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Abstract

Jurisdictions in Canada, notably in Ontario and Quebec, are proposing a laudable goal of increasing publicly funded access to psychotherapy. Ontario and Quebec will likely follow the lead of the Increasing Access to Psychotherapy (IAPT) program in the United Kingdom and train psychotherapists to provide cognitive–behavioural therapy. Results from IAPT provide some important lessons about taking an approach that prefers one brand of psychotherapy. We argue that such policy decisions are based on a medical model approach to psychotherapy that makes erroneous assumptions about what psychotherapy is, what is the nature of the evidence, and how training and services should be delivered. In this article, we review critically these assumptions and the state of the art of the research about what makes psychotherapy work. Psychotherapy is effective and preferable to antidepressant medication. Differences between psychotherapies account for a small proportion of variance in patient outcomes. The largest known predictors of patient outcomes are patient factors (coping style, resistance/reactance, interpersonal problems, culture) and therapeutic relationship factors (therapeutic alliance). Also notable are therapist factors (facilitative interpersonal skills, empathy, and managing countertransference), and practices like progress monitoring. Canadian jurisdictions should note that training therapists to adapt treatment and interpersonal stances to patient characteristics, to develop and maintain the therapeutic relationship, to enhance therapist facilitative interpersonal skills, and to engage in progress monitoring has a greater chance of achieving a reduction in the burden caused by depression and anxiety among their citizens than focusing on delivering a particular brand of psychotherapy.
Will Publicly Funded Psychotherapy in Canada Be Evidence Based?
A Review of What Makes Psychotherapy Work and a Proposal
Giorgio A. Tasca
University of Ottawa
Joel M. Town and Allan Abbass
Dalhousie University
Jeremy Clarke
London School of Economics
Jurisdictions in Canada, notably in Ontario and Quebec, are proposing a laudable goal of increasing
publicly funded access to psychotherapy. Ontario and Quebec will likely follow the lead of the Increasing
Access to Psychotherapy (IAPT) program in the United Kingdom and train psychotherapists to provide
cognitive– behavioural therapy. Results from IAPT provide some important lessons about taking an
approach that prefers one brand of psychotherapy. We argue that such policy decisions are based on a
medical model approach to psychotherapy that makes erroneous assumptions about what psychotherapy
is, what is the nature of the evidence, and how training and services should be delivered. In this article,
we review critically these assumptions and the state of the art of the research about what makes
psychotherapy work. Psychotherapy is effective and preferable to antidepressant medication. Differences
between psychotherapies account for a small proportion of variance in patient outcomes. The largest
known predictors of patient outcomes are patient factors (coping style, resistance/reactance, interpersonal
problems, culture) and therapeutic relationship factors (therapeutic alliance). Also notable are therapist
factors (facilitative interpersonal skills, empathy, and managing countertransference), and practices like
progress monitoring. Canadian jurisdictions should note that training therapists to adapt treatment and
interpersonal stances to patient characteristics, to develop and maintain the therapeutic relationship, to
enhance therapist facilitative interpersonal skills, and to engage in progress monitoring has a greater
chance of achieving a reduction in the burden caused by depression and anxiety among their citizens than
focusing on delivering a particular brand of psychotherapy.
Keywords: psychotherapy, improving access to psychotherapy, outcomes, patient factors, therapeutic
relationship
In 2017, the provincial government of Ontario, Canada, an-
nounced new funding ($25 million per year for 3 years) to improve
access to psychotherapy among its citizens with mild to moderate
depression and anxiety disorders (Ontario Ministry of Health &
Long Term Care, 2017). This was welcome news for a population
that to date receives insufficient government assistance to access
psychotherapy. For the most part, unless one is fortunate enough to
work for an employer that provides sufficient extended health
benefits for psychological treatment, many Canadians have little
access to timely psychotherapy. This plan by the government of
Ontario is meant to address this shortcoming of the health system
regarding mental health care. Later in the year, the Quebec gov-
ernment announced a similar measure to increase access to psy-
chotherapy (Anderssen, 2017). The challenge at this stage, in
Ontario and Quebec, is how the money will be allocated, how
treatment will be provided, what kind of treatment, and to whom.
To help to make this decision in Ontario, the Ministry of Health
and Long Term Care (MOHLTC) received a consultation from
Health Quality Ontario (HQO), a government funded organisation
that studies and evaluates the provision of health interventions. In
its report, HQO emphasised the need to deliver evidence-based
psychotherapy to those with mild to moderate depression and
anxiety, and made a number of recommendations in that regard
(HQO, n.d.). Among the recommendations was the need to provide
“structured psychotherapy” by trained practitioners. Currently, the
MOHLTC and its partners have interpreted this to mean providing
time-limited cognitive– behavioural therapy (CBT; The Royal
Mental Health Care, 2017). Five main psychiatric hospitals in
Ontario will organise and provide training to community-based
therapists. On the face of it, the MOHLTC appears to be relying on
aspects of the Improving Access to Psychotherapy (IAPT) pro-
gram in the United Kingdom as a successful model for it to follow
Giorgio A. Tasca, School of Psychology, University of Ottawa; Joel M.
Town, Departments of Psychiatry and Psychology and Neuroscience, Dal-
housie University; Allan Abbass, Centre for Emotions and Health, Dal-
housie University; Jeremy Clarke, Centre for Philosophy of Natural and
Social Science, London School of Economics.
Jeremy Clarke was former National Advisor for the Improving Access to
Psychotherapy program in the United Kingdom from 2008 to 2013.
