of empirically supported treatments were dominated by behavioral and cognitive-behavioral treatments, with a few exemplars of psychodynamic-derived treatments and no humanistic treatments, which may reflect the fact that behavioral and cognitive-behavioral treatments are easier to manualize than are humanistic or psychodynamic treatments and fit more neatly into the clinical trial paradigm. (Location 708)
Essentially, the adoption of the EST scheme created a Medical Model of psychotherapy. In medicine, the Medical Model involves a) disease or illness, b) biological explanation, c) mechanism of change, d) therapeutic actions, and e) specificity. The only modification needed for the psychotherapy version is that the biological explanation is transformed to a psychological explanation. (Location 722)
As will be discussed throughout this book, specificity in psychotherapy, for theoretical and methodological reasons, is a problematic concept. (Location 728)
Barlow (2004) suggested that treatments for particular disorders that have been established as effective should be designated as psychological treatments to differentiate them from generic psychotherapy; the former being established treatments within health delivery systems (i.e., reimbursable by third-party payers) and the latter, which “is often used outside of the scope of health care systems” (p. 869). (Location 731)
Progress and Omissions
disorders. Psychotherapy, whose history is entwined with medicine, also has progressed. Originating in the United States in secular and spiritual spheres, psychotherapy was legitimized by an association with medicine. When criticized as ineffective, the randomized design and meta-analyses were sufficiently powerful to demonstrate the effectiveness of psychotherapy and retain its respectability. (Location 785)
While a majority of Americans consider themselves religious or spiritual, psychotherapy, for the most part, has become a secular and amoral healing practice. (Location 801)
The notion of psychotherapy as an opportunity to grow or as an opportunity to make meaning is not considered in any substantial manner in the current empirical investigations of psychotherapy. (Location 810)
experimento desarrollo beneficios investigación favorite cita psicoterapia
The focus on the treatment/disorder matrix to the exclusion of other factors is nowhere more apparent than in a special issue of the Journal of Consulting and Clinical Psychology (Kendall, 1998) on ESTs—in methodological articles and reviews of ESTs in child, adolescent, adult, family and marital, and health, only two articles mentioned culture, ethnicity, or race as an important consideration (viz., Baucom et al., 1998; Kazdin & Weisz, 1998) and then not prominently. (Location 824)
Referring to a race in Alice and Wonderland in which contestants started when they wanted and ended when they wanted, Rosenzweig used the metaphor “At last the Dodo bird said, ‘Everybody has won and all must have prizes’” to refer to the competition among the various psychotherapies. The general equivalence of the benefits of psychotherapy has been called the Dodo bird effect. Rosenzweig’s unrecognized factors have become known as common factors, as they are aspects of therapy that are common to all, or at least most, psychotherapies, and include such aspects of therapy as hope, expectation, relationship with the therapist, belief, and corrective experience. (Location 850)
favorite efectos cita psicoterapia evidencia
Attributing potency to common factors is analogous to saying that medications are potent because of the placebo effect, which of course would be most detrimental to the fundamental assumption of modern medicine. Advocates of particular treatments have assiduously resisted the common factor explanation. Indeed, acceptance of common factors as the cause of the benefits of psychotherapy would collapse the entire scaffolding of the theoretical bases of modern psychotherapy as conceptualized by the field and presented to the public. Consequently, the field of psychotherapy has attempted to establish the primacy of treatment and has attempted, through the use of placebo-type control groups and other designs, to rule out common factors as the critical component explaining the benefits of psychotherapy (see Chapter 8). (Location 858)
Closely aligned with the common factor models were attempts to describe and test hypotheses related to the process of psychotherapy—what happens in psychotherapy sessions and how do these events lead to patient change. The history of process research can be traced to Rogers’ sound recordings and transcripts of client-centered therapy (see e.g., Rogers, (Location 864)
The focus on treatments and the avoidance of provider effects in education, agriculture, and medicine was extended to psychotherapy, where therapists similarly were ignored as an important source of variation in outcomes (Wampold & Bhati, 2004). In Chapter 6, the implications of ignoring therapist effects in psychotherapy will be discussed more fully and, as well, the variability in outcomes due to the psychotherapist will be estimated. (Location 887)
A similar omission is related to the role of patients. In each of the venues where randomized designs were used, the units receiving the treatment were assumed to be passive subjects. (Location 890)
Summary
The contention of this volume is that several important aspects of psychotherapy have been ignored, to the detriment of understanding how psychotherapy works, to policy, and to practice. (Location 901)
Chapter 2 The Contextual Model Psychotherapy as a Socially Situated Healing Practice
Definitions and Terminology
Psychotherapy is a primarily interpersonal treatment that is a) based on psychological principles; b) involves a trained therapist and a client who is seeking help for a mental disorder, problem, or complaint; c) is intended by the therapist to be remedial for the client disorder, problem, or complaint; and d) is adapted or individualized for the particular client and his or her disorder, problem, or complaint. (Location 934)
Because the relationship between training and outcome in psychotherapy has not been established, the amount of training is not specified, but here it is assumed that the training be typical for therapists practicing a given form of therapy and that the client believes the therapist has sufficient training to assist the client. (Location 944)
It may turn out that psychotherapy is efficacious because Western cultures value the activity rather than because the specific ingredients of psychotherapy are efficacious, but that does not alter how psychotherapy is defined here. (Location 957)
placebo psicoterapia evidencia investigación
The term common factors is misunderstood and even used in a pejorative manner, as we shall see. (Location 1003)
A psychotherapy treatment contains both specific ingredients and incidental aspects, both, one, or none of which might be remedial. The term specific effects will be used to refer to the benefits produced by the specific ingredients; general effects will be used to refer to the benefits produced by the incidental aspects (i.e., the common factors). (Location 1008)
We choose to use the term therapeutic elements to denote those constituents that create the benefits of psychotherapy regardless of their status as specific ingredients or common factors. (Location 1016)
Essentially, the goal of this book is to identify the therapeutic elements of psychotherapy by examining the research evidence—in simple terms, what makes psychotherapy work? (Location 1023)
Levels of Abstraction
Four levels of abstraction will be presented here: therapeutic techniques, therapeutic strategies, theoretical approaches, and meta-theoretical models. These four levels are not distinct (i.e., the boundaries between them are ill-defined) and it would be impossible to classify each and every research question and theoretical explication into one and only one of the levels. Some studies have examined questions that do not fit neatly into one of the levels and some studies have examined questions that seem to span two or more levels. Nevertheless, it is necessary to understand how the thesis of this book, which contrasts the Medical Model with the Contextual Model, exists at a meta-theoretical level. At this level of abstraction, the vast array of research results produced by psychotherapy research create a convergent and coherent conclusion. (Location 1038)
abstracción psicoterapia niveles investigación