Psychotherapy Does it Work Why Does it Work

Psychotherapy: Does it Work? Why Does it Work? Bruce E. Wampold, Ph. D. , ABPP Department of Counseling Psychology Department of Psychiatry University of Wisconsin-- Madison & Research Institute Modum Bad Psychiatric Center Vikersund NORWAY

Does it work? Psychotherapy v. No-tx � Eysenck, science, and behaviorism � Evidence from RCTs: ◦ Smith and Glass (1977) ◦ Effect size: ◦ g = (mean Tx - mean Control)/SD � es =. 80 � Accounts for 13% of variance in outcomes � Average treated person does better than 80% of untreated persons

Psychotherapy works � NNT = 3 – three patients need to be treated to obtain one additional success � Aspirin 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 safe � Effects in practice comparable to benchmarks created by RCTs � Elite club: Medicine and psychotherapy

Effect sizes d r % variance nnt Description . 2 . 10 1. 0% 9 small . 3 . 15 2. 2% 6 . 4 . 20 3. 8% 5 . 25 5. 9% 4 . 6 . 29 8. 3% 4 . 7 . 33 10. 9% 3 . 8 . 37 13. 8% 3 Tx v. No Tx Medium Large

How does it work? �Treatment �Common factors �Interaction of specific and common factors– the contextual model

Specific Treatment Effects �Psychological 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 groups �Inference: Specified treatment differences will exist

Treatment Differences �Treatment 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) �All direct comparisons across disorders �Effects homogeneously distributed about zero– No evidence to reject the null hypothesis �Upper bound ◦ d =. 2 ◦ % variance < 1% ◦ NNT = 9 ◦ SMALL

Effect sizes d r % variance nnt Description . 2 . 10 1. 0% 9 small . 3 . 15 2. 2% 6 . 4 . 20 3. 8% 5 . 25 5. 9% 4 . 6 . 29 8. 3% 4 . 7 . 33 10. 9% 3 . 8 . 37 13. 8% 3 Tx A v. Tx B Medium Large

Depression (see http: //www. div 12. org/Psychological. Treatments �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 therapy �Behavioral/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 et al. 1996) The purpose of this study was to “provide an experimental test of 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 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”

PTSD �PE, Stress Inoculation Training v. Supportive Counseling (Foa et al. ) �PE, SIT scientifically designed treatments �PE, SIT > Supportive Counseling �Conclusion: ◦ Exposure, cognitive change needed.

Supportive Counseling �“Patients were taught a general problemsolving 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 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 Childhood Sexual Abuse (Intent to treat) Measure % not ptsd Clinician PTSD BDI Tx A 27. 6% 53. 1 12. 9 Tx B 31. 8% 47. 2 10. 8 Effect size Spielberger TAI TSI Beliefs Dissoc. experiences Cook Hostility Qual of Life 46. 2 2. 7 12. 4 21. 6 39. 5 46. 4 2. 4 11. 5 17. 1 39. 0 . 02 -. 41 -. 09 -. 54. 03 -. 22 -. 18

PTSD Dropout Rate Tx A Tx B Enrolled 29 22 Completed 17 20 Dropped out 12 2 % dropped out WL chose tx 41% 5/10 dropped 9% 0/9 dropped

PTSD �“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. ”

PTSD � Tx 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? � Mc. Donagh et al. 2005

Present Centered Therapy

Present Centered Therapy � 3 Trials �Comparable (or better) than Evidencebased Treatment �> 2 Research groups �Manualized �Meets standards for evidence-based treatment (Frost et al. , submitted) �Consider EMDR ◦ Pseudo science, Mesmerism

Resick et al. 2008 PTSD �Cognitive Processing Therapy �Cognitive therapy only �Written Accounts � 2 hr/wk, 6 weeks (writing 45 -60 min) �All 3 treatments showed improvement

Post Traumatic Diagnostic Scale

PTSD �Prolonged 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 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)

Children �Depression and Anxiety ◦ CBT = non-CBT (when intended to be therapeutic) Spielmans, Pasek, & Mc. Fall, 2007 �Depression, anxiety, conduct disorder, ADHD ◦ Small differences ◦ Entirely explained by allegiance of researcher � Miller, Wampold, & Varhely, 2008

Meta-analysis of studies comparing 2 treatments

Meta-analysis of studies comparing 2 treatments � 9 comparisons �Overall effect not significant �Only 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…. Common Factors

Alliance �Bond (i. e. , relationship) �Agreement on Goals �Agreement on Tasks

Alliance and outcome correlation �Horvath et al. (2011) reviewed 190 studies, > 14, 000 patients �Correlation of alliance at early session and outcome �r =. 27 d =. 57 > MEDIUM

Effect sizes-- Alliance d r % variance nnt Description . 2 . 10 1. 0% 9 small . 3 . 15 2. 2% 6 . 4 . 20 3. 8% 5 . 25 5. 9% 4 . 6 . 29 8. 3% 4 . 7 . 33 10. 9% 3 . 8 . 37 13. 8% 3 Alliance Medium Large

Alliance and outcome correlation �Horvath et al. (2011) reviewed 190 studies, > 14, 000 patients �Correlation of alliance at early session and outcome �r =. 27 d =. 57 > MEDIUM �Not 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 that Work: Norcross Relationships that Work (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 Factors 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 . 14 Webb, De. Rubeis, & Barber, 2010 NOT SIGNIFICANT