Correspondence concerning this article should be addressed to Giorgio
A. Tasca, School of Psychology, University of Ottawa, 136 Jean-Jacques
Lussier, Ottawa, Ontario, Canada, K1N6N5. E-mail: gtasca@uottawa.ca
Canadian Psychology / Psychologie canadienne
0708-5591/18/$12.00 2018, Vol. 59, No. 4, 293–300
© 2018 Canadian Psychological Association http://dx.doi.org/10.1037/cap0000151
293
(National Health Service [NHS], n.d.). Quebec announced a sim-
ilar plan to follow aspects of the IAPT model (Delorme, 2018).
The HQO report and its interpretation make a number of as-
sumptions about the definition of psychotherapy and the state and
quality of the evidence. These assumptions have implications for
the way in which psychotherapy and the evidence is understood
and how psychotherapy can and should be delivered. In this article,
we argue that if the aim is simply to increase and achieve new
access targets, then the United Kingdom. IAPT model offers a
good template (Clark et al., 2018). But if the aim is to reduce the
burden of depression, then the IAPT example offers some impor-
tant lessons. After a decade of government investing some £1.3
billion, IAPT has certainly increased access to CBT (NHS Digital,
n.d.a;n.d.b). Around 1 million people annually now access IAPT
services, almost all of whom wait less than 6 weeks from referral
to treatment (Baker, 2017). But IAPT has yet to make any real
impact on reducing the burden of depression and its social and
economic consequences (Jorm, Patten, Brugha, & Mojtabai, 2017;
McManus, Bebbington, Jenkins, & Brugha, 2016;Organisation for
Economic Co-Operation and Development, 2014). This is partly
because (a) between 2007 and 2017, substantially less than half of
patients referred, in some cases less than a third, chose to take up
and complete the IAPT treatment on offer (NHS Digital, n.d.c;
Johns, 2017); (b) less than half of IAPT patients who complete
treatment achieve recovery (NHS Digital, n.d.c); and (c) less than
half of treatment completers who achieve recovery from low-
intensity CBT (the most common intervention) remain recovered
at 12 months posttreatment (Ali et al., 2017). Hence, contrary to
IAPT claims that almost 50% of patients recover, in reality only
10% to 20% of patients achieve real lasting recovery in IAPT.
There is also a clear disparity between reported recovery rates in
the most deprived areas of the United Kingdom (35%) and the
least deprived areas (55%; NHS Digital, n.d.b), with most deprived
areas overrepresented by people on social security, which is im-
portant as these were the target group IAPT promised to help, and
the basis for the original claim that the programme ‘would pay for
itself’. It appears that flaws in IAPT’s original design and imple-
mentation in the United Kingdom may have had unintended con-
sequences for those who need help most. Thus, it is not yet clear
that IAPT’s model, based on CBT, is either cost-effective or
sustainable (McCrone, 2013).
We suggest an alternative model of training and delivering
psychotherapy in Canada that is more closely aligned with the
research evidence for what makes psychotherapy work. Such a
model may achieve all of the important aims that IAPT in the
United Kingdom originally set out to deliver (Layard & Clark,
2014). Adopting this in Ontario and Quebec, as we demonstrate
below, would make increased access to psychotherapy a cost-
effective, sustainable policy.
What Is Psychotherapy and What Is
Evidence-Based Practice?
In 2012, the American Psychological Association (APA,
2012) released a report on the Recognition of Psychotherapy
Effectiveness. In it, the APA defined psychotherapy as the “. . .
informed and intentional application of clinical methods and
interpersonal stances derived from established psychological
principles for the purpose of assisting people to modify their
behaviours, cognitions, emotions, and/or other personal char-
acteristics in directions that the participants deem desirable” (p.
1). The phrase “interpersonal stances” is critical to this defini-
tion in that it recognizes the important role of the quality of the
therapeutic relationship in predicting patient outcomes (Nor-
cross & Lambert, 2011). We will return to this issue below
when we review the evidence for the impact of the therapeutic
relationship relative to differences between therapeutic ap-
proaches.
A second key aspect of that APA (2012) report was the defini-
tion of evidence-based practice (EBP), originally put forward in
2006 by APA, as the “. . . integration of the best available research
with clinical expertise in the context of patient characteristics,
culture and preferences” (APA Task Force on Evidence Based
Practice, 2006, p. 273). This represents a broader view of EBP that
goes beyond exclusively relying on establishing empirically sup-
ported treatments (EST; Chambless & Hollon, 1998). The EST
approach developed lists of psychotherapies that were deemed
efficacious if the treatment demonstrated superior effects to a
control condition or was equally effective to another EST in
randomized controlled trials. This approach tends to pit psycho-
therapies against each other in an effort to identify which treatment
is most efficacious. However, the broader EBP approach adopted
by APA in 2006 relies on three key and equal aspects: the research
evidence, clinical expertise, and patient characteristics. As our
review below indicates, it turns out that patient characteristics are
the largest predictor of patient outcomes, which is an important
consideration when designing a public mental health programme
covering a heterogeneous population, and in which health inequal-
ities may limit access for some (Dixon-Woods et al., 2005).
Despite the APA definitions of psychotherapy and of EBP,
which recognise the importance of the therapeutic relationship and
patient factors in determining outcomes, some researchers and
writers conceptualise psychotherapy as if it were a pharmacolog-
ical intervention (Wampold & Imel, 2015). This is indicative of a
medical model of psychotherapy in which its effectiveness is due
to specific interventions (cognitive restructuring, transference in-
terpretations, two-chair techniques) targeting specific causes of
disorders (cognitive distortions, inner conflict, emotional block-
ages). This is much the same as the way that a pharmacologist
conceptualizes a pharmacological intervention (selective serotonin
reuptake inhibitors) that target dysfunction in a specific neu-
rotransmitter system (the serotonin system) as the cause of depres-
sion. A medical model of psychotherapy suggests that some brands
of psychotherapy will be more effective than others because of
their specific interventions. Such a model also suggests that psy-
chotherapy research and practice must control for all so-called
nonspecific aspects of psychotherapy (differences between thera-
pists, the therapeutic relationship) to isolate the effects of the active
ingredient on the mechanism causing the disorder (Wampold & Imel,
2015). However in CBT, for example, there is little research support-
ing the theory that challenging cognitions leads to symptomatic im-
provement (Longmore & Worrell, 2007).
