Psychotherapy: Does it Work? Why Does it Psychotherapy: Does it Work? Why Does it Work?Work? Psychotherapy: Does it Work? Why Does it Psychotherapy: Does it Work? Why Does it Work?Work?
Bruce E. Wampold, Ph.D., ABPPDepartment of Counseling PsychologyDepartment of PsychiatryUniversity of Wisconsin-- Madison
&
Research InstituteModum Bad Psychiatric CenterVikersund NORWAY
Does it work?Does it work?Psychotherapy v. No-tx Psychotherapy v. No-tx Eysenck, science, and behaviorismEvidence from RCTs:
◦ Smith and Glass (1977)◦ Effect size: ◦ g = (mean Tx - mean Control)/SD
es = .80Accounts for 13% of variance in outcomesAverage treated person does better than
80% of untreated persons
Psychotherapy worksPsychotherapy worksNNT = 3 – three patients need to be treated
to obtain one additional successAspirin as a prophylaxis for heart attacks
(NNT = 129)Superior to interventions in cardiology,
geriatric medicine, asthma, flu vaccine, cataract surgery
Comparable to psychopharmacology interventions
Enduring and safeEffects in practice comparable to
benchmarks created by RCTsElite club: Medicine and psychotherapy
Effect sizesEffect sizesd r %
variancennt Description
.2 .10 1.0% 9 small
.3 .15 2.2% 6
.4 .20 3.8% 5
.5 .25 5.9% 4 Medium
.6 .29 8.3% 4
.7 .33 10.9% 3
.8 .37 13.8% 3 Large
Tx v. No Tx
How does it work?How does it work?TreatmentCommon factorsInteraction of specific and
common factors– the contextual model
Specific Treatment EffectsSpecific Treatment EffectsPsychological treatments = built on
characteristics found in a variety of treatments, including “the therapeutic alliance, the induction of positive expectancy of change, and remoralization,” but contain important “specific psychological procedures targeted at the psychopathology at hand” (Barlow, 2004, p. 873).
Empirically Supported Treatments ◦Evidence based treatments◦2 trials, > control or = EST, manual, 2
different groupsInference: Specified treatment
differences will exist
Treatment DifferencesTreatment DifferencesTreatment intended to be
therapeutic◦Psychological rationale, trained
therapists who have allegiance to tx, no proscription of usual therapeutic actions
Null Hypothesis:◦All treatment intended to be
therapeutic are equally effective
Wampold et al. (1997)Wampold et al. (1997)All direct comparisons across
disordersEffects homogeneously distributed
about zero– No evidence to reject the null hypothesis
Upper bound◦d = .2◦% variance < 1%◦NNT = 9◦SMALL
Effect sizesEffect sizesd r %
variancennt Description
.2 .10 1.0% 9 small
.3 .15 2.2% 6
.4 .20 3.8% 5
.5 .25 5.9% 4 Medium
.6 .29 8.3% 4
.7 .33 10.9% 3
.8 .37 13.8% 3 Large
Tx A v. Tx B
Depression Depression (see (see
http://www.div12.org/PsychologicalTreatmentshttp://www.div12.org/PsychologicalTreatments
ESTs: behavioral activation, cognitive therapy, interpersonal therapy, brief dynamic therapy, reminiscence therapy, self-control therapy, social problem solving therapy, self-system therapy, acceptance and commitment therapy, behavioral couple therapy, self/management self-control therapy… and
The case of process-experiential therapyBehavioral/cognitive behavioral not
superior to verbal therapies intended to be therapeutic
Dynamic therapies produce effect sizes comparable to CBT
Does CBT work through specific ingredients?
CT for Depression (Jacobson CT for Depression (Jacobson et al. 1996)et al. 1996) The purpose of this study was to “provide an experimental
test of the theory of change put forth by A. T. Beck, A. J. Rush, B. F. Shaw, and G. Emery (1979) to explain the efficacy of cognitive-behavioral therapy (CT) for depression” (p. 295).
