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Highlights
· This review article highlights 8 themes that characterize the psychotherapy research literature.
Each represents a controversial issue.
· Implications of the 8 themes for psychotherapy training in psychiatry are presented.
· It is recommended that trainees be familiar with such themes and their implications for
training, as well as with basic research methods and evaluative criteria, as part of their
introduction to a broad range of psychotherapies.
Scientific journals continually publish a large volume of A simple approach is tempting. Learning to be a skillful psy-
research articles on psychotherapy. Adair and Vohra have chotherapist is a challenging task that takes time, effort, and
described the difficult challenge that all researchers face in hard work, even when trainees feel confident about the useful-
keeping up with the current literature (4). The difficulty for ness of psychotherapy. Highlighting ambiguities, doubts, and
providers and consumers of psychotherapy training is even uncertainties can be problematic, particularly if this is done in
greater: many are primarily clinicians who often do not have a way that leads to expectations of poor outcome, weak moti-
the resources to monitor new publications comprehensively. vation, or diminished morale. Most trainees desire direct reas-
Even when research articles are available, however, they are surance that they are learning both effective techniques and
often not read and thus do not inform psychotherapy training. how to provide them skillfully.
There are several reasons for this. Researchers usually write
Although tempting, a simple approach has several disadvan-
for other researchers, not for administrators, teachers, or train-
tages. The outcome of psychotherapy is multiply determined;
ees. Articles are often difficult to understand because they are
therapist technique is but a single factor. Choosing a promising
laden with jargon. Much research is regarded as artificial and
therapy from a list and attempting to conduct it skillfully will
not applicable to clinical settings (for example, randomized
not guarantee success. Patient, therapist, and relationship fac-
clinical trials [RCTs] of therapy efficacy). Much psychother-
tors are also influential and need to be considered in treating
apy research focuses on brief therapies and neglects long-term
individual patients. To assume otherwise will lead to disap-
therapies that are still provided by many private practitioners.
pointments. Similarly, therapists following a simple model of
In addition, research reports are usually written tentatively,
treatment will be disillusioned when the inevitable limitations
with many qualifications and limitations that do not inspire
of particular techniques become evident. As the field continues
confidence in clinicians, teachers, and trainees.
to develop, a relatively simple approach will not help the thera-
Another problem is the lack of research on training and super- pist evaluate evidence for new or emerging techniques; to do
vision. There is no body of research literature comparing the so, one must be a well-informed consumer. It is the responsibil-
effectiveness of different approaches to training and supervi- ity of training programs to produce such trainees.
sion. Training models are based on tradition, not research. For
example, didactic course work, supervised treatment of cases, In taking a relatively complex approach, this article highlights
and personal psychotherapy is the time-worn model of most 8 themes that characterize the current psychotherapy research
psychodynamic therapy training (5). A more fundamental literature. Each theme represents a controversial issue that has
problem is the lack of training for effective supervision. implications for psychotherapy training and practice. Many of
Because most training programs devote little attention to the the themes are related to each other and represent different
topic of supervision, there is little to study. Most supervisors positions in regard to the controversial issues. Before present-
must rely on their personal experiences as a guide to conduct- ing these themes, which are expressed as conclusions, their
ing supervision. historical context is briefly considered.
Either a relatively simple or a relatively complex approach Just 50 years ago, there were no controlled or comparative
can be taken in addressing the implications of psychotherapy outcome studies of the psychotherapies. Nevertheless, in
research for training and in making recommendations for cur- 1952, Eysenck published a review claiming that psychother-
ricula. The simple approach would provide lists of therapies apy was not effective (6). He compared the outcome reports of
that have the most evidence of efficacy for particular prob- 24 studies, most of which involved psychodynamic therapies,
lems, provide references from the research literature, and with the outcome reports of 2 control studies involving
emphasize teaching those approaches in training programs. patients who had not received psychotherapy. Eysenck con-
cluded that two-thirds of the patients improved substantially
The more complex approach would also attend to evidence of
within 2 years, whether or not they received psychotherapy.
