So I think students need to understand the value of treatment models within a developmental context and an understanding of the general aspects that models bring to the table.

The next larger context is the alliance. In an important way, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. The alliance cannot happen without technique. If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity. Although it is possible for a strong relationship to develop, there can be no agreement about the tasks of therapy, a critical aspect of the alliance, without some discussion and negotiation of what “treatment” will be used—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

The issue of resonance and the agreement about tasks—finding a framework for therapy that both the therapist and the client can believe in—is why it makes a lot of sense to ask clients about their ideas about how to proceed, or at the very least getting client approval of any intervention plan. Not surprisingly, Frank and Frank (1991) said it best: “Ideally, therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem’’ (p. xv). But Frank was not the first and in fact the idea of matching client preferences and worldview goes back to Paul Hoch, Milton Erickson, and the MRI. Traditionally, such a process has not been the case—the search has been for interventions that promote change by validating the therapist’s favored theory. Serving the alliance requires taking a different angle—the search for ideas that promote change by validating the client’s view of what is helpful—or what I have called, based on the work of Erickson and the MRI, the client’s theory of change (Duncan et al., 1992; Duncan & Moynihan, 1994). Here is an article about the client’s theory of change:

Finally, the third context is regarding evidence based treatment itself and the difference between evidence based treatments and evidence based practice as defined by APA. Jeff Reese and I recently wrote a chapter about this and I will post it after it is published. They are two fundamentally different approaches to defining and disseminating evidence (Littell, 2010; see her chapter in Heart and Soul of Change)—one that seeks to improve clinical practice via the dissemination of treatments meeting a minimum standard of empirical support (EBT) and another that describes a process of research application to practice that includes clinical judgment and client preferences (EBP). That psychotherapists might possess the psychological equivalent of a “pill” for emotional distress resonates strongly with many, and is nothing if not seductive as it teases the desire to be as helpful as possible to clients. A treatment for a specific “disorder,” from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. This is the essence of an EBT approach, characterized by Division 12, depicting confidence in the available evidence and appealing to those who believe that more structure and consistency and less clinician judgment is needed to bring about positive outcomes in mental health and substance abuse services. On the other hand, EBP reflects the understanding that scientific evidence is tentative and that outcome is dependent not only on applying the various types of empirical research but also on the participants. EBP appeals to those who value clinician autonomy and individualized treatment decisions based on unique presentations of clients. The APA Task Force definition on EBP exemplifies this approach to the evidence: “the integration of the best available research with clinical expertise in the context of patient [sic] characteristics, culture, and preferences” (APA Task Force 2006, p. 273).
The first part, “the integration of the best available research,” includes the consideration of EBTs without privileging them, as well as the wide range of findings regarding the alliance and other common factors. Next, “with clinical expertise,” in contrast to the EBT mentality of the therapist as an interchangeable part, brings the therapist into the equation—highlighting what therapists bring is consistent with emerging research about the importance of clinician variability to outcome. Moreover, the Task Force submitted: “Clinical expertise also entails the monitoring of patient progress…” (APA, 2006, p. 276–277). Finally, “in the context of patient characteristics, culture, and preferences” rightfully emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations, how well any model or technique resonates. In short, EBP accommodates the common factors, reinforces the importance of the therapist and client, and includes client feedback as a necessary component.

So if these larger contexts of understanding EBTs are included, I believe that EBTs should be taught in graduate training programs. Graduate training should call for a more sophisticated and empirically informed clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches, there is indeed differential effectiveness for the client in the room now—therapists need expertise in a broad range of intervention options, including evidence based treatments, but must remember that the proof of the pudding is in the taste.

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When you consider the research of antipsychotics with kids (the TEOSS study found that only 12% of kids benefited from antipsychotics and that serious adverse events were all but guaranteed), this is quite a distressing situation. My presentation and the resulting paper will call for a higher standard of prescriptive care. Where children are concerned, the stakes are higher. They are, essentially, involuntary patients—most do not have a voice to say no to treatments or devise their own, and depend on adults to safeguard their wellbeing (Sparks & Duncan, 2008). Moreover, poor children often have fewer adults watching over them and are vulnerable to dangerous drugs used as interventions of control rather than therapy, and therefore require more care to ensure equitable treatment. The evidence demands that the trend of rising prescriptions and lower psychosocial intervention be stopped and a higher standard of care implemented: 1) psychosocial intervention should be considered first–families and youth should have a voice in decisions about their care, especially the disenfranchised; 2) no off label prescribing; 3) no polypharmacy; 4) immediate separation of the pharmaceutical company influence from science and practice; and 5) monitoring treatment response with consumer rated measures. My presentation will call for a higher standard of care for our most vulnerable and precious commodity, our children, that invites unity among all concerned health professionals. It is time to no longer accept prescriptive practices that do not follow the evidence and increasingly put clients at perilous risk for serious health consequences, dependence, and disability. Read more about psychiatric drugs here and watch a video here.

On another note, we have applied for evidence based treatment status with SAMHSA thanks to the Norway Feedback Trial (congrats to Morten Anker on his Ph.D., just conferred this week) and the two RCTs by Jeff Reese. I’ll keep you posted.

Finally, don’t forget the free webinar this month about my book, On Becoming a Better Therapist: November 23rd at 6:00 PM Central. Register now!

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.