Complete Cognitive Therapy (CT)◦ Behavioral activation (monitoring, activity assignment,
social skills training)◦ Dysfunctional thoughts (Monitoring, assessment, reality
testing, alternative cognitions, examination of attributional biases, homework)
◦ Core Schema (Identify core beliefs and alternatives, advantages and disadvantages, modification of core beliefs)
Activation + modification of dysfunctional thoughts (AT) Behavioral Activation (BA) CT v. AT v. BA
Jacobson resultsJacobson results“According to the cognitive theory of depression,
CT should work significantly better than AT, which in turn, should work significantly better than BA.”
BA = AT = CT“These findings run contrary to hypotheses
generated by the cognitive model of depression put forth by Beck and his associates (1979), who proposed that direct efforts aimed at modifying negative schema are necessary to maximize treatment outcome and prevent relapse.”
Depression placebo responsive… “real disorders”
PTSDPTSD
PE, Stress Inoculation Training v. Supportive Counseling (Foa et al.)
PE, SIT scientifically designed treatments
PE, SIT > Supportive CounselingConclusion:
◦Exposure, cognitive change needed.
Supportive CounselingSupportive Counseling“Patients were taught a general problem-
solving technique. Therapists played an indirect and unconditionally supportive role. Homework consisted of the patient’s keeping a diary of daily problems and her attempts at problem solving. Patients were immediately redirected to focus on current daily problems if discussions of the assault occurred.”
Belief of therapists delivering Supportive Counseling?
But examine another study…
PTSD in Adult Female Childhood PTSD in Adult Female Childhood Sexual Abuse (Completer Sample)Sexual Abuse (Completer Sample)Measure Tx A Tx B ES
% not ptsd(3 month follow up)
47.1%82.4%
35.0%42.1
Clinician PTSD 38.5 47.2 .34
BDI 7.5 10.4 .31
Spielberger TAI 39.4 45.6 .53
TSI Beliefs 2.2 2.4 .39
Dissoc. experiences 7.6 9.4 .24
Cook Hostility 12.9 14.9 .27
Qual of Life 47.1 38.9 .58
PTSD in Adult Female PTSD in Adult Female Childhood Sexual Abuse Childhood Sexual Abuse (Intent to treat)(Intent to treat)Measure Tx A Tx B Effect size
% not ptsd 27.6% 31.8%
Clinician PTSD 53.1 47.2 -.22
BDI 12.9 10.8 -.18
Spielberger TAI 46.2 46.4 .02
TSI Beliefs 2.7 2.4 -.41
Dissoc. experiences
12.4 11.5 -.09
Cook Hostility 21.6 17.1 -.54
Qual of Life 39.5 39.0 .03
PTSD Dropout RatePTSD Dropout RateTx A Tx B
Enrolled 29 22
Completed 17 20
Dropped out 12 2
% dropped out
41% 9%
WL chose tx 5/10 dropped
0/9 dropped
PTSDPTSD“As expected, our hypothesis
that Tx A would be more effective than WL received consistent support. There was no effect of either tx on quality of life. Our hypothesis that Tx A would be superior to Tx B received support (at follow-up only). In summary, for women who remained in Tx A, it was highly effective.”
