The diagnosis du jour is Post Traumatic Stress Disorder (PTSD). If you want to know what really works best, check out:

Benish, S., Imel, Z. E., & Wampold, B. E. (2007). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28, 746-759.

This study is pretty cool for a lot of reasons. CBT has been demonstrated to be effective and is widely believed to be the treatment of choice, but several approaches with diverse rationales and methods have also been shown to be effective: eye-movement desensitization and reprocessing, cognitive therapy without exposure, hypnotherapy, psychodynamic therapy, and present-centered therapy. The above meta-analysis comparing these treatments found all of them about equally effective. What is remarkable here is the diversity of methods that achieve about the same results. Two of the treatments, cognitive therapy without exposure and present-centered therapy, were designed to exclude any therapeutic actions that might involve exposure (clients were not allowed to discuss their traumas because that invoked imaginal exposure). Despite the presumed extraordinary benefits of exposure for PTSD, the two treatments without it, or in which it was incidental (psychodynamic) were just as effective.

To punctuate the point that it is the more powerful general effects of delivering a model of treatment v. the specific effects of a given model, consider “present centered therapy” mentioned above as a treatment that works for PTSD. Researchers testing the efficacy of CBT for (PTSD) wanted a comparison group that contained curative factors shared by all treatments (warm empathic relationship) while excluding those believed unique to CBT (exposure). This control treatment, present centered therapy (PCT), contained no treatment rationale and no therapeutic actions. Moreover, to rule out any possibility of exposure, even covert in nature, clients were not allowed to talk about the traumatic events that had precipitated therapy. PCT was, of course, found to be less effective than CBT—it wasn’t really a treatment with professed “active” ingredients. However, when later a manual containing a rationale and condition-specific treatment actions was added to facilitate standardization in training and delivery, few differences in efficacy were found between PCT and CBT in the treatment of PTSD (McDonagh et al., 2005). In fact, significantly fewer clients dropped out of PCT than CBT. Thus, when PCT was made to resemble a bona fide treatment, that is, it added placebo, expectancy, and allegiance variables, it was not only as effective but also more acceptable than CBT.

Speaking of evidence based treatments, just got back from a debate about it in Wilmington, NC which was great fun. But even better was that I ran across list member Chris Hall who has written a beautiful article that deconstructs evidence based practice from a practitioner’s point of view. Even beyond the dodo verdict and all the other empirical arguments, Chris presents an elegant argument about why it just does not make clinical sense. Check it out:

Although certainly holding sway over many and unfortunately many states and governing bodies are still holding on to idea that some approaches should be implemented, I believe the whole idea is on the downturn and will be soon looked at as an unhelpful fad. Consider an article just published in Journal of Consulting and Clinical Psychology by Webb, DeRubeis, and Barber, a meta-analysis examining the relationship between adherence to and competence in delivering a particular approach and outcome. The conclusion (drum roll please): “neither adherence nor competence was…related to patient outcome and indeed that the aggregate estimates of their effects were very close to zero.” They also discuss how most studies of competence are confounded by the alliance, a point made by Littell in her chapter in the Heart and Soul of Change and evident to anyone that reads a treatment manual.

Also check out David Elliott’s new video describing the ASIST program. While many if not most of you already understand what ASIST offers, it will be a great introduction for folks just getting their feet wet. And as I am finding out, many will look at a video long before they will read!

Finally, I am very pleased to announce that Brian DeSantis has joined the Project as a Leader. Brian and I go way back—we were graduate students together. His area of expertise is integrated health care, and Brian has been applying CDOI in primary care for some time. And as he recently posted, he was also instrumental in getting the University of the Rockies on board with the ORS/SRS. Read about Brian here.

The upcoming conference in New Orleans will present the latest findings about the common factors—what works in therapy—and will demonstrate how to deliver them via client based outcome feedback. The common factors have a storied history that started with Saul Rosenzweig’s (1936) classic article “Implicit Common Factors in Diverse Forms of Psychotherapy.” In addition to the original invocation of the dodo bird and seminal explication of the common factors of change, Rosenzwieg also provided the best explanation for the common factors, still used today. Namely, given that all approaches achieve roughly similar results, there must be pantheoretical factors accounting for the observed changes beyond the presumed differences among schools.

In 1936, writing in the American Journal of Orthopsychiatry, Rosenzweig observed that no form of psychotherapy or healing is without cures to its credit. Concluding that success is therefore not a reliable guide to the validity of a theory, he suggested that some potent implicit common factors, perhaps more important than the methods purposely employed, explained the uniformity of success of seemingly diverse methods. Rosenzweig summarized these common factors in addition to the therapeutic relationship:
(1) the operation of implicit, unverbalized factors, such as catharsis, and the yet undefined effect of the personality of the good therapist; (2) the formal consistency of the therapeutic ideology as a basis for reintegration; (3) the alternative formulation of psychological events and the interdependence of personality organization as concepts which reduce the effectual importance of mooted differences between one form of psychotherapy and another (p. 415).

Preparing for the conference in New Orleans, once again, stimulated my reflections about the person who started it all. On August 9, 2004, Saul Rosenzweig died at the age of 97. Rosenzweig’s prolific accomplishments, over 225 publications, are notable in surprisingly varied contexts: his seminal discussion of experimenter bias (Rosenzweig, 1933), the correspondence with Freud (Rosenzweig, 1985), the Picture-Frustration Study (Rosenzweig, 1976), his response to Eysenck’s (1952) critique of psychotherapy (Rosenzweig, 1954), and his New York Times acclaimed analysis of Freud’s visit to the US (Rosenzweig, 1992). And of course, germane here, he published the first known proposal for the common factors in 1936 at the ripe old age of 29.

I invite you to read Rosenzweig’s seminal contribution so that you may experience firsthand how far four journal pages can reach—laying the groundwork for common factors and predicting perhaps the most replicated finding in all of psychotherapy, the dodo verdict. I also invite you into my conversation with him that sheds light on his sources of inspiration for both the common factors and the first invocation of the dodo bird. His first person account of the historical context—where and how the common factors journey started—enables readers to more fully appreciate where we are now.

I think it important to remember where ideas come from and to credit those whose shoulders we now stand. In fact, I believed this to be so important that I persevered to include a tribute to Saul in the prologue of the new edition of the Heart and Soul of Change. His contribution warranted that at the very least.

I had the great privilege to spend some time with Saul on several occasions and he was a pure delight, witty and still quite active in his work. My interview of him for the Journal of Psychotherapy Integration is one of the high points of my career. So that you might enjoy a flavor of what he was like, check out the video of when Saul was presented the Heart and Soul of Change award back in 2002.

Of course a lot has happened with the common factors since Saul first wrote about them. I’ll pick up with Jerome Frank next time.