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Research In Psychotherapy
Furhan Iqbal
Cambridge [email protected]
‘In Psychoanalysis there has existed from
the first an inseparable bond between
cure and research’.
Freud (1926).
Is psychotherapy scientific or
hermeneutic?
Evidence based medicine and the search
for scientific evidence
Hierarchies of evidence
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Meta-analysis
RCT
Case-control studies
Cohort studies
Surveys
Case reports
Qualitative and Quantitative research
Evidence is dependent on research
However……!
The research agenda itself is influenced by social, cultural,
political and economic factors
and influence
What should be researched and why?
How should the research take place and how shall it be
funded?
The essential research question for
clinicians….!
Paul’s Litany
‘What treatment, by whom is most effective for this individual
with this specific problem and under which set of
circumstances?’
History of research in Psychotherapy
Psychotherapy has concerned itself with two areas of research
i.e. outcome and process of psychotherapy
Outcome
‘Is psychotherapy effective?’
Process
‘If psychotherapy is effective what makes it so?’
Process V Outcome Research
Outcome:
Is psychotherapy effective?
Which psychotherapy is more effective?
How can treatments be made more cost effective?
Process:
Are there objective methods for evaluating process?
What components of psychotherapy are related to outcome?
How does change occur in psychotherapy?
Eysenk (1952) critique of the
effectiveness of psychotherapy
Conducted a meta analysis and severely criticised
psychotherapy (psychodynamic) as being ineffective.
Concluded that two thirds of neurotics treated with nonbehavioural psychotherapy improved over 2 years
compared with an equal proportion of individuals not
receiving treatment over 2 years
Severely criticised but triggered research in the area
Lambert and Bergin (1978)
Criticised the handling of data by Eysenck suggesting
that he used more stringent criteria to calculate
improvement for those in receipt of psychotherapy
and using more liberal criteria to calculate
spontaneous improvement (43% compared with
Eysenck’s claim of 67%) in the group not in receipt of
treatment.
They also concluded from his data that individuals
treated by psychotherapy improved more rapidly.
Sloane et al. (1975)
Compared psychodynamic psychotherapy and
behavioural treatment with a waiting list control using
an average of 14-session duration of treatment in 90
subjects with 30 randomly assigned to each group.
Concluded that behavioural and psychodynamic
treatment groups were broadly similar in terms of
improvement both being vastly superior to the waiting
list control.
They also found that the gains in both treatment groups
were maintained at follow up.
Smith and Glass (1977)
Meta-analysis of 475 controlled studies (treatment Vs.
no treatment) using 18 different therapies
Concluded that psychotherapy was more effective
than no treatment with an average effect size of 0.85
(range 0.18 for reality therapy-2.38 for cognitive
therapy)
Further meta-analysis of studies in psychotherapy
confirm these findings despite improvements in
techniques and more recent studies
Models of Research in psychotherapy and
its application in clinical practice
Two dominant models exist
1. The hourglass model and
2. Benchmarking
The hourglass model (Salkovskis, 1995)
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Development of new treatment or technique
evaluated in efficacy studies
evaluated in effectiveness studies
implemented in clinical practice
Problems with delay in translating treatments to clinical
practice and actual implementation in clinical practice
outside studies generally poor
Benchmarking (Parry and Richardson,
1996)
The effectiveness of psychotherapy is evaluated in clinical
setting using before and after evaluation.
Overcomes the difficulties in the previous model and is much
more clinically relevant
Plagued by the lack of a comparison group
Heterogeneity Vs. Homogeneity
Clinical samples are heterogenous not only in terms of
diagnoses but also on a range of other measures compared
with samples used in RCTs with attempts to maintain
homogeneity
Studies relying on homogeneity will give reliable results but
lose out on generalisability and therefore will be of less
clinical relevance
The Equivalence Paradox
Referred to by Luborsky as ‘The Dodo bird verdict’
‘All have won and so all must have prizes’ (Alice in
Wonderland)
Bergin and Garfield (1994)
‘ We have to face the fact that in a majority of studies,
different approaches to the same symptoms for example
depression show little difference in efficacy’
Stiles, Shapiro and Elliott (1986)
‘Are all psychotherapies equivalent?’
Possible explanations:
• Lack of stringency in research methods
• Different therapies are equivalent due to the overriding
effect of common factors
New research strategies need to be developed to detect
differences
Michael Barkham differs and suggests
that
‘Equivalence occurs after therapies have had their
impact…different processes leading to similar changes’
Common factors in Psychotherapy
It is thought that common factors in psychotherapy account
for much of the positive effects seen in psychotherapy
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Instillation of hope
Congruence of expectations of therapist and patient
Presence of an explanatory structure
Optimal levels of emotional arousal
Development of a sense of mastery
Intense, emotionally charged confiding relationship
The Drug metaphor….!