efficacy. However, instead of focusing on current lists of ther-
Subsequently, there were many criticisms of his review. It was
apies, problems, and references, this approach would direct
argued that patient samples and outcome criteria differed
readers to reviews of the research literature summarizing the
between the treatment studies and the control studies, that
specific evidence of efficacy. The more complex approach
control patients actually received treatment, and that his inter-
would also present limitations and controversies associated
pretation of the treatment studies’ results was biased.
with the evidence. This approach would require familiarity
with basic research methodology and evaluative criteria, Although Eysenck did not appear to win the debate on aca-
which would have to be covered as part of the training. It demic grounds, he scored a victory on psychological grounds.
would emphasize general themes emerging in the field rather People invested in the practice of psychotherapy seemed
than simply listing specific findings. It would convey tenta- embarrassed, off-balance, and demoralized. In time, the
tive rather than definitive observations about the evidence. debate set the stage for a counteroffensive that included
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controlled studies and new reviews. Probably the most influ- research investigator and the theoretical orientation of the treat-
ential review was that of Smith, Glass, and Miller (7). Using a ment that emerges as most effective in comparative outcome
new review method called metaanalysis, which involved cal- studies (12). After statistical adjustments are made for the alle-
culating an effect size for each outcome variable and then giance effect, the outcome differences among therapies usually
averaging the effect sizes across studies, they summarized the disappear. The strongest opponents of this theme are the advo-
results of 485 controlled studies. These authors concluded cates of the empirically supported therapies (EST) movement.
that psychotherapies in general are effective and that there is They claim that the therapies on their lists have evidence of
little difference in effectiveness among the different types of superiority over other therapies for specific diagnoses (13).
psychotherapies. These conclusions were regarded as inaccu- Other opponents are the advocates of aptitude–treatment inter-
rate by a number of people, many of whom were advocates of actions (ATI). This group believes that there are optimal
behaviour therapy (8). They attacked the review methodology matches between patients scoring high on a particular charac-
and the conclusions. Debate about the validity of metaanalysis teristic and specific therapies and patients scoring low on the
and the conclusions one can draw from it has continued to the same characteristic and other specific therapies. They contend
present time. Nevertheless, many metaanalyses continue to be that, when effect sizes are averaged across therapies in
published. In an extensive current review of the outcome liter- metaanalyses, these specific matches (interactions) become
ature, Lambert and Ogles (9) came to the same general conclu- obscured. Opponents also attribute the small number of out-
sions as Smith, Glass, and Miller and acknowledged that the come differences in comparative studies to such factors as
controversy has not subsided. Unfortunately, one of weak methodology; low power owing to small sample size;
Eysenck’s legacies is a polemical climate that has too often led treatment of mildly disturbed, single-diagnosis patients; use of
to attacks and counterattacks between vested-interest groups. brief therapies; and overreliance on symptoms as outcome
The latest example is the debate concerning the value of creat- criteria (14).
ing lists of “empirically supported therapies,” discussed
below as a controversial theme. Implications
Another strong force that has influenced the type of therapies Trainees should be familiar with metaanalysis as a review
studied and practised in North America is health care reform, method, together with its strengths and limitations. They
often referred to as the managed care movement. As should be aware of the findings of major metaanalytic reviews
third-party controller of health care funds, managed care com- that focus on the therapies for which they are being trained.
panies have favoured short-term therapies. Further, decisions
about which therapies to fund have frequently been influ- Theme 2: Common Factors of Therapies are
enced by practice guidelines. These are policy statements More Strongly Related to Outcome Than
from major organizations about the proper treatment of cer- Unique Factors
tain disorders. The preference for short-term therapies has
Common factors are therapeutic factors that are present across
created pressure for researchers to study them and compete in
therapies (for example, a helping relationship, a convincing
determining which therapies meet criteria for empirical sup-
rationale, and feedback concerning progress) (15). In con-
port. It has added fuel to the polemical climate that has charac-
trast, unique factors differ across therapies (for example,
terized psychotherapy research and has resulted in what some
interpretation of transference). Those who believe that there
believe to be extreme positions and simplistic claims that cer-
are few differences in outcome among most therapies, as indi-
tain techniques are superior. Within the context of these
cated by metaanalytic reviews, often attribute this to the pres-
developments, the major themes that characterize the current
ence of common factors. In a series of studies of the actual
psychotherapy literature are considered next. Each is pre-
process of therapies with distinct orientations (that is,
sented as a conclusion. Following this, implications for train-
psychodynamic, cognitive-behavioural, and interpersonal),
ing are considered.
Jones and colleagues found that they had much in common,
particularly in regard to what appeared to be the effective
Theme 1: There Are Few Differences in the ingredients of favourable change (16). Separate research has
Outcomes of Most Psychotherapies found it difficult to demonstrate that the unique theoretical
Metaanalytic reviews have strongly supported this theme, base of different therapies accounts for their effective-
which represents what has been referred to as “the dodo bird ness—additional evidence for the greater importance of com-
effect” (10,11); that is, everybody has won, so all shall have mon factors. For example, a recent review of the literature
prizes. When differences among therapies have emerged, they found little evidence for the unique theoretical underpinnings
have often been attributed to “the allegiance effect.” This refers of cognitive-behavioural therapy (CBT) (17). Similarly, a
to the strong relation between the theoretical orientation of the review of the literature found little evidence that eye
movements were a necessary component of eye-movement Alternative methods include naturalistic, correlational,
desensitization and reprocessing therapy (18). process–outcome, structural modelling, and qualitative
approaches, each of which can provide valid data about ther-
Implications apy outcomes.
Trainees should be familiar with the common factors and
learn how to facilitate them skillfully in their clinical work. Implications
Trainees should be familiar with the criteria and lists of thera-
Theme 3: The Criteria for Empirically pies associated with the EST movement. They should also be
Supported Therapies Should be Used to Select aware of its limitations. Important patient, therapist, and rela-
Which Therapies Are Taught in Training tionship factors should be covered, as well as the many differ-
Programs ent approaches to studying the effectiveness of the
Criteria for empirically supported therapies and lists of thera- psychotherapies.
pies that meet those criteria were originally championed by an
American Psychological Association task force (19). Subse- Theme 4: There Are Some Good Matches
quent lists have been prepared (20,21). The criteria have Between Specific Patient Characteristics and
emphasized RCT designs, treatment manuals, homogeneous Specific Therapies
diagnostic groups, and independent replications. Many Evidence for good matches has come from the EST movement
advocates have been from the behavioural and cognitive- and ATI research. The former has focused on patient diagno-
behavioural orientations, with associated treatments dominat- ses and the latter on patient personality dimensions. Perhaps
ing the lists. To their credit, they have advocated an account- the strongest evidence for matches, as identified by the EST
able, evidence-based approach to choosing treatment for movement (21), involves the anxiety disorders and forms of
specific problems. However, their approach has been viewed CBT. Examples include CBT for panic disorder and general-
by many as premature and restrictive. Opponents of the EST ized anxiety disorder, exposure for phobias, and exposure and
movement, which have included both clinicians and research- response prevention for obsessive–compulsive disorders.
ers, have criticized the use of RCT methodology. While
Evidence from ATI studies has most often demonstrated a
accepting the strong internal validity of RCTs (that is, having
match between a personality dimension and 2 or more distinct
confidence that the treatment was responsible for the outcome
therapies. Researchers have emphasized the importance of
differences), they have emphasized the weak external validity
making a priori, theoretically based predictions in ATI stud-
(that is, generalization to clinical practice) of RCTs. They
ies; this enhances the chances of finding a match as well as the
have argued that clinicians usually do not accept patients ran-
credibility of the findings. Two examples that are frequently
domly, treat patients restricted for age and sex, treat patients
cited come from the work of Beutler and colleagues (27) con-
with minimal comorbidity, or use manualized, time-limited
cerning the personality dimensions of externalization and
therapies (22). They have described RCT studies as tests of
reactance. Externalizing patients responded better to skills-
efficacy, not tests of effectiveness (that is, studies conducted
oriented, symptom-focused therapies, whereas internalizing
in natural clinical settings). In the UK, difficulties have been
patients responded better to insight-oriented therapies.