This may appear to be an esoteric discussion at first, but bear
with us. Conceptualising psychotherapy as a medical intervention
has a profound impact on how one views and practices psycho-
therapy, and for how governments fund psychotherapy. Within the
medical model approach, the therapist, the therapeutic relationship,
and patient characteristics (other than specific symptoms) are only
294 TASCA, TOWN, ABBASS, AND CLARKE
peripherally relevant to the workings of psychotherapy or at least
need to be controlled as background noise. Therefore, within a
medical model, psychotherapy practice is about applying a specific
intervention while trying to control for or simply ignoring differ-
ence between therapists, the therapeutic relationship, and patient
characteristics and preferences. This is akin to viewing psycho-
therapy as a medical technology device. Further, a medical model
predicts that some psychotherapy will demonstrate superior effi-
cacy to others because their specific ingredients or actions will
target the purported specific causes of a disorder. Practically, for
funders like government departments, this means that one should
fund one brand of psychotherapy and not another. However, as we
demonstrate below, there is diminishing evidence that any one
form of bona fide psychotherapy is on average more effective than
another bona fide psychotherapy for many disorders, and this is
especially true for depression. Moreover, IAPT’s own outcome
data shows broad equivalence for its different therapies: counsel-
ling, interpersonal psychotherapy, couple therapy, brief dynamic
therapy, and CBT, with the latter being marginally less effective in
recent reports (NHS Digital, n.d.a,n.d.b;Pybis, Saxon, Hill, &
Barkham, 2017;Royal College of Psychiatrists, 2011,2013).
Bona Fide Psychotherapies Are Effective
By bona fide psychotherapies, we mean psychotherapies that are
based on a psychological theory, meant to be effective for a
specific disorder, delivered by a trained therapist, and have dem-
onstrated evidence for their efficacy or effectiveness (Wampold &
Imel, 2015). The field has known for some time that psychother-
apies are more effective than no treatment (Lambert & Bergin,
1994;Grissom, 1996), such that the effect sizes for psychotherapy
are as large as or larger than most common medical interventions
(Rosnow & Rosenthal, 2003). The average effect size for psycho-
therapy versus no treatment is large (d.80 or r.37) indicating
that the average patient is better off than 79% of untreated controls
(Wampold & Imel, 2015).
Psychotherapies are as effective as antidepressant medications
for reducing depressive symptoms (Spielmans, Berman, & Usitalo,
2011). However, there is also evidence that psychotherapy has better
long-term outcomes (de Maat, Dekker, Schoevers, & De Jonghe,
2006;Imel, Malterer, McKay, & Wampold, 2008;Spielmans et al.,
2011), lower drop-out rates (Cuijpers, van Straten, Andersson, &
van Oppen, 2008), and psychotherapy is less susceptible to treat-
ment resistance after an unsuccessful course of therapy (Wampold
& Imel, 2015). Turner, Matthews, Linardatos, Tell, and Rosenthal
(2008) unequivocally demonstrated that the effects of antidepres-
sant medications are inflated by publication bias and active sup-
pression of negative data by the pharmaceutical industry. While
publication bias is also evident in trials of psychotherapy and CBT
in particular, the resulting inflation seems to be smaller (Cuijpers
et al., 2008). Further, a meta-analysis indicated that 75% of pa-
tients would prefer psychotherapy over medications if they had the
choice (McHugh, Whitton, Peckham, Welge, & Otto, 2013), and
that patients who receive their preferred treatment tend to have
better outcomes (Swift, Callahan, & Vollmer, 2011). In the United
Kingdom, a large cross-sectional survey of National Health Ser-
vice patients treated for depression also showed that a choice of
their preferred type of therapy was important to them, and would
impact their outcome (Williams et al., 2016). Yet, by far, most
patients in North America are offered medications for mental
disorders (Olfson & Marcus, 2010) likely because of limited
accessibility to specialized psychotherapy, even if psychother-
apy is cost-effective (Vasiliadis, Dezetter, Latimer, Drapeau, &
Lesage, 2017). Hence, the Ontario and Quebec government plan
for publicly funded psychotherapy is an important step to fill
the gap in access to a range of efficacious psychotherapies for
depression and anxiety disorders.
Bona Fide Psychotherapies Do Not Differ for
Depression Outcomes
A number of bona fide psychotherapies for depression exist, in-
cluding CBT (Beck, 2011), interpersonal psychotherapy (Klerman,
Weissman, Rounsaville, & Chevron, 1984), emotion-focused
therapy (Greenberg, 2010), short-term psychodynamic psycho-
therapy (Luborsky et al., 1995), behavioural activation (Martel,
Dimidjian, & Herman-Dunn, 2010), and others. The best way to
summarise the outcome literature on the relative efficacy of psycho-
logical treatments is to conduct meta-analyses of studies that directly
compare treatments to each other. Meta-analysis can produce the most
reliable estimates of the effect of treatments, and meta-analyses of
studies that directly compare treatments reduce between-study error
and bias. The vast majority of meta-analyses of direct comparisons
show that there is no difference between psychological therapies
when treating patients with depression (see e.g., Cuijpers et al., 2008;
Cuijpers et al., 2013). There is also evidence that the effects of CBT
are declining over time (Johnsen & Friborg, 2015), likely because
more recent studies are of higher quality leading to lower effects, and
the initial enthusiasm of developers of CBT may have inflated early
findings. Also, the particular brand of psychotherapy is not a signif-
icant moderator of drop-out rates from treatment (another indicator of
outcomes; Swift & Greenberg, 2012). To summarize, psychotherapy
is effective, it is just as effective as antidepressant medications,
psychotherapy is preferred by 75% of patients, and differences be-
tween treatments account for a small amount of the variability in
patient outcomes.
