1. Psychology 6104 How Effective is Psychotherapy?
Incorporating a BPS Approach to Psychotherapy Dr. Kim Vaughn
October 2014 Jacqueline Flowers
2. What is Psychotherapy? Is Psychotherapy Effective? Are the
Benefits of Psychotherapy Clinically Significant? Do the Benefits
of Psychotherapy Last? How does the Effectiveness of Psychotherapy
Compare to Medication? Does Psychotherapy Work for Everyone? Do All
Therapies Work Equally Well? How Do We Explain the Effectiveness of
Psychotherapy? Lamberts Four Factors Wampolds Therapist Competence
Measuring Therapist Competence If Therapies are fairly Equivalent
what about What else accounts for the effectiveness of therapy?
Reducing Treatment Failures by Broadening Treatment Options by
Monitoring and Outcome Assessment By Evidence Based Practice A
Biopsychosocial Model The Focus of the BPS Approach to Therapy A
BPS Treatment Approach
3. What is Psychotherapy? According to the Canadian Counselling
and Psychotherapy Association Definition of counselling:
Counselling is a relational process based upon the ethical use of
specific professional competencies to facilitate human change.
Counselling addresses wellness, relationships, personal growth,
career development, mental health, and psychological illness or
distress. The counselling process is characterized by the
application of recognized cognitive, affective, expressive,
somatic, spiritual, developmental, behavioural, learning, and
systemic principles. Who are Counsellors? Canadian Counselling and
Psychotherapy Association. (2014). Retrieved from
http://www.ccpa-accp.ca/en/theprofession/whoarecounsellors/ On the
American Psychological Association web page they define
psychotherapy as follows: Psychotherapy is a collaborative
treatment based on the relationship between an individual and a
psychologist. Grounded in dialogue, it provides a supportive
environment that allows you to talk openly with someone whos
objective, neutral and nonjudgmental. You and your psychologist
will work together to identify and change the thought and behavior
patterns that are keeping you from feeling your best.
4. Is Psychotherapy Effective? The evidence supporting the
effectiveness of psychotherapy is extensive o Meta analyses of
studies on the effectiveness of psychotherapy show effect sizes
ranging from 0.75 and 0.85 o Wampold (2001) concluded that a
reasonable and defensible point estimate for the efficacy of
psychotherapy would be .80 (Melchert 2011)
5. Are The Benefits Of Psychotherapy Clinically Significant?
Lambert and Archer (2006) concluded that approximately three
quarters of patients who undergo treatment show positive benefits,
and 40-60% return to a state of normal functioning. (Melchert,
2011) The average client receiving psychotherapy is better off than
79% of untreated clients. Although psychotherapy does not work
perfectly or for all clients, it is, simply put, remarkably
effective. (Campbell et al, 2013)
6. Do The Benefits Of Psychotherapy Last? There tends to be
some decay in the psychotherapy benefits over time for most
psychotherapies, though the decay is far less than for psychotropic
medicationsthe benefits of some therapies have actually been found
to increase over time. (Melchert 2011)
7. How Does the Effectiveness of Psychotherapy Compare with
Medications? www.apa.org/psychotherapy "Psychological interventions
have generally been shown to be equal or greater in effectiveness
than medicines for a range of psychological disorders except for
the most severe conditions such as schizophrenia and bipolar
affective disorder" (as cited in Hunsley et al, 2014) DEPRESSION
STUDIES - Taken collectively, these meta-analyses suggest that
pharmacotherapy and psychological treatment have comparable success
rates in treating depression, with better results at follow-up for
psychological treatment. These results provide substantial evidence
that both psychological treatments and antidepressant medication
work for many depressed adults, thus providing those suffering from
depression a viable choice of treatment options. There is also
evidence that combining the two treatments can yield greater
effects than is obtained with either treatment on its own. (Hunsley
et al. 2014) However, mood-stabilizing medication appears to
prevent relapse in relatively few patients, as 70% to 85% of
patients relapse within 5 years; additionally, 30% to 50% of
patients do not adhere to their medication treatments and/or
continue to experience significant residual symptoms while on the
medications (Szentagotai & David, 2010). Although psychotherapy
alone cannot successfully treat this disorder, increasing evidence
suggests that, as an adjunct to mood- stabilizing medication, it
can significantly reduce relapse rates and improve overall
functioning and well-being in youth, adults, and older adults.