PTSDPTSDTx A = CBT, prolonged imaginal exposure, in
vivo exposure, cognitive restructuring, breathing retraining◦ Psychologist therapist, Foa supervisor◦ Cogent rationale
Tx B = PCT (Present-centered treatment)◦ Rationale: impact of trauma on current functioning,
systematic approach to problem solving, manual.◦ MSW therapists, trained by authors◦ No cognitive or behavioral components (no
exposure)Quality of Life? McDonagh et al. 2005
Present Centered TherapyPresent Centered Therapy RCT 1: PCGT v TFGT
Scnurr et al. 2003 Vietnam Vets
RCT 2: PCT v CBT McDonagh et al. 2005
Childhood Sexual Abuse
RCT 3: PFGT v TFGT Classen 2011
Childhood Sexual Abuse/HIV Risk PCGT TFGT No
Difference PCGT TFGT No
Difference PCGT TFGT No Difference
Drop Rate***
CAPS Total severity
Drop Rate *
CAPS Total HIV risk *
Anger/ Irratability**
PTSD Severity
CAPS B BDI Sexual revictimization
CAPS C STAI Substance Use PTSD
Checklist DES Risky Sex
General Health Q
COOK # of partners
SF-36 Physical
STAXI Avoidance
SF Mental QOLI Reexperiencing Interpersonal
Problems Depression Dissociation Sexual
Concerns Dysfunction
Sex Impaired Self-
references Tension
Reduction Posstraumatic
Growth Drop Rate
Present Centered TherapyPresent Centered Therapy3 TrialsComparable (or better) than
Evidence-based Treatment> 2 Research groupsManualizedMeets standards for evidence-
based treatment (Frost et al., submitted)
Consider EMDR◦Pseudo science, Mesmerism
Resick et al. 2008 PTSDResick et al. 2008 PTSDCognitive Processing Therapy Cognitive therapy onlyWritten Accounts2hr/wk, 6 weeks (writing 45-60
min)All 3 treatments showed
improvement
Post Traumatic Diagnostic Post Traumatic Diagnostic ScaleScale
PTSDPTSDProlonged exposure, CBT, EMDR,
hypnotherapy, psychodynamic, trauma desensitization, present-centered therapy, CBT without exposure
No differences among treatments intended to be therapeutic (Benish, Imel, & Wampold, 2008)
Other diagnosesOther diagnoses◦Panic: Panic Control Tx,
Psychodynamic (Mildrod et al., 2007)
◦Alcohol Use Disorders Meta-analysis of all tx, including CBT, MI,
AA, etc. No differences (Imel et al., 2008)
ChildrenChildrenDepression and Anxiety
◦CBT = non-CBT (when intended to be therapeutic) Spielmans, Pasek, & McFall, 2007
Depression, anxiety, conduct disorder, ADHD◦Small differences◦Entirely explained by allegiance of
researcher Miller, Wampold, & Varhely, 2008
Meta-analysis of studies Meta-analysis of studies comparing 2 treatmentscomparing 2 treatments
Meta-analysis of studies Meta-analysis of studies comparing 2 treatmentscomparing 2 treatments9 comparisonsOverall effect not significantOnly 1 of 9 statistically significant
◦Markowitz: HIV Depressed men, IPT > CBT
NIMH funded 1992-2009$11,760,874 (78,848,306 SEK)Value?
If not treatment, then….If not treatment, then….Common Factors
AllianceAllianceBond (i.e., relationship) Agreement on Goals Agreement on Tasks
Alliance and outcome Alliance and outcome correlationcorrelationHorvath et al. (2011) reviewed
190 studies, > 14,000 patientsCorrelation of alliance at early
session and outcomer = .27 d = .57 > MEDIUM
Effect sizes-- AllianceEffect sizes-- Allianced r %
variancennt Description
.2 .10 1.0% 9 small
.3 .15 2.2% 6
.4 .20 3.8% 5
.5 .25 5.9% 4 Medium
.6 .29 8.3% 4
.7 .33 10.9% 3
.8 .37 13.8% 3 Large
Alliance
Alliance and outcome Alliance and outcome correlationcorrelationHorvath et al. (2011) reviewed 190
studies, > 14,000 patientsCorrelation of alliance at early
session and outcomer = .27 d = .57 > MEDIUMNot confounded by improvement
(Klein et al. 2003; Crits-Christoph et al. 2011)
Other factors (Flückiger et al., 2012)
◦CBT v non CBT◦Manual driven or not/Specific treatment◦Allegiance to alliance
Therapist or patient contribution?