Ignoring the Evidence
Why do psychologists reject science?
By Sharon Begley | NEWSWEEK

Published Oct 2, 2009

From the magazine issue dated Oct 12, 2009

It’s a good thing couches are too heavy to throw, because the fight brewing among therapists is getting ugly. For years, psychologists who conduct research have lamented what they see as an antiscience bias among clinicians, who treat patients. But now the gloves have come off. In a two-years-in-the-making analysis to be published in November in Perspectives on Psychological Science, psychologists led by Timothy B. Baker of the University of Wisconsin charge that many clinicians fail to “use the interventions for which there is the strongest evidence of efficacy” and “give more weight to their personal experiences than to science.” As a result, patients have no assurance that their “treatment will be informed by science.” Walter Mischel of Columbia University, who wrote an accompanying editorial, is even more scathing. “The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment,” he told me, and there is a “widening gulf between clinical practice and science.”

The “widening” reflects the substantial progress that psycho-logical research has made in identifying the most effective treatments. Thanks to clinical trials as rigorous as those for, say, cardiology, we now know that cognitive and cognitive-behavior therapy (teaching patients to think about their thoughts in new, healthier ways and to act on those new ways of thinking) are effective against depression, panic disorder, bulimia nervosa, obsessive-compulsive disorder, and -posttraumatic-stress disorder, with multiple trials showing that these treatments—the tools of psychology—bring more durable benefits with lower relapse rates than drugs, which non-M.D. psychologists cannot prescribe. Studies have also shown that behavioral couples therapy helps alcoholics stay on the wagon, and that family therapy can help schizophrenics function. Neuroscience has identified the brain mechanisms by which these interventions work, giving them added credibility.

You wouldn’t know this if you sought help from a typical psychologist. Millions of patients are instead receiving chaotic meditation therapy, facilitated communication, dolphin-assisted therapy, eye-movement desensitization, and well, “someone once stopped counting at 1,000 forms of psychotherapy in use,” says Baker. Although many treatments are effective, they “are used infrequently,” he and his coauthors point out. “Relatively few psychologists learn or practice” them.

Why in the world not? Earlier this year I wrote a column asking, facetiously, why doctors “hate science,” meaning why do many resist evidence-based medicine. The problem is even worse in psychology. For one thing, says Baker, clinical psychologists are “deeply ambivalent about the role of science” and “lack solid science training”—a result of science-lite curricula, especially in Psy.D. programs. Also, one third of patients get better no matter what therapy (if any) they have, “and psychologists remember these successes, attributing them, wrongly, to the treatment. It’s very threatening to think our profession is a charade.”

When confronted with evidence that treatments they offer are not supported by science, clinicians argue that they know better than some study what works. In surveys, they admit they value personal experience over research evidence, and a 2006 Presidential Task Force of the American Psychological Association—the 150,000-strong group dominated by clinicians—gave equal weight to the personal experiences of the clinician and to scientific evidence, a stance they defend as a way to avoid “cookbook medicine.” A 2008 survey of 591 psychologists in private practice found that they rely more on their own and colleagues’ experience than on science when deciding how to treat a patient. (This is less true of psychiatrists, since these M.D.s receive extensive scientific training.) If they keep on this path as insurers demand evidence-based medicine, warns Mischel, psychology will “discredit and marginalize itself.”

If public shaming doesn’t help, Baker’s team suggests a new accreditation system to “stigmatize ascientific training programs and practitioners.” (The APA says its current system does require scientific training and competence.) Two years ago the Association for Psychological Science launched such a system to compete with the APA’s.

That may produce a new generation of therapists who apply science, but it won’t do a thing about those now in practice.

Find this article at
http://www.newsweek.com/id/216506

My Response
There are many inaccuracies in this story—not the least of which is the distortion of APA’s definition of evidence based practice, which unequivocally does not give equal weight to the personal experiences of the clinician and scientific evidence—but I will focus here on the “evidence” claiming that the noted approaches are the most effective. Perhaps clinicians are ignoring the researchers quoted in the article because the brand of evidence they are selling is not credible or relevant to their work. They fail to mention the most replicated piece of evidence in the psychological literature: Namely, that no one treatment model, including the cognitive and cognitive behavioral models canonized in the article, have reliably shown any superiority over other treatments. Moreover, treatment models account for a very small amount of the variance of change. As just one example of these robustly demonstrated findings, consider the landmark NIMH study of depression in which cognitive behavioral therapy was compared to interpersonal therapy and antidepressants. No differences emerged between the treatments—they all worked about the same (although the talk therapies did better at follow-up). Treatment model differences accounted for only 2% of variance of change. What did explain the changes achieved by the clients? The quality of the relationship/alliance between the clinician and the client accounted for 21% of the variance. The person of the clinician, not what treatment was delivered explained another 8%. This is why clinicians don’t rally around the flag of different treatments making false claims about superior effectiveness. They know that other factors are far more important—psychotherapy is a richly nuanced interpersonal event that defies being reduced to a diagnosis and treatment model.

The much ballyhooed models have only shown themselves to be better than sham treatments or no treatment at all, which is not exactly news to write home to mom about. Think about it. What if one of your friends went out on a date with a new person, and when you asked about the guy, your friend replied, “He was better than nothing—he was unequivocally better than watching TV or washing my hair.” (Or, if your friend was a researcher: “…he was significantly better, at a 95% confidence level, than watching TV or washing my hair). How impressed would you be?

Finally, the success of any treatment is not guaranteed regardless of its evidentiary support or the expertise of the therapist. As the APA Task Force noted, the response of the client is variable and therefore must be monitored and treatment tailored accordingly to ensure a positive outcome. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve treatment outcomes regardless of the treatment administered, a far more powerful influence on outcome that the specific approach administered.