(Hunsley et al. 2014) Bipolar Disorder
8. Does Psychotherapy Work for Everyone? 25% of patients are
early responders showing a dramatic improvement within the first
few weeks of therapy 5-10% of patients experience a steadily
declining state of health that fails to respond to the most
effective therapies and therapists 15-25% of patients neither
improve or decline during therapy The severity and complexity of
the patients mental health state are widely variable and therefore
the effects of therapy are also variable (Melchert, 2011)
9. Do All Therapies Work Equally Well? The Dodo Bird Verdict
The researchers Lambert and Wampold are known for their research
into the common factors model explaining the effectiveness of
psychotherapy. Rosenzweig introduced the metaphor of the Dodo Bird,
after the feathered creature in Lewis Carroll's Alice in
Wonderland, who declared following a race that everyone has won,
and all must have prizes. The Dodo Bird verdict has since come to
refer to the claim that all therapies are equivalent in their
effects Rosenweig suggested that a few common factors such as the
therapeutic relationship, showing respect for the client(s), and
giving hope, were the reason that psychotherapy was effective.
(Lillien et al, 2012)
10. How Do We Explain the Effectiveness of Psychotherapy? 15%
30% 15% 40% Lamberts (1992) estimates regarding the factors
explaining the effectiveness of psychotherapy Specific Techniques
Common Expectancy Extratherapeutic Change Common Factors +
Extra-therapeutic Changes There is controversy over which elements
of therapy most contribute to its effectiveness.
11. Lamberts Four Factors Specific Techniques (15%) the
effectiveness of particular treatment or techniques for particular
disorders Expectancy (15%) expectations that one will improve as
the result of being in treatment Common Factors (30%) factors found
across therapies, such as empathy, warmth, acceptance and
encouragement to take risks Extra therapeutic Change (40%) factors
associated with the patient ( e.g., severity of psychopathology and
level of ego strength or the patients environment (e.g.,
availability of social support) (Melchert, 2011)
12. Wampolds Therapist Competence Intrapersonal component
Avoids negative or hostile behaviors toward client Doesnt allow
dysfunctional personality characteristics to influence care
Interactive component Able to develop a collaborative relationship
with patients Able to get patients to process emotion effectively
Interpersonal skill Selective response to patients needs Open and
clear communication Communicates openness and empathy Type of
Treatment Provided 0 - 8% Unexplained Patient Characteristics 22%
Therapist Competence 70% (Wampold, 2001)
13. While therapist competence is a factor in the effectiveness
of psychotherapy, the therapist may not be as competent as they
think In one study in which therapists were asked to gauge their
effectiveness, nearly one quarter of the sample believed that 90%
or more of their clients improved. Half the sample reported that
none of their clients deteriorated while under their care (Walfish,
McAlister, ODonnell, & Lambert, 2010). Our self-distorted view
was revealed in an outcome study showing that the least effective
therapists rated themselves as being on par with the most effective
therapists (as cited in Beihl, 2011). Measuring Therapist
Competence
14. If therapies are fairly equivalent in effectiveness what
about Although most researchers agree that common factors play key
roles in psychotherapy, some doubt that all methods are equally
effective. Even Wampold has been careful to note that his
conclusion holds for only bona fide treatments; it does not extend
to all 500 or so therapies. For example, few experts would contend
that rebirthing therapy, premised on the dubious idea that we must
relive the trauma of our birth to cure neurosis, works as well as
cognitive-behavior therapy for most psychological conditions.