Psychotherapy Relationships Psychotherapy Relationships that Work: Norcrossthat Work: NorcrossRelationships that Work Relationships that Work (2011)(2011)
Factor # Studies
# Patients
Effect size d
Alliance 190 > 14,000 .57
Alliance-Child & Adolescents
29 2630 .39
Alliance-Couple & Family 24 1461 .54
Empathy 59 3599 .63
Goal Consensus, Collaboration
15 1302 .72
Positive regard, affirmation
18 1067 .56
Congruence, genuineness 16 863 .49
Common Factors—Specific Common Factors—Specific FactorsFactors
Factor # Studies
# Patients
Effect size d
Alliance 190 > 14,000 .57
Alliance-Child & Adolescents
29 2630 .39
Alliance-Couple & Family 24 1461 .54
Empathy 59 3599 .63
Goal Consensus, Collaboration
15 1302 .72
Positive regard, affirmation
18 1067 .56
Congruence, genuineness 16 863 .49
Adherence to specific protocol
28 .04
Rated competence 18 .14Webb, DeRubeis, & Barber, 2010
NOT SIGNIFICANT
Correlations v. RCTsCorrelations v. RCTsCorrelation does imply causation Issues with RCTs
◦Selection and Generalizability◦Blinding◦Distinguishability◦Active ingredients◦Therapist effects◦Outcome measures
Therapist Effects Therapist Effects Definition: Some therapists
consistently attain better outcomes than other therapists
Not due to contribution of patientsNot due to chance Generalizable to the population of
therapistsCompare to effects for other factors
(e.g., treatment differences)
Therapist Effects– The Therapist Effects– The EvidenceEvidenceClinical Trials
◦Selected, trained, supervised and monitored
◦8% of variability due to therapists◦Tx differences: At most 1 percent
Naturalistic settings◦3% to 17% due to therapists◦Across age, severity, & diagnosis◦Possibly not across racial and ethnic
groups◦Cross validated
NIMH TDCRP reanalysisNIMH TDCRP reanalysisNested Design (CBT and IPT)Well trained therapists, adherence
monitored, supervisionElkin:
◦ The treatment conditions being compared in this study are, in actuality, “packages” of particular therapeutic approaches and the therapists who choose to and are chosen to administer them…. The central question… is whether the outcome findings for each of the treatments, and especially for differences between them, might be attributable to the particular therapists participating in the study.
$6,000,000 (40,198,715.15 SEK)
Random Effects ModelingRandom Effects ModelingTherapists considered a random factorTherapists nested within treatments
(multilevel model)Final observations, controlling for pretest at
patient and therapist level◦ Kim, Wampold, & Bolt, Psychotherapy Research, 2006
Random Effects ModelingRandom Effects ModelingTherapists considered a random factorTherapists nested within treatments
(multilevel model)Final observations, controlling for pretest at
patient and therapist levelTherapist slope fixed and random
◦ Kim, Wampold, & Bolt, Psychotherapy Research, 2006
Greater Severity
Greater Severity
Variance due to Tx: CBT v Variance due to Tx: CBT v IPT IPT
Variable Treatment
Therapist
BDI 0%
HRSD 0%
HSCL-90 0%
GAS 0%
Variance due to Tx and Variance due to Tx and TherapistsTherapists
Variable Treatment
Therapist
BDI 0% 5% - 12%
HRSD 0% 7% - 12%
HSCL-90 0% 4% - 10%
GAS 0% 8% - 10%
Note: Elkin et al. (2006) found negligible therapist effects in the same data
Psychiatrist Effects– Psychiatrist Effects– PsychopharmacologyPsychopharmacology
Antidepressants: Imipramine v. Placebo
30 minutes, biweekly3% due to treatment9% due to therapistBest psychiatrists got better
outcome with placebo than worst psychiatrists with imipramine (McKay, Imel & Wamold, 2006)
Effect sizes– Therapists Effect sizes– Therapists EffectsEffectsd r %
variancennt Description
.2 .10 1.0% 9 small
.3 .15 2.2% 6
.4 .20 3.8% 5
.5 .25 5.9% 4 Medium
.6 .29 8.3% 4
.7 .33 10.9% 3
.8 .37 13.8% 3 Large
Therapists Effects
Therapists make a Therapists make a differencedifferenceCharacteristics and Actions of
Effective Therapists?Consult Beutler (Handbook of
Psychotherapy and Behavior Change)◦We don’t know◦And we don’t care◦Education, agriculture, medicine…. And psychotherapy
Fundamental unanswered questionBeginning to accumulate evidenceBtw: therapist effects inflates
treatment differences
Alliance: Patient v. Therapist Alliance: Patient v. Therapist Contribution to AllianceContribution to AllianceCounseling center consortium dataOQ pre and post, Alliance 4th session331 patients, 80 therapistsAlliance/outcome correlation .243% of variance due to therapistsWhat is correlation of alliance with
outcome◦ Within therapists?◦ Between therapists?