Finally, a meta-analysis demonstrated that therapist adherence
to (r.02) and competence in (r.07) a treatment manual of a
specific intervention bear almost no relationship to patient out-
comes (Webb, Derubeis, & Barber, 2010). In other words, the
degree to which a therapist learns to follow and apply a psycho-
logical treatment manual, like CBT (Beck, 2011), interpersonal
psychotherapy (Klerman et al., 1984), or short-term psychody-
namic psychotherapy (Luborsky et al., 1995), has almost no impact
whether their patients get better. If there are no differences be-
tween treatments, and the degree to which one follows a treatment
manual does not improve outcomes, then what is it that accounts
for the positive effects of psychotherapy? And what can these
predictors tell us about how to train therapists to achieve the best
possible patient outcomes for all?
Factors That Reliably Predict Patient Outcomes
In 2011, Norcross and Lambert did a sweeping review of the
psychotherapy outcome and process literature, and also surveyed
the leading psychotherapy researchers in the world about predic-
tors of patient outcomes. They produced a striking pie chart
illustrating the amount of patient outcome variance accounted for
295
WHAT MAKES PSYCHOTHERAPY WORK
by those factors studied over the decades. By far, the largest
known predictor of outcomes was patient factors, which accounted
for 30% of the variance, followed by the therapeutic relationship at
12%, specific treatment effects at 8%
1
, and differences between
therapists at 7%. A remarkable aspect of these findings is that
while most of the funding, training, and research in psychotherapy
focus on specific treatment models (accounting for at most 8% of
the variance in patient outcomes), more important predictors of
outcomes lie in other areas including patient characteristics (30%
of the variance) and the therapeutic relationship (12% of the
variance). This is not to say that specific treatments are not
relevant, but that an overemphasis on their effect represents an
oversimplification of how change occurs in psychotherapy.
Patient Factors
Patient factors include a number of aspects that affect outcomes and
that can be adapted to, managed, or enhanced by trained and knowl-
edgeable therapists. For example, in a meta-analysis, Constantino,
Arnkoff, Glass, Ametrano, and Smith (2011) found a significant
association between patient expectations of receiving benefit and
outcomes, r.24, p.001. In other words the degree to which
a therapist helps to instill a sense of hope in patients may improve
their outcomes. Patient coping style and its impact on therapy has
long been of interest to therapists and researchers. A meta-anslysis
by Beutler, Harwood, Kimpara, Verdirame, and Blau (2011) found
a significant effect of coping style on patient outcomes, r.26,
p.001. Specifically, patients with externalizing coping tend to
do better in symptom-focused treatment, whereas patients with
internalizing coping tend to have better outcomes in insight-
oriented treatments. Another meta-analysis found a significant
association, r.38, p.001, for matching patient resistance/
reactance to therapist directiveness. Patients higher in resistance or
reactance had better outcomes if therapists were less directive,
whereas patients with lower resistance or reactance did better with
therapists who were more directive (Beutler et al., 2011). Simi-
larly, there is evidence from systematic reviews and meta analyses
that higher pretreatment interpersonal problems and interpersonal
distress (McFarquhar, Luyten, & Fonagy, 2018), greater attach-
ment anxiety (Levy, Ellison, Scott, & Bernecker, 2011), higher
functional impairment (Beutler et al., 2002), and greater severity,
complexity, and comorbidity (Bohart & Wade, 2013) are associ-
ated with poorer outcomes. Finally, a meta-analysis found that
adapting psychotherapy to patient culture results in better out-
comes than culturally unadapted psychotherapy (Benish, Quintana,
& Wampold, 2011). This latter issue is well illustrated by data
from IAPT in the United Kingdom. As noted above, patients living
in the most economically deprived areas were less likely to finish
a course of treatment and less likely to recover (NHS Digital,
n.d.b).
Therapeutic Relationship
The most studied therapeutic relationship factor is the therapeu-
tic alliance. Therapeutic alliance is commonly defined as the
emotional bond between therapist and patient plus a collaborative
agreement on the tasks and goals of therapy. In a large meta-
analysis of over 200 studies, Horvath, Del Re, Flückiger, and
Symonds, (2011) found a highly robust relationship between
higher alliance and better patient outcomes, r.28, p.001.
Who measured the alliance (patient, therapist, rater), when it was
measured (early, middle, or late in therapy), which scale was used,
and what type of therapy made little difference to this significant
association. There is now a growing consensus that the alliance is
a necessary precursor to symptom change in all types of therapy
(Zilcha-Mano, 2017). Research is also indicating that the quality of
the alliance fluctuates throughout treatment, and this fluctuation
has implications for treatment. For example, alliance ruptures
(disagreements or tensions between therapists and patients) likely
occur in 50% of cases within the first six sessions of therapy (Muran
et al., 2009). Unresolved alliance ruptures are significantly associated
with poorer patient outcomes (Muran et al., 2009). In a meta-analysis,
Safran, Muran, and Eubanks-Carter (2011) reported that therapists
ability to repair alliance ruptures was associated with better patient
outcomes, r.24, p.002, and that training therapists to identify
and repair alliance ruptures is associated with better pre- to posttreat-
ment patient outcomes, r.56, p.001.