Correlations v. RCTs �Correlation does imply causation �Issues with RCTs ◦ Selection and Generalizability ◦ Blinding ◦ Distinguishability ◦ Active ingredients ◦ Therapist effects ◦ Outcome measures

Therapist Effects �Definition: Some therapists consistently attain better outcomes than otherapists �Not due to contribution of patients �Not due to chance �Generalizable to the population of therapists �Compare to effects for other factors (e. g. , treatment differences)

Therapist Effects– The Evidence �Clinical 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 reanalysis � Nested Design (CBT and IPT) � Well trained therapists, adherence monitored, supervision � Elkin: ◦ The treatment conditions being compared in this study are, in actuality, “packages” of particular therapeutic approaches and 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 (40, 198, 715. 15 SEK)

Random Effects Modeling � Therapists considered a random factor � Therapists nested within treatments (multilevel model) � Final observations, controlling for pretest at patient and therapist level ◦ Kim, Wampold, & Bolt, Psychotherapy Research, 2006

Random Effects Modeling � Therapists considered a random factor � Therapists nested within treatments (multilevel model) � Final observations, controlling for pretest at patient and therapist level � Therapist slope fixed and random ◦ Kim, Wampold, & Bolt, Psychotherapy Research, 2006 Greater Severity

Variance due to Tx: CBT v IPT Variable Treatment BDI 0% HRSD 0% HSCL-90 0% GAS 0% Therapist

Variance due to Tx and Therapists 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– Psychopharmacology �Antidepressants: Imipramine v. Placebo � 30 minutes, biweekly � 3% due to treatment � 9% due to therapist �Best psychiatrists got better outcome with placebo than worst psychiatrists with imipramine (Mc. Kay, Imel & Wamold, 2006)

Effect sizes– Therapists Effects d r % variance nnt Description. 2 . 10 1. 0% 9 . 3 . 15 2. 2% 6 . 4 . 20 3. 8% 5 . 25 5. 9% 4 . 6 . 29 8. 3% 4 . 7 . 33 10. 9% 3 . 8 . 37 13. 8% 3 Therapists Effects small Medium Large

Therapists make a difference �Characteristics 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 question �Beginning to accumulate evidence �Btw: therapist effects inflates treatment differences

Alliance: Patient v. Therapist Contribution to Alliance �Counseling center consortium data �OQ pre and post, Alliance 4 th session � 331 patients, 80 therapists �Alliance/outcome correlation. 24 � 3% of variance due to therapists �What is correlation of alliance with outcome ◦ Within therapists? ◦ Between therapists? �And the results….

Within or between? Better therapist

Therapist contribution to alliance is critical �Patient contribution to alliance not predictive of outcome �Therapist contribution is predictive of outcome �Interaction not significant �Alliance is not a result of outcome

Interpersonal skills �Verbal 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)

Conclusions �Treatment ◦ Particular treatment not important ◦ Treatment IS important �Who delivers the treatment is primary ◦ Therapist who can form alliances with patients ◦ Interpersonal skills

AN EVIDENCED-BASED MODEL OF PSYCHOTHERAPY

Relationship Elements Real relationship, belongingness, social connection Therapist Better Quality of Life Trust, Understanding, Expertise Patient Creation of expectation through explanation and some form of treatment Symptom Reduction Tasks/Goals Therapeutic Actions Healthy Actions

Initial formation of therapeutic bond Humans Therapist Trust, Understanding, Expertise Patient evolved to discriminate between those who can be trusted and those who cannot 50 ms Context, healing practice Nonverbal

Real Relationship �Transference-free genuine relationship based on realistic perceptions (Gelso, 2009) �Social relations = well being �Social isolation = pathology �Psychotherapy is uniquely ENDURING Real relationship, belongingness, social connection Trust, Understanding, Expertise Better Quality of Life

Expectation �Expectation influence on well being �Placebo effects �Created in interpersonal interaction �Explanation of disorder �Agreement about tasks and goals of Tx �Treatment actions Trust, Understanding, Expertise Better Quality of Life Creation of expectation through explanation and some form of treatment Symptom Reduction

Specific Actions �Indirect Effect �Agreement tasks & goals adherence to protocol �Healthy actions �Need to develop and test protocols Better Quality of Life Trust, Understanding, Expertise Symptom Reduction Tasks/Goals Therapeutic Actions Healthy Actions

Conclusions �Relationship factors critical ◦ Real relationship ◦ Explanation expectations ◦ Agreement about tasks and goals healthy actions �Human evolved to heal through social means �Treatment important, but is the particular treatment?

IMPROVE QUALITY OF CARE �Disseminate Evidence-based Treatments �Measure and manage outcomes ◦ Use best therapists ◦ Help poorer therapists improve �Provide therapists feedback �Provide training ◦ Common fctors ◦ Specific treatments

Thank You Bruce E. Wampold, Ph. D. , ABPP Patricia L. Wolleat Professor of Counseling Psychology Clinical Professor, Psychiatry University of Wisconsin--Madison Director, Research Institute Modum Bad Psychiatric Center Vikersund, Norway bwampold@wisc. edu