Common Factor? A behavioural perspective on the therapeutic - PowerPoint PPT Presentation

Common Factor? A behavioural perspective on the therapeutic relationship David Gillanders Academic Director, Doctoral Programme in Clinical Psychology University of Edinburgh The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

DISCLOSURE OF INTERESTS • I can confirm that I have received no sponsorship or financial aid or other relations that could be relevant to this meeting • As a peer reviewed ACT trainer I do receive free books from New Harbinger The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

DISCLOSURE OF INTERESTS • To see a full catalogue of ACT related books go to www.newharbinger.com (Other publishers are available) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

WE HUMANS CANT HELP COMPARING… The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

COMPARING THERAPIES • Saul Rosenzweig, 1936 – “Implicit common factors” – The Dodo Bird Verdict • Jerome Frank, 1975 – Provide for a need to be heard / accepted – Provide a rationale that explains the situation The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

COMPARING THERAPIES • Bruce Wampold - – “bona fide and non bona fide treatments” – Trained therapist – Face to face contact, individualised treatment – Psychologically valid components • For typical outpatient depression studies, there are no differences between theoretical approach The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

COMPARING THERAPIES • Luborsky et al., 2002 • Meta analyses of meta analyses: 17 metanalyses, • Adult patients with common problems (depression, anxiety, OCD, ‘neuroses’) • CT, BT, CBT, REBT, Dynamic Psychotherapy The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

COMPARING THERAPIES • Average mean difference in effect size between active comparisons • Cohen’s d = .20, and non significant • Differences between treatments are small The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

IT’S CONTROVERSIAL • Robust critiques from several authors: • Same studies used multiple times • Active and control comparisons lumped together • Active treatment and pharmacotherapy confounded in some dynamic therapies • Collapsing different problems together and different severities of patients The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

IT’S CONTROVERSIAL • Lack of specification of procedures, therapies that are quite different put together in the same category The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

IT’S CONTROVERSIAL • …differences among competently conducted psychotherapies may be small for some problems (e.g., adult depression) but quite striking for others (e.g., agoraphobia). Even within the category of behavior therapy, clear differences emerge. For example, in four separate studies, exposure and response prevention (ERP) for OCD was compared to progressive muscle relaxation training. In all studies, ERP was significantly superior to the other treatment. As a clinician, should I conclude that I can safely ignore these findings and base my treatment on relaxation because, overall, if I were to average all possible differences between psychotherapies for all possible problems, the average difference would be small? Obviously not.” Chambless, 2002, Clin. Psych. Sci & Prac, 9: 13-16 The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

IT’S CONTROVERSIAL “If we accept the Dodo bird verdict then it follows that regardless of the nature of your psychological problem, seek any form of therapy. This is absurd and not even the strongest advocates of the common factors hypothesis actually dispense this advice” Wilson, 1985 ” Rachman & The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

LIKE MIXING PAINT… The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

MISUNDERSTANDINGS • Common factor advocates feel misrepresented in these critiques • Other sources of variance in outcomes – not just the specific treatment package but significant therapist variability Messer & Wampold, 2002, Clin. Psych. Sci & Prac, 9: 21-25. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

MISUNDERSTANDINGS • Seeking to redress the balance • A misinterpretation of the EST field: more concern about what is delivered rather than how it is delivered • An emphasis on therapist rather than therapy factors The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

MISUNDERSTANDINGS • “In the common factor or contextual model, the purpose of specific ingredients is to construct a coherent treatment that therapists believe in, and this provides a convincing rationale to clients. Furthermore, these ingredients cannot be studied independently of the healing context and atmosphere in which they occur.” Messer & Wampold, 2002, Clin. Psych. Sci & Prac, 9: 21-25. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

MISUNDERSTANDINGS • “In the common factor or contextual model, the purpose of specific ingredients is to construct a coherent treatment that therapists believe in, and this provides a convincing rationale to clients. Furthermore, these ingredients cannot be studied independently of the healing context and atmosphere in which they occur.” Messer & Wampold, 2002, Clin. Psych. Sci & Prac, 9: 21-25. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

MISUNDERSTANDINGS • “In the common factor or contextual model, the purpose of specific ingredients is to construct a coherent treatment that therapists believe in, and this provides a convincing rationale to clients. Furthermore, these ingredients cannot be studied independently of the healing context and atmosphere in which they occur.” Messer & Wampold, 2002, Clin. Psych. Sci & Prac, 9: 21-25. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

AXIOMS • The relationship is the common contextual factor across all therapies • It is that aspect of the context that has greatest influence on outcomes • The specific techniques are also a feature of the context though one that has relatively less influence Messer & Wampold, 2002, Clin. Psych. Sci & Prac, 9: 21-25. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

HOW POWERFUL IS THE RELATIONSHIP? • Metaanalysis of the correlation between relationship and outcome • Overall correlation between relationship and outcome r = .275 (95% CI = .25 - .30), p <.0001 • High variability: range of r = .18 to .42 Horvath et al., 2011, Psychotherapy , 48, (1), 9-16. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

HOW POWERFUL IS THE RELATIONSHIP? • This amounts to around 7.5% of the variance in treatment outcome • Correlation is not moderated by how the alliance is measured, from whose perspective it is evaluated, when it is assessed, the way the outcome is evaluated, or the type of therapy involved. Horvath et al., 2011, Psychotherapy , 48, (1), 9-16. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

HOW POWERFUL IS THE RELATIONSHIP? Flückiger et al., 2012, Journal of Couns. Psych., 59, (1), 10 – 17. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

NECESSARY BUT NOT SUFFICIENT • RCT of 112 people for Bulimia Nervosa • Alliance high throughout treatment (89% of max) • Alliance did not predict outcome or drop out • Alliance not correlated with initial severity of BN, interpersonal problems or depression and anxiety • Best predictor of outcome was severity of BN at mid treatment (Raykos et al., 2014, BRAT , 57, 65 – 71) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk