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According to the
editors of this book, the question of whether or not psychotherapy is
effective has been positively settled in the affirmative by more than
forty years of substantive research. But the question of why it
is effective remains a point of contention among both researchers and
practitioners. Some researchers assert that specific techniques or
treatment approaches can and should be designed for specific disorders
or symptoms, and that this "empirically validated treatment" (EVT)
approach is what will save psychotherapy in the age of managed care.
Other researchers disagree. A primary assertion of this book is that the
recent move among some professionals toward EVT is a step in exactly the
wrong direction. The authors report that the bulk of the empirical
research efforts in this area have failed to correlate positive outcomes
with specific techniques, and they suggest that such correlations will
likely never be found. The majority of the thirteen articles that make
up The Heart and Soul of Change was chosen by the editors to
support the position that the effectiveness of psychotherapy is due
primarily to client factors and the therapeutic relationship, not to the
expertise of, nor the techniques employed by, adherents of specific
theoretical orientations. In the introductory
chapter, the editors briefly review previous works and research that
have identified what are called "the big four" factors in
therapeutic effectiveness. Client factors are reported to make up a
substantial 40% of the variance found in treatment outcome; these
factors are defined as "what clients bring to the therapy room and
what influences their lives outside it" (p. 9), e.g., personal
history and personality characteristics. Relationship factors, meaning
the pan-theoretical qualities of the therapist, such as warmth, caring,
empathy and etc., are said to account for another 30% of outcome
variance. Placebo effects, hope and expectancy represent another 15% of
outcome variance, with only the last 15% left to account for variance
associated with theoretical models or specific techniques. The chapters
that follow are broadly divided into four sections: (1) the existing
empirical support for the common factors view of therapy effectiveness,
(2) a detailed examination of each of the four factors, (3) the role of
these factors in a variety of domains and settings, and (4) the
implications of the common factors position for reimbursement systems
and clinicians. The first section’s
review of the research on therapy outcome affirms that psychotherapy has
been shown effective with a broad range of problems and with many types
of clients. This is very reassuring news for both clients and therapists
and, possibly, for third-party payers. However, an effectively
operationalized definition of positive outcome is not provided in this
book, and a serious consideration of this issue would have been very
welcome to the reader. Treatment success is global and abstract rather
than specific and clear, as shown in the explanation in one of the book’s
chapters that "[i]n most cases, clients are not ‘cured,’ but
helped to achieve improved functioning . . . and more productive or
meaningful relationships" (p. 165). In fact, although
this book does not take up the issue, the definition of treatment
success is a matter of some abstraction in the professional literature
as well. Major sources of difficulty involve definition and measurement.
Is success to be measured in client satisfaction? One author in this
book observes, "there is no reason to believe that a high degree of
[client] satisfaction is necessarily a sign of successful outcome"
(p. 395). Functional or real-life changes would be a more precise
indicator of success, but because of the obvious and numerous problems
to be overcome in the measurement of such real-life outcomes, the
primary tool used to measure therapy success is client self-report.
Unfortunately, the serious threats to validity in self-report methods
are difficult, perhaps impossible, to adequately manage. (See, for
example, Schwarz, 1999.) In managed care and community mental health
settings, successful outcome is also often couched in terms of cost
containment the client who requires significantly fewer services this
year than last has received successful treatment. The second section
of Heart and Soul provides chapters that address in more detail
the most relevant client factors, the therapeutic relationship, and the
role of hope or expectancy. An additional article discusses the
usefulness of therapy models, even in the absence of empirical data that
supports one model over another. Of particular note in one chapter is
the claim that "it is now possible to predict who signs up, shows
up, finishes up, and ends up better off as a result of therapy" (p.
228). If one accepts the premise that certain client characteristics are
essential to predicting therapy success, and if it is truly possible to
identify which clients currently show such characteristics, then the
client recruitment and selection processes can be refined and treatment
success rates can be maximized. This would be of equal interest to
therapists, researchers and managed-care funding sources. The chapters of the
"Special Applications" section of the book are not as directly
relevant to the general psychotherapist but are interesting nonetheless.
The role of the placebo effect is explored and related to the positive
client characteristics of optimism, expectancy and hope. The use of
psychoactive medications is discussed, and the correlations of their
effects with other therapeutic and situational factors are noted:
"Medication response can be readily altered by who delivers the
drug, how its properties are described [to the patient], the degree of
familiarity with the setting in which it is presented, and the ethnic
identity or socioeconomic status of the person ingesting it" (p.
301). This may help explain why medications and therapy are sometimes
found to be more effective than either alone. The final section
of the book highlights the growing importance of therapy outcome
research to managed care and third party reimbursers. Important findings
derived from the rapidly growing therapy client database include the
remarkable variability of therapy success overall, the unhelpfulness (so
far at least) of the EVT approach, the significant differences among the
outcomes achieved by different therapists and systems, and the
predictability of eventual therapy outcome after only a few sessions. One nagging
question that remains after finishing this provocative book, if the
authors’ claims about the centrality of client factors are correct, is
whether there is really much value in the rigorous training of
therapists, at least in the areas of technical skills and theoretical
models. Perhaps training programs could more profitably select trainees
based on their personal characteristics and provide to this select group
of apprentices an abbreviated course of preparation largely focused on
general relationship skills and professional ethics, and that would be
enough. Both the increasing demand of the marketplace to know the value
of what is bought, and the growing predilection of public mental health
departments to design programs around paraprofessionals suggest this
question is not just academic. Reference Schwarz,
N. (1999). Self-Reports: How the Questions Shape the Answers. American
Psychologist, 54(2), 93-105. |