Therapist Effects
Finally, therapist effects (i.e., differences between therapists)
appear to have a small but significant effect on patient outcomes
(Wampold & Brown, 2005). That is, some therapists are reliably
more (or less) effective than others. Training therapists with a
treatment manual is, in part, designed to diminish therapist effects,
but as noted previously, adherence and competence to a manual
appear to have little bearing on patient outcomes (Webb et al.,
2010). Data from IAPT and NHS-funded services in the United
Kingdom also illustrate this point by revealing that considerable
variability in patient dropping out (12.1%) and deterioration
(10.1%) was explained by differences between therapists (Saxon,
Barkham, Foster, & Parry, 2017). Using data collected from
33,243 patients treated for depression within IAPT services, re-
search found that variability between service providers had a
significant effect on patient outcomes while the type of therapy
they received did not (Saxon, Firth, & Barkham, 2017). To illus-
trate the practical importance of even small therapist differences,
one large study in the United States of over 700 therapists and
7000 patients found that 16% of the therapists (n112) were
reliably harmful (Kraus, Castonguay, Boswell, Nordberg, & Hayes,
2011). Those patients (n1,120) treated by reliably harmful thera-
pists on average got worse due to therapy, and this result was main-
tained even after within-therapist case mix variables (size of therapist
caseload, patient diagnosis, patient severity) were controlled. The
implications of this research are that therapists need to be trained in
those factors that lead to better patient outcomes, and that relying on
therapist adherence to a treatment protocol may not improve matters.
What are the therapist factors that are associated with better
outcomes? One potential candidate is therapist facilitative inter-
1
Meta-analyses indicate that differences between treatments account for
approximately 8% of the variance and that this may be the upper bound of
this estimate (see Wampold & Imel, 2015;Wampold & Serlin, 2014).
Wampold and Imel (2015) argued that this percentage is inflated by
researcher allegiance (i.e., the effects of a researcher’s preference for a
particular treatment modality for which they have the greatest affinity).
When researcher allegiance is controlled, the amount of patient outcome
variance accounted for by differences between treatments reduces from 8%
to 1% (see also Lambert & Ogles, 2004).
296 TASCA, TOWN, ABBASS, AND CLARKE
personal skills—which includes verbal fluency, warmth, and emo-
tional expression. Research has shown that therapist facilitative
interpersonal skills predict patient outcomes with large effects
(Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009). In
particular, therapist empathy is highly associated with positive
patient outcomes (Elliott, Bohart, Watson, & Greenberg, 2011).
Another candidate is therapists’ ability to identity and manage
countertransference (Hayes, Gelso, & Hummel, 2011), which re-
fers to therapists’ emotional reactions triggered by patients but
which implicates a therapist’s unresolved conflicts. In a meta-
analysis, Hayes and colleagues (2011) found that training thera-
pists to manage countertransference was associated to better pa-
tient outcomes with moderate effects. This is consistent with a
meta-analysis indicating that therapists (not patients) are largely
responsible for the alliance-outcome relationship (Del Re, Flückiger,
Horvath, Symonds, & Wampold, 2012).
A therapist practice that robustly improves patient outcomes is
progress monitoring, or the regular assessment of patient outcome
during therapy (e.g., weekly or biweekly). The assessment patient
progress is done with psychometrically sound instruments fol-
lowed by feedback to the therapist on the status of the patient
relative to standardized norms. The feedback process alerts ther-
apists to changes in patient status on a week-to-week basis, which
allows therapists to alter their interventions or to attend to a
previously unknown or negative process in the therapy. In a
meta-analysis, Lambert and Shimokawa (2011) found that provid-
ing therapists with feedback about patient progress was moderately
and significantly associated with positive outcomes, r.24, p
.001. In particular, using a progress monitoring system cut the
percentage of patients who deteriorated by half. This is important
because approximately 8% of patients get worse after psychother-
apy (Lambert, 2010).
An Alternative Model for Creating Capable,
Multidisciplinary Therapy Teams
The Ontario and Quebec plans to fund CBT for mild to mod-
erate depression and anxiety appear to be largely based on a
medical model, following the influential example of IAPT in the
United Kingdom. There is an obvious appeal to follow a model
that has shown it can improve access (Clark et al., 2018). However,
an overemphasis on apparently cost-effective ways to scale-up access
rapidly, such as use of computerized CBT, other low-intensity CBT
interventions, and stepped care is unlikely to yield the kinds of
longer-term benefits that offering a genuine choice of efficacious
psychotherapies could deliver (Ali et al., 2017). We suggest an alter-
native model that heeds these lessons and that follows from the
research on what makes psychotherapy work.
As Wampold and Imel (2015) argued, the medical model does
not apply well to psychotherapy because it de-contextualizes psy-
chotherapy by treating it as a set of technical procedures that are
not impacted by the therapeutic relationship, patient, and therapist.
However, as our review of the evidence indicates, it is precisely
these contextual factors (Norcross & Lambert, 2011) and not
adherence to a particular treatment protocol (Webb et al., 2010)
that predict better patient outcomes. A contextual model of psy-
chotherapy (Wampold & Imel, 2015) holds that (a) therapists need
to work within a theoretical orientation based on established psy-
chological principles and sets of procedures to address symptoms;
(b) patients and therapists need to agree on the tasks (based on
these procedures) and goals of therapy, which in part requires the
development, maintenance, and repair of the therapeutic alliance
(Horvath et al., 2011;Safran et al., 2011); (c) patients and thera-
pists need to like working with each other (another aspect of the
alliance), which in part requires therapists to have a high level of
facilitative interpersonal skills including empathy (Anderson et al.,
2009); and, crucially, (d) therapists must take into account patient
characteristics and preferences when designing and delivering
interventions, including patient coping style, reactance, interper-
sonal style, and culture.
This alternative contextual approach would not give primacy or
preference to a single therapeutic orientation like CBT, as has
happened in the United Kingdom. Instead, it would recognise that
therapists trained in many bona fide psychotherapies are likely to
be effective in treating the wide range of patients with heteroge-
neous presentations of depressive and other disorders (see Cuijpers
et al., 2008,2013;Wampold & Imel, 2015). We argue that the
training of capable multidisciplinary teams of therapists should be
consistent with the existing research to provide truly evidence-
based care to patients.