(Hunsley et al, 2002) Jeane Newmaker was charged with child abuse
and neglect after taking part in an attachment therapy rebirthing
session that killed her adopted child Candace.
http://www.mentalfloss.com/blogs/wp-content/uploads/2011/04/candace20_350x249.jpg
15. So what else accounts for the effectiveness of
psychotherapy if not the specific technique or the competence of
the therapist? Although the therapeutic alliance is an important
predictor of outcome, it only accounts for about 7% of outcome
variation. About 87% of outcome variability is related to
extratherapeutic-client factorsunique aspects of each client and
his or her environmentabout which little is known (Wampold, 2001).
In an earlier slide we saw that 5-10% of patients experience a
steadily declining state of health that fails to respond to the
most effective therapies and therapists and15-25% of patients
neither improve or decline during therapy. By taking a holistic BPS
approach to therapy we can reduce the influence of these
extra-therapeutic client factors on the outcome of therapy. What
else accounts for the Effectiveness of Psychotherapy?
Extra-therapeutic Client Factors
16. Reducing Failures by Broadening Of Treatment Options. In
their review of the Dodo bird verdict, Stiles, Shapiro, and Elliott
(1986) concluded that the search for "winners" among treatments was
the wrong direction for psychotherapy research to take. Instead,
they argued that much more would be gained by examining differences
among techniques as they are used in the process of treatment.
Rather than determining the relative superiority of two treatments,
they suggested that much more would be learned by comparing
techniques that have been proposed to be useful in achieving
intermediate, small changes in a session of treatment for example,
comparing a two-chair technique with reflective listening for
resolving decisional conflicts.(as cited in Hunsley et al, 2002)
From the biopsychosocial metatheoretical perspective, the current
research literature suggests that there are a variety of
therapeutic interventions available to address patient needs and
maximize their biopsychosocial functioning. (Melchert, 2011)
17. Reducing Treatment Failures by Monitoring and Assessing
Outcomes There is evidence, however, that the ongoing monitoring of
treatment outcomes can reduce the number of failed treatments.
Outcomes assessment is valuable because it generally focuses on
what is most meaningful to patients and other stakeholders. A BPS
approach to outcomes assessment would include both global and
generic measures of assessment. (Melchert, 2011) By monitoring the
patient and modifying the techniques and treatment plan accordingly
we may be able to identify when a treatment is failing and also
identify what techniques work well. Studies have shown that when
feedback is obtained from the client regarding treatment progress
and the alliance, the likelihood of improvement increases, and the
likelihood of deterioration decreases. (Beihl ,2011)
18. Reducing Failures by Evidence Based Practice Evidence-based
practice is a trans- disciplinary approach that aims to improve
accountability for health care practices and promote lifelong
learning.(Spring, 2007) EBP practice guidelines frame treatment
recommendations no- mothetically. They specify the best
research-supported treatment for a disorder, biopsychosocial
condition, or life problem. (Spring, 2007) Consistent with ethical
codes and professional standards, evidence-based practice entails
the monitoring and evaluation of services provided to clients
throughout treatment (from initial intake to treatment termination
and maintenance of gains.(Canadian Psychological Association, 2012)
http://www.psychotherapy.net/data/uploads/4ddbf47876130.jpg
19. A Biopsychosocial Model Stop searching for a reductionist,
purely biological explanation for psychological phenomenon. "It is
implausible to expect any one explanation (e.g., neurotransmitter
dysregulation, irrational thinking, childhood trauma) to fully
account for mental disorders," he writes. "No portion of the
biopsychosocial model has a monopoly on the truth. (Deacon, 2013).
The late George Engel believed that to understand and respond
adequately to patients sufferingand to give them a sense of being
understoodclinicians must attend simultaneously to the biological,
psychological, and social dimensions of illness. He offered a
holistic alternative to the prevailing biomedical model that had
dominated industrialized societies since the mid-20th century. His
new model came to be known as the biopsychosocial model.