And the results….
Within or between?Within or between?
Better therapist
Therapist contribution to Therapist contribution to alliance is criticalalliance is criticalPatient contribution to alliance
not predictive of outcome Therapist contribution is
predictive of outcomeInteraction not significantAlliance is not a result of
outcome
Interpersonal skillsInterpersonal skillsVerbal fluency, interpersonal
perception, affective modulation and expressiveness, warmth and acceptance, empathy, focus on others
Measured with a challenge test◦Responses to vignettes
Accounts for therapist differences ◦Anderson, Ogles, Patterson, Lambert, &
Vermeersch, D. A. (2009)◦Supported in meta-analyses (see Norcross,
Psychotherapy Relationships that Work)
ConclusionsConclusionsTreatment
◦Particular treatment not important◦Treatment IS important
Who delivers the treatment is primary◦Therapist who can form alliances
with patients◦Interpersonal skills
AN EVIDENCED-AN EVIDENCED-BASED MODEL OF BASED MODEL OF PSYCHOTHERAPYPSYCHOTHERAPY
Creation of expectation through explanation and some form of treatment
Real relationship, belongingness, social connection
Trust, Understanding,
Expertise
Patient
Therapist
Tasks/Goals Therapeutic Actions
Healthy Actions
Symptom Reduction
Better Quality of
Life
Relationship ElementsRelationship Elements
Initial formation of Initial formation of therapeutic bondtherapeutic bond
Humans evolved to discriminate between those who can be trusted and those who cannot
50 msContext, healing
practiceNonverbal
Trust, Understanding,
Expertise
Patient
Therapist
Real RelationshipReal RelationshipTransference-free genuine
relationship based on realistic perceptions (Gelso, 2009)
Social relations = well beingSocial isolation = pathologyPsychotherapy is uniquely
ENDURING
Real relationship, belongingness, social connection
Trust, Understanding,
Expertise
Better Quality of
Life
ExpectationExpectationExpectation influence on well beingPlacebo effectsCreated in interpersonal interactionExplanation of disorderAgreement about tasks and goals of
TxTreatment actions
Creation of expectation through explanation and some form of treatment
Trust, Understanding,
Expertise
Symptom Reduction
Better Quality of
Life
Specific ActionsSpecific ActionsIndirect EffectAgreement tasks & goals adherence
to protocolHealthy actionsNeed to develop and test protocols
Trust, Understanding,
Expertise
Tasks/Goals Therapeutic Actions
Healthy Actions
Symptom Reduction
Better Quality of
Life
ConclusionsConclusionsRelationship factors critical
◦Real relationship◦Explanation expectations◦Agreement about tasks and goals
healthy actionsHuman evolved to heal through
social means Treatment important, but is the
particular treatment?
IMPROVE QUALITY OF IMPROVE QUALITY OF CARECAREDisseminate Evidence-based
TreatmentsMeasure and manage outcomes
◦Use best therapists◦Help poorer therapists improve
Provide therapists feedbackProvide training
◦Common fctors◦Specific treatments
Thank YouThank You
Bruce E. Wampold, Ph.D., ABPPPatricia L. Wolleat Professor of Counseling PsychologyClinical Professor, PsychiatryUniversity of Wisconsin--Madison Director, Research InstituteModum Bad Psychiatric CenterVikersund, Norway