A Proposal
Rather than exclusively focusing the training of therapists on
only one particular treatment manual or protocol, therapist training
across a number of effective approaches should target those skills
that the evidence indicates directly improves patient outcomes.
Meta analyses indicate that methods like continuous progress
monitoring and feedback (Lambert & Shimokawa, 2011) and
video review of therapist skills (Town et al., 2012) can improve
therapist reflective practice and patient outcomes. Thus, it is im-
portant for evidence-based curriculums to train therapists compe-
tently to (a) develop and maintain a therapeutic alliance (Horvath
et al., 2011), (b) identify and repair alliance ruptures (Safran et al.,
2011), (c) properly assess patient characteristics that affect out-
comes (expectations, coping style, attachment, reactance, func-
tional impairment, interpersonal problems, level of social support,
motivation) and modify interpersonal stances and interventions
according to those patient characteristics (Beutler et al., 2002,
2011;Constantino et al., 2011;Levy et al., 2011;McFarquhar et
al., 2018), (d) adapt their interpersonal stance and intervention
according to a patient’s culture and context (Benish et al., 2011),
(e) enhance their facilitative interpersonal skills (Anderson, Crow-
ley, Himawan, Holmberg, & Uhlin, 2016) such as empathy (Elliott
et al., 2011) and identify and manage countertransference (Hayes
et al., 2011), and (f) use regular progress monitoring to identify
patients who might be deteriorating and then use the feedback to
alter therapist interpersonal stances and interventions.
We recognise that these evidence-based skills that therapists
must learn are complex and multifaceted. However, these skills
reflect what psychotherapy is: the “. . . informed and intentional
application of clinical methods and interpersonal stances derived
from established psychological principles for the purpose of as-
sisting people . . .” (APA, 2012, p. 1). Hence, although the training
of competence in these skills and stances may be more involved
than training someone to adhere to a treatment manual, such
training is more closely aligned with the research evidence and so
will result in better mental health outcomes for the population
297
WHAT MAKES PSYCHOTHERAPY WORK
being treated. Moreover, it offers a better career framework for
practitioners who can be recruited and retained from a wider range
of backgrounds.
We strongly encourage the Ontario MOHLTC, Quebec, and
other Canadian jurisdictions charged with increasing access to
psychotherapy to follow the evidence and not focus solely or
primarily on one brand of psychotherapy, CBT, as happened in the
United Kingdom. They should train therapists across a range of
effective approaches on those interpersonal stances and skills that
the research indicates will improve patient outcomes. Such an
approach would result in capable multidisciplinary teams that
tackle the serious challenge of reducing the burden of depression
and anxiety and their associated health and social inequalities.
Résumé
Certaines régions du Canada, notamment l’Ontario et le Québec,
proposent comme objectif louable d’accroître l’accès aux traite-
ments de psychothérapie financés par les deniers publics. Les deux
provinces suivront probablement l’exemple du programme Increasing
Access to Psychotherapy (IAPT) du Royaume-Uni, et formeront des
psychothérapeutes offrant la thérapie cognitivo-comportementale.
Les résultats de l’IAPT fournissent d’importantes leçons sur
l’adoption d’une approche privilégiant un type de psychothérapie
en particulier. Nous avançons que de telles décisions politiques
sont basées sur un modèle médical a
`l’égard de la psychothérapie
qui fait des suppositions erronées au sujet de la nature de cette
discipline, de la nature des preuves et de la façon dont la formation
et les services doivent être dispensés. Dans cet article, nous ex-
aminons d’un œil critique ces suppositions et faisons le point des
connaissances sur ce qui explique l’efficacité de la psychothérapie.
La psychothérapie est efficace et préférable au traitement au
moyen d’antidépresseurs. Les différences entre les psycho-
thérapies expliquent la petite proportion de la variance dans les
résultats chez les patients. Les principales variables prédictives des
résultats sont reliées au patient (mode d’adaptation, résistance et
réactance, problèmes interpersonnels, culture), et a
`la relation
thérapeutique (alliance thérapeutique). Sont également importants
les facteurs reliés au thérapeute (compétences de facilitation inter-
personnelles, empathie, gestion du contre-transfert) ainsi que les
pratiques, comme le suivi des progrès. Dans leurs décisions, les
régions du Canada doivent aussi tenir compte du fait qu’apprendre
aux thérapeutes a
`adapter le traitement et la posture thérapeutique
selon les caractéristiques du patient, a
`développer et a
`maintenir la
relation thérapeutique, a
`améliorer leurs compétences de facilita-
tion interpersonnelles et a
`surveiller les progrès sont autant
d’éléments qui augmenteront les chances de réduire le fardeau que
créent la dépression et l’anxiété parmi la population, mieux que ne
le fera l’offre d’un type de psychothérapie en particulier.
Mots-clés : psychothérapie, améliorer l’accès a
`la psychothérapie,
résultats, facteurs liés au patient, relation thérapeutique.
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Revision received March 28, 2018
Accepted March 28, 2018
300 TASCA, TOWN, ABBASS, AND CLARKE
... For example, in the UK, the Improving Access to Psychological Therapies (IAPT) program is primarily built upon training in and delivery of CBT nation-wide, while PDT methods are seldom used and taught. This is despite the limited and perhaps dubious evidence of the efficacy of CBT delivered in the IAPT program (Shedler, 2018;Tasca et al., 2018). ...
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... The treatment is time-limited and often based on a stepped care approach beginning with guided online modules. Despite being made aware of the weak, inconsistent, or dubious evidence in support of IAPT (see Tasca et al., 2018 for a review), the Ontario government has gone ahead with their plans for IASP. Routine outcome measurement is not done in Ontario public mental health services to evaluate such implementations. ...
