Toward a working through of some core conflicts in psychotherapy research

Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104-3309, USA.
Psychotherapy Research (Impact Factor: 1.75). 02/2009; 19(1):1-12. DOI: 10.1080/10503300802609680
Source: PubMed

ABSTRACT The author discusses the evidence for six basic statements that many, but not all, psychotherapy researchers adhere to: (1) The therapeutic alliance has a causal role in outcome, (2) therapeutic techniques explain patients' outcome, (3) therapists determine outcome, (4) patients determine therapy outcome, (5) randomized controlled trials (RCTs) provide valuable data, (6) data from RCTs are almost worthless. These "truths" combine to form three core conflicts: Is psychotherapy about the alliance or techniques? Does the patient or therapist determine the outcome? Are RCTs a blessing or a curse? After showing that these statements oversimplify the research of the therapeutic process, the author recommends keeping both sides of the conflict in awareness and endorses a pluralistic methodological approach for the study of both efficacy and the mechanisms of psychotherapy.
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    • "Another reason for challenging the assumption that therapists' reported alliance predicts outcome is the possibility of reverse causation. Some researchers have argued that the quality of the alliance may be the result of preceding symptomatic change, and that it is early symptomatic improvement that accounts for the alliance-outcome association (e.g., Barber, 2009; DeRubeis, Brotman , & Gibbons, 2005; DeRubeis & Feeley, 1990). Several studies have examined the temporal relationship between patient-reported alliance and outcome (Falkenström et al., 2013; Zilcha-Mano, Dinger, McCarthy, & Barber, 2014; Zilcha-Mano & Errázuriz, in press), but almost nothing is known about the temporal relationship between therapist-reported alliance and outcome. "
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    ABSTRACT: Most of the literature on the alliance-outcome association is based exclusively on differences between patient reports on alliance. Much less is known about the unique contribution of the therapist's report to this association across treatment, that is, the association between therapist-reported alliance and outcome over the course of treatment, after controlling for the patient's contribution. The present study is the first to examine the unique contribution of the therapist-reported alliance to outcome, accounting for reverse causation (symptomatic levels predicting alliance), at several time points in the course of treatment. Of 156 patients randomized to dynamic supportive-expressive psychotherapy, antidepressant medication with clinical management, and placebo with clinical management, 149 were included in the present study. Alliance was assessed from the perspective of both the patient and the therapist. Outcome measures included the patients' self-reported and diagnostician-rated depressive symptoms. Overall, the findings demonstrate that the therapists' contribution to the alliance-outcome association was explained mainly by prior symptomatic levels. However, when a time lag of several sessions was introduced between alliance and symptoms, a positive association emerged between alliance at 1 time point and symptomatic distress assessed several sessions later in the treatment, controlling for previous symptomatic level. The findings were similar whether or not we controlled for the patient's perspective on the alliance. Taken together, the findings attest to the importance of improving therapists' ability to detect deterioration in the alliance. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Journal of Counseling Psychology 08/2015; DOI:10.1037/cou0000106 · 3.23 Impact Factor
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    • "Thus, process-outcome research is needed to determine the active ingredients. While some progress has been made, this remains a priority for CBT researchers, as it is also for psychotherapy researchers of all stripes (Barber, 2009). Better understanding the mechanisms at play in CBT will help better understand how to further enhance CBT treatments in several regards . "
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    ABSTRACT: Cognitive behavior therapy (CBT) has come to be a widely practiced psychotherapy throughout the world. The present article reviews theory, history, and evidence for CBT. It is meant as an effort to summarize the forms and scope of CBT to date for the uninitiated. Elements of CBT such as cognitive therapy, behavior therapy, and so-called "third wave" CBT, such as dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT) are covered. The evidence for the efficacy of CBT for various disorders is reviewed, including depression, anxiety disorders, personality disorders, eating disorders, substance abuse, schizophrenia, chronic pain, insomnia, and child/adolescent disorders. The relative efficacy of medication and CBT, or their combination, is also briefly considered. Future directions for research and treatment development are proposed.
    Psychodynamic Psychiatry 08/2015; 43(3):423-461. DOI:10.1521/pdps.2015.43.3.423
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    • "indicating that, when averaging across studies, higher alliance ratings are associated with greater symptom improvement. Although intriguing, it is important to note that the vast majority of alliance studies do not control for temporal confounds (Barber, 2009; Webb et al., 2011). In other words, most studies are not predicting subsequent symptom change. "
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    ABSTRACT: Objective Numerous studies have reported associations between the therapeutic alliance and depressive symptom improvement in outpatient samples. However, little is known regarding the temporal relationship between the alliance and symptom change among relatively severely depressed patients receiving treatment in naturalistic, psychiatric hospital settings. Method Adult patients with major depression (n=103) receiving combined cognitive behavioral therapy and pharmacological treatment at a psychiatric hospital completed repeated assessments of the therapeutic alliance and depressive symptoms, as well as a pretreatment assessment of their expectation of symptom improvement. Results Results indicated that the alliance and treatment outcome expectancies significantly predicted subsequent depressive symptom change. However, in a model in which prior symptom change and treatment outcome expectancies were statistically controlled, the alliance-outcome association was rendered nonsignificant. The alliance was significantly associated with prior symptom improvement. Conclusions Findings highlight the importance of controlling for plausible third variable and temporal confounds to minimize biased estimates of alliance-outcome associations in future studies. Overall, results were more consistent with the alliance being a consequence, rather than a cause, of symptom change. Finally, findings contribute to a growing body of evidence supporting the role of treatment outcome expectancies in predicting symptom improvement, even within our relatively severely depressed sample.
    Behaviour Research and Therapy 10/2014; 61. DOI:10.1016/j.brat.2014.07.015 · 3.85 Impact Factor
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