What makes psychotherapy research unique

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Journal of Consulting and Clinical Psychology, 78 , Zilcha-Mano, S. Is the alliance really therapeutic? A recent study compared the benefits of 7 major psychotherapies for depression and concluded that none were more or less effective than the others.

When we compare effect sizes of different psychotherapies on particular patient diagnoses, we find that there are no significant differences among psychotherapy approaches. This applies whether we are looking at different treatments for adults with particular diagnoses, for youths, for couples and families, or for those with alcohol and drug abuse.

The research, however, does not support this. Psychotherapy is an effective treatment for many mental disorders, and it is a valuable adjunct treatment for most others. While most research has demonstrated robust benefits for the neuroses-type disorders involving anxiety or depression, recent research has demonstrated significant benefit for patients with psychotic disorders and even to those with some neurological disorders such as Alzheimer disease. This article provides both a strong endorsement of referring patients for psychotherapy and a dilemma.

It indicates that the research discriminating between the benefits of different types or schools of psychotherapy is weak. It also indicates that the particular therapist is a potent factor for outcome and that ongoing measurement of therapeutic progress and therapeutic alliance offers substantial benefit.

The dilemma is that at this time there is no systematic way to find out which therapists are most effective or to measure progress and alliance. The research strongly supports referring patients for psychotherapy.

The dilemma of finding effective psychotherapists may be best solved by developing referring relationships with a small number of therapists who report measuring progress and alliance and by obtaining feedback from your patients to verify their effectiveness.

In their meta-analysis, Ahn and Wampold 17 examined the effects of removing components of psychotherapeutic treatments and found no evidence that removing or adding a specific ingredient altered outcomes. These conclusions are not, predictably, without their detractors.

Schools of psychotherapy can be fiercely tribal in defending the superiority of their approaches. In a recent article, the research data were interpreted as indicating that psychodynamic psychotherapy is as effective as or more effective than other forms of therapy and was met with inevitable critiques from advocates of other approaches. A greater challenge to the equivalence conclusion comes from studies that have randomly assigned patients with a given diagnosis to receive different forms of psychotherapy.

While there are many such studies, and some do find apparent superiority of one treatment over another, how these apparent differences should be interpreted is a source of dispute. Treatments that are intended to be therapeutic, that the therapist believes in, and for which there is a compelling rationale work. There are characteristics of psychotherapy that lead to poor or damaging outcomes; others predict good outcomes. The data indicate that some therapists are consistently better than other therapists, that therapeutic relationship factors account for much of the variability in outcome attributable to psychotherapy, and that a major way that better therapists achieve their better outcomes is through enhancing the therapeutic relationship.

Consistent with this, patients do not emphasize particular psychotherapies or methods when accounting for their improvement but instead emphasize the relationship with their therapists.

Each psychotherapy includes different active ingredients that promote patient improvement. Given the complexity of human beings and their brains, it is foolhardy to suggest that there is only one way to help someone with emotional distress.

What we find, however, is that these ingredients do not work very well unless the person delivering them is genuinely caring and empathic, and able to form a solid therapeutic alliance with the patient.

Similar results are found when we examine the effectiveness of antidepressant medication. The most effective psychiatrists helped their patients more using placebo than did the less effective psychiatrists who treated their patients with an antidepressant.

While the field of psychotherapy absorbs the evidence, which suggests that different approaches are equivalent, the biggest shift in psychotherapy practice in recent years has been toward the systematic measurement of patient progress and therapeutic alliance. A pervasive human foible that physicians and psychotherapists do not escape is the belief that we are all better than average. Psychotherapists tend to believe that we have good rapport and alliances with our patients and that our effectiveness with our patients is better than that of most other therapists.

For the most part, we draw these conclusions without much evidence. It turns out that collecting these data in a consistent way actually is a potent way of increasing therapeutic effectiveness.

When patients are not experiencing a good alliance with the therapist, these tools allow the therapist to find out immediately and to take steps to improve it or refer the patient to another therapist. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential to [evidence-based practice in psychology] EBPP.

Psychiatrist David Burns, 32 who popularized cognitive-behavioral therapy through his best-selling books eg, Feeling Good , serves as a good example for the transformation that is taking place in psychotherapy.

Almost 30 years ago, the American Psychiatric Association convened a Commission on Psychotherapies to review and integrate the research data that were available at that time. Controversy still reigns over the question of whether certain types of therapy are more effective than other types for certain kinds of problems. What has also not been adequately studied is what aspects or elements of the complex therapeutic interaction are relatively the most effective… Psychotherapy is a highly complex set of interactions that take place between individuals over an often indeterminate period of time.

It is an open-ended, interactive feedback process in contrast to the closed, one-way causation that is typical of most laboratory research. Research has not as yet been able to fully document these complex sets of interactions. Although there has been a veritable explosion of psychotherapy research over the past few decades, it has not provided the simple answers we were seeking. Unfortunately, at this point there is little available guidance on which psychotherapy is most effective and which psychotherapists will best serve your patients.

BP wrote most of the introduction, the part about RCTs, and the discussion. FF wrote most of the part about process research. We have sent the developing manuscript back and forth to each other and made revisions.

The submitted version is approved by both. Both authors have contributed to the manuscript. No external funding for this article. Open access publication fees are paid by Stockholm University Library.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: a quarter century on.

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Fonagy P, Luyten P.