... Age differences were found for ADHD (F(2, 1498) [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54] were more likely than older adults (55 and older) to identify ADHD (24%, 24%, and 15% respectively) as most difficult condition. In general, young adults reported more conditions than older adults, specifically, OCD (23% and 18%), schizophrenia (29% and 22%), as well as eating (30% and 19%) and developmental (25% and 15%) disorders. ...
... Closely behind ADHD, were anxiety-related conditions, including OCD, SUD, and GAD. Psychotherapy is more effective and is, in the long-term, more enduring than treatment with medications alone, especially for these conditions [44]. OCD is difficult to find treatment for, as medication rarely provides full relief, and few therapists are trained in CBT treatments, such as exposure and ritual prevention [40]. ...
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There are growing concerns in Canada about access barriers to quality mental health care, which has worsened significantly by the COVID-19 pandemic and for some Canadians more than others. With a nationally representative sample of 1501 adults, surveyed by the Angus Reid Institute, this study examined the mental health conditions Canadians experience the most difficulties in accessing care. Among half of the respondents who sought mental health care, the majority encountered challenges in accessing help for posttraumatic stress disorder (PTSD) (34%) and depression (33%). When examining the data based only on those seeking care for specific conditions, attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), substance use disorders, and generalized anxiety disorder (GAD) emerged as those for which it was most difficult to find treatment. Indigenous and Black Canadians had significantly more difficulty finding care across several conditions. We discuss the implications of these findings, including the critical need to increase the supply and diversity of mental health providers across Canada. This study is one of the first to provide quantitative data on the perceived barriers in accessing mental health care, while exploring the role of race and ethnicity and other social identities.
... This addition resulted in only a modest and negligible rise in insurance costs. As a well-resourced, compassionate, and progressive nation, there have been calls for Canada to do the same (Tasca et al., 2018;Williams, 2022). ...
... New research is urgently needed to determine why Canadians seem to be having so many poor interactions with their mental health care providers, and to unearth the impediments to creating a strong therapeutic alliance (e.g., Tasca et al., 2018). There is a racial component to this finding as well, given that negative experiences posed a notable barrier for Indigenous and Middle Eastern participants, and as such, it could indicate a need for more clinician training in building rapport, connection, and empathy, especially when working with diverse clients (e.g., Jones et al., 2021;Miller et al., 2015). ...
... Research in the field of FIT has shown that FIT use has a positive impact on treatment outcomes (Brattland et al., 2018;Harmon et al., 2007;Lambert & Barley, 2002;Lambert et al. 2003;Slade et al. 2008;Tasca et al., 2018;Kelley & Bickman, 2009;Whipple et al., 2003;Duncan, 2016;Bickman et al., 2011;Connolly Gibbons et al., 2015;Lambert, 2007;Unutzer et al., 2002 among others). ...
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Introduction: Feedback-informed treatment (FIT) is a way of systematically monitoring and using client feedback in psychotherapeutic processes. Research shows that FIT has a positive impact on therapeutic outcomes by improving client engagement, increasing treatment effectiveness and reducing client drop-out. However, organisations often encounter barriers when implementing FIT. Methods: This study uses a narrative literature review to identify barriers and facilitators to implementing FIT in organisations. The analysis is based on 43 relevant sources obtained through a search of scientific databases. Results: 9 categories of barriers were identified, including limited resources , negative attitudes of therapists, lack of training and knowledge, privacy concerns, and technological and systemic problems. The 12 categories of facilitators include organisational support and culture, training, technological adaptability and active client involvement. Discussion: Successful FIT implementation requires multi-level support within the organisation, including a clear vision, appropriate training and support for therapists. Key challenges for therapists are motivation and integration of FIT into existing treatment process, and at the organisational level, a deliberate approach to developing a culture of feedback. For organisations that successfully implement FIT, this can be a step towards continuous improvement of therapeutic outcomes. Conclusion: There are challenges but also clear benefits to implementing FIT, especially when supported by a holistic approach, a culture of feedback and quality training.
... In several countries, PDTs have been given low priority, or even been omitted completely, in national treatment guidelines for common mental health problems (e.g., Abbass, Tasca, et al., 2020;Martindale, 2022;Okada, 2022;Plakun, 2020). While such omissions have been challenged as being based on biased views of PDT and its research base (e.g., Abbass et al., 2017;Leichsenring & Rabung, 2011;Leichsenring et al., 2022Leichsenring et al., , 2023McPherson et al., 2018;Tasca et al., 2018), efforts to change the notion that there is a lack of evidence for PDTs have so far had limited impact, and PDTs have generally become more and more marginalized in recent years (Yakeley, 2020(Yakeley, , 2021. This marginalization is not only a concern when it comes to the provision of PDTs in the public health sector but also affects future training opportunities and research funding. ...
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Background: Internationally, the clinical outcomes of routine mental health services are rarely recorded or reported; however, an exception is the English Improving Access to Psychological Therapies (IAPT) service, which delivers psychological therapies recommended by the National Institute for Health and Care Excellence for depression and anxiety disorders to more than 537 000 patients in the UK each year. A session-by-session outcome monitoring system ensures that IAPT obtains symptom scores before and after treatment for 98% of patients. Service outcomes can then be reported, along with contextual information, on public websites. Methods: We used publicly available data to identify predictors of variability in clinical performance. Using β regression models, we analysed the outcome data released by National Health Service Digital and Public Health England for the 2014-15 financial year (April 1, 2014, to March 31, 2015) and developed a predictive model of reliable improvement and reliable recovery. We then tested whether these predictors were also associated with changes in service outcome between 2014-15 and 2015-16. Findings: Five service organisation features predicted clinical outcomes in 2014-15. Percentage of cases with a problem descriptor, number of treatment sessions, and percentage of referrals treated were positively associated with outcome. The time waited to start treatment and percentage of appointments missed were negatively associated with outcome. Additive odd ratios suggest that moving from the lowest to highest level on an organisational factor could improve service outcomes by 11-42%, dependent on the factor. Consistent with a causal model, most organisational factors also predicted between-year changes in outcome, together accounting for 33% of variance in reliable improvement and 22% for reliable recovery. Social deprivation was negatively associated with some outcomes, but the effect was partly mitigated by the organisational factors. Interpretation: Traditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes. Funding: Wellcome Trust.