(Borrell-Carri et al., 2004 )
http://savvywillingandable.wordpress.com/2013/09/25/the-biopsychosocial-model-explained/
20. Focus of the BPS Approach A biopsychosocial approach to
behavioral health care emphasizes a broad, holistic, systemic, and
developmental perspective to understanding treatment.(Melchert,
2011) BPS Treatment is focused on Current and long term
developmental functioning Health and wellness strengths across all
domains Monitoring progress and improving resilience over time
Collaboration with other professionals and third parties The role
of risk, protective and compensatory factors in treatment and
behavior change.
21. A BPS TREATMENT APPROACH S B P SYMPTOMS B P S B P S
Etiology Treatment Plan Treatment DIAGNOSIS Consider the 26
biological, social and psychological components connected to the
symptoms. Consider the biological, social and psychological factors
connected to the plan of treatment. Consider the biological, social
and psychological factors connected to the treatment Use an in
depth intake form that allows for modification as more elements of
etiology are revealed. Consider what EBP strategy will best address
the needs of the client Implement the plan of treatment considering
the BPS resources and collaborations at your disposal.
22. References Beihl, H. Psychotherapy: Shifting from technique
to client. (Fall 2011). BC Psychologist, 18-22. Campbell, L. F.,
Norcross, J. C., Vasquez, M. T., & Kaslow, N. J. (2013).
Recognition of psychotherapy effectiveness: The APA resolution.
Psychotherapy, 50(1), 98-101. doi:10.1037/a0031817 Canadian
Psychological Association. (2012). Evidence based practice of
psychological disorders: A Canadian perspective. Report of the CPA
Task Force on Evidence-Based Practice of Psychological Treatments,
Canadian Psychological Association (CPA). Borrell-Carri, F.,
Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial
model 25 years later: principles, practice, and scientific inquiry.
The Annals of Family Medicine, 2(6), 576-582. Deacon, B. J. (2013).
The biomedical model of mental disorder: A critical analysis of its
validity, utility, and effects on psychotherapy research. Clinical
psychology review, 33(7), 846-861. Hunsley, J., & Di Giulio, G.
(2002). Dodo Bird, Phoenix, or Urban Legend? The Question of
Psychotherapy Equivalence. The Scientific Review of Mental Health
Practice: Objective Investigations of Controversial and Unorthodox
Claims in Clinical Psychology, Psychiatry, and Social Work.
Hunsley, J., Elliott, K., & Therrien, Z. (2014). The Efficacy
and Effectiveness of Psychological Treatments for Mood, Anxiety,
and Related Disorders. Canadian Psychology, 55(3), 161-176.
doi:10.1037/a0036933 Lilien, S., & Arkowitz, H. (2012, August
2). Are All Psychotherapies Created Equal? Scientific American
Melchert, T. P. (2011). Foundations of professional psychology: The
end of theoretical orientations and the emergence of the
biopsychosocial approach. Elsevier. Spring, B. (2007).
Evidence-based Practice In Clinical Psychology: What It Is, Why It
Matters; What You Need To Know. Journal of Clinical Psychology,
63(7), 611-631. Retrieved October 10, 2014, from
http://faculty.weber.edu/eamsel/Classes/Science and Profession
(2010)/Papers/Spring 2007.pdf Wampold, B. E. (2001). The Great
Psychotherapy Debate: Models, Methods and Findings. New York:
Lawrence Erlbaum. Who are Counsellors? | Canadian Counselling and
Psychotherapy Association. (2014). Retrieved from http://www.ccpa-
accp.ca/en/theprofession/whoarecounsellors/ Understanding
psychotherapy and how it works. (2014). Retrieved from
http://www.apa.org/helpcenter/understanding-psychotherapy.aspx