Psychological interventions are conceptualised as the
equivalent of a drug and hence there impact may be
evaluated in similar ways
It implies that ‘pure’ and ‘unadulterated’ forms of treatment
are more effective
Lead the way in developing methodologically rigorous
studies in psychotherapy
Fails to take into account individual difference in therapists
The development of treatment manuals
An attempt to purify the treatment delivered, which can then
be subjected to the rigorous evaluation demanded in our
current world
‘It is foolish to believe that the use of manuals alone will
‘standardise’ a therapy. The actual delivery of of therapy is
dependent on the contributions and interactions that take
place between people’ Koss and Shaing, 1994)
Treatment integrity
Simply defined as the extent to which treatment procedures
carried out as intended
The concept was intended to cover three different aspects
• adherence (therapist using procedures characteristic of the
model)
• competence (defines the appropriate delivery of predefined
elements)
• differentiation (refers to whether treatments differ along
critical dimensions)
Levels of competence of therapist
Milne et al (1999) attempt to grade competency of therapist
(they recognise that some therapists may even be harmful)
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Novice
Advanced beginner
Competent
Proficient
Expert
Interestingly they refer to the expert as
‘The therapist no longer uses rules, guidelines or maxims. He
or she has deep tacit understanding of the issue and is able
to use novel problem solving techniques. The skills are
demonstrated even in the face of difficulties (e.g excessive
avoidance)’
Clearly in such cases the type of therapy and techniques
involved are more difficult to define and subsequently
measure.
Psychotherapy…claims of the therapist
and reality….!
The Menninger project (Wallerstein, 1986)
Intensive study spanning 25 years starting in 1954
Detailed information including transcripts available to
researchers
42 patients included for intensive study comparing
psychoanalysis with psychoanalytic therapy
No difference between 2 groups in terms of outcome
By the end of therapy only 6/22 remained within the
parameter of classical psychoanalysis
Main conclusions
• Positive dependent transference correlated with successful
treatment outcome
• Weak relationship between insight and change
• For a highly disturbed group of patients the best form of
therapy was ‘supportive-expressive’ and long term
alongside other forms of both formal and informal support
• Kernberg (1975) suggested the use of a modified analytic
approach in the treatment of this highly disturbed group
The Sheffield Psychotherapy Projects I
and II
Comparison of CBT and PIT
Both treatments found to be equally effective in the treatment
of depression
16 sessions were found to be superior to 8 sessions of PIT
Since then the results have been replicated and effectiveness
studies have been conducted
The dose response curve
• Howard et al (1986)
• Improvement in psychotherapy follows a negative
logarithmic curve
• 75% of total improvement seen in first 30 session
The sleeper effect
Improvement is seen only after some time and hence the need
for long term evaluation of outcomes in psychotherapy
Therapeutic alliance
Therapeutic alliance is the most consistent and reliable
predictor of outcome in psychotherapy
It essentially refers to
• Therapeutic bond between patient and therapist
• Agreement about the task of psychotherapy
• Agreement about the goals of psychotherapy
Can meaning be quantified….Core
Conflictual Relationship Theme (CCRT)
• Tool devised by Luborsky and Crits-Christoph to study
transference (Process) in psychodynamic psychotherapy
• Clients bring to session Relationship Episodes (RE).
Consists of a wish in relation to another person, the
response of the other and the subsequent response of the
individual to the other person’s response
• CCRT pervasiveness decreases in the course of successful
treatment
Attachment theory
Developed from research findings emphasising the
importance of attachment in humans
Seeking of attachments considered to be innate and crucial for
the development of the infant
Describe secure versus insecure attachment patterns
Well researched using tools
Strange situation test (Ainsworth)
Adult attachment interview (Main)
Immense interest in its application to psychotherapy and
attempts are now being made to bridge the gap between
psychoanalysis and attachment theory
Psychotherapy and personality disorders
Good evidence that psychotherapy is effective in the
treatment of personality disorders
Leichsenring and Leibing (2003)
Meta analysis of cognitive therapy and psychodynamic
psychotherapy
Both were effective in the treatment of personality disorders
Conclusions in relation to psychotherapy
research
Psychotherapy research is realistic
The efficacy of psychotherapy is borne out in studies on a
range of outcome measures
The research is far from perfect and these issues are now
being addressed
The best evidence in psychotherapy especially is not
generated by one method and is probably accumulated
using a variety of different strategies to answer different
research questions