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Background: Depression and anxiety disorders are relapse-prone conditions, even after successful treatment with pharmacotherapy or psychotherapy. Cognitive behavioural therapy (CBT) is known to prevent relapse, but there is little evidence of the durability of remission after low intensity forms of CBT (LiCBT). Method: This study aimed to examine relapse rates 12 months after completing routinely-delivered LiCBT. A cohort of 439 LiCBT completers with remission of symptoms provided monthly depression (PHQ-9) and anxiety (GAD-7) measures during 12 months after treatment. Survival analysis was conducted to model time-to-relapse while controlling for patient characteristics. Results: Overall, 53% of cases relapsed within 1 year. Of these relapse events, the majority (79%) occurred within the first 6 months post-treatment. Cases reporting residual depression symptoms (PHQ-9 = 5 to 9) at the end of treatment had significantly higher risk of relapse (hazard ratio = 1.90, p < 0.001). Conclusions: The high rate of relapse after LiCBT highlights the need for relapse prevention, particularly for those with residual depression symptoms.
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Background: Interpersonal problems are commonly reported by depressed patients, but the effect of psychotherapeutic treatment on them remains unclear. This paper reviews the effectiveness of psychotherapeutic interventions for depression on interpersonal problems as measured by the Inventory of Interpersonal Problems (IIP). Methods: An electronic database search identified articles reporting IIP outcome scores for individual adult psychotherapy for depression. A systematic review and, where possible, meta-analysis was conducted. Results: Twenty-eight studies met inclusion criteria, 10 of which could be included in a meta-analysis investigating changes in the IIP after brief psychotherapy. Reasons for exclusion from the meta-analysis were too few participants with a diagnosis of depression (n=13), IIP means and SDs unobtainable (n=3) and long-term therapy (n=2). A large effect size (g=0.74, 95% CI=0.56-0.93) was found for improvement in IIP scores after brief treatment. Limitations: Paucity of IIP reporting and treatment type variability mean results are preliminary. Heterogeneity for improvement in IIP after brief psychotherapy was high (I(2)=75%). Conclusions: Despite being central to theories of depression, interpersonal problems are infrequently included in outcome studies. Brief psychotherapy was associated with moderate to large effect sizes in reduction in interpersonal problems. Of the dimensions underlying interpersonal behaviour, the dominance dimension may be more amenable to change than the affiliation dimension. Yet, high pre-treatment affiliation appeared to be associated with better outcomes than low affiliation, supporting the theory that more affiliative patients may develop a better therapeutic relationship with the therapist and consequently respond more positively than more hostile patients.
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Many people identified as having common mental disorders in community surveys do not receive treatment. Modelling has suggested that closing this “treatment gap” should reduce the population prevalence of those disorders. To evaluate the effects of reducing the treatment gap in industrialized countries, data from 1990 to 2015 were reviewed from four English-speaking countries: Australia, Canada, England and the US. These data show that the prevalence of mood and anxiety disorders and symptoms has not decreased, despite substantial increases in the provision of treatment, particularly antidepressants. Several hypotheses for this lack of improvement were considered. There was no support for the hypothesis that reductions in prevalence due to treatment have been masked by increases in risk factors. However, there was little evidence relevant to the hypothesis that improvements have been masked by increased reporting of symptoms because of greater public awareness of common mental disorders or willingness to disclose. A more strongly supported hypothesis for the lack of improvement is that much of the treatment provided does not meet the minimal standards of clinical practice guidelines and is not targeted optimally to those in greatest need. Lack of attention to prevention of common mental disorders may also be a factor. Reducing the prevalence of common mental disorders remains an unsolved challenge for health systems globally, which may require greater attention to the “quality gap” and “prevention gap”. There is also a need for nations to monitor outcomes by using standardized measures of service provision and mental disorders over time.
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Background: In the psychological therapies, patient outcomes are not always positive. Some patients leave therapy prematurely (dropout), while others experience deterioration in their psychological well-being. Methods: The sample for dropout comprised patients (n = 10 521) seen by 85 therapists, who attended at least the initial session of one-to-one therapy and completed a Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at pre-treatment. The subsample for patient deterioration comprised patients (n = 6405) seen by the same 85 therapists but who attended two or more sessions, completed therapy and returned a CORE-OM at pre-treatment and post-treatment. Multilevel modelling was used to estimate the extent of therapist effects for both outcomes after controlling for patient characteristics. Results: Therapist effects accounted for 12.6% of dropout variance and 10.1% of deterioration variance. Dropout rates for therapists ranged from 1.2% to 73.2%, while rates of deterioration ranged from 0% to 15.4%. There was no significant correlation between therapist dropout rate and deterioration rate (Spearman's rho = 0.07, p = 0.52). Conclusions: The methods provide a reliable means for identifying therapists who return consistently poorer rates of patient dropout and deterioration compared with their peers. The variability between therapists and the identification of patient risk factors as significant predictors has implications for the delivery of safe psychological therapy services. Copyright © 2016 John Wiley & Sons, Ltd. Key practitioner message: Therapists play an important role in contributing to patient dropout and deterioration, irrespective of case mix. Therapist effects on patient dropout and deterioration appear to act independently. Being unemployed as a patient was the strongest predictor of both dropout and deterioration. Patient risk to self or others was also an important predictor.