reported in teaching general practitioners basic CBT skills
Reactance refers to resistance to directives. High-reactant
(23) and in bringing about superior improvement with CBT,
patients responded better to self-directive therapies, whereas
compared with nondirective counselling (24). These findings
low-reactant patients responded better to directive therapies
highlight the difficulty of transferring the practices of
(28). Another example concerns quality of interpersonal rela-
research clinics that conduct RCTs to primary care settings.
tionships. Patients with a history of relatively gratifying inter-
Opponents of the EST movement have also emphasized the personal relationships do better in confrontive, insight-
importance of nondiagnostic patient characteristics, therapist oriented therapies, while patients with a history of relatively
characteristics, and patient–therapist relationship characteris- problematic relationships do better in supportive psycho-
tics in affecting outcomes. To counter the EST movement, therapies. This match has been found in both individual and
some opponents have created their own task force and com- group therapies (29,30). The ATI approach may have particu-
piled lists of empirically supported relationships (25,26). lar promise with group therapies. A review of the
These lists highlight such relationship characteristics as the group-therapy literature found that 83% of the ATI studies
therapeutic alliance, goal consensus, self-disclosure, and had significant findings (31).
group cohesion in group therapies. Opponents have also
argued that RCTs suffer from dropouts, which undermines Implications
random assignment, and that they are but one of many meth- Trainees should be aware of the specific matches identified by
ods to investigate the effectiveness of the psychotherapies. the EST movement. They should also be familiar with
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Other controversial themes that characterize the field of psy- treating problems that are severe and recurrent, and the fact
chotherapy research also have implications for training. Three that many teachers find them to be a useful means of learning
additional examples follow. First is the theme that supportive about patients and psychotherapy, long-term therapies should
therapy is a distinct form of psychotherapy that is effective for be included in the curriculum. A similar argument can be
many types of problems (50,51). Second is the theme that inte- made for including couple and family therapies.
gration of different techniques has become a recommended
The combination of psychotherapies and medications is a nat-
approach to the practice of psychotherapy; examples include
ural and important topic for the curriculum of psychiatrists in
cognitive behavioral analysis system of psychotherapy
psychotherapy training because they have general training in
(CBASP) for chronic depression (52) and coping strategies
medicine and, therefore, a unique area of expertise among
therapy (CST) for bulimia nervosa (53). Third is the theme
mental health professionals. Further, given their expected
that transference and countertransference are important
leadership role in many mental health teams, it is important
events to be recognized and dealt with in all types of psycho-
that psychiatrists receive training in supervising, consulting,
therapy, not just in dynamically oriented psychotherapies
and making referrals.
(54). Space limitations do not permit elaboration and consid-
eration of the implications of these and other themes. It is important that the curriculum not be restricted to the
acquisition of specific clinical skills. As indicated previously,
the field of psychotherapy research is continually evolving in
Discussion terms of both methodology and content. Teachers should be
The implications of the themes that have emerged from the encouraged to integrate research evidence of effectiveness,
research literature suggest specific content for a curriculum in reviews of the literature, and the latest studies that contribute
psychotherapy training. To be informed consumers, trainees new information about the psychotherapies with the teaching
require training in basic research methodology. This includes of clinical skills. Obviously, research does not address many
becoming familiar with the different methods of reviewing areas of training. Hopefully, considerably more areas will be
research literature, such as metaanalysis; an appreciation of covered. In the meantime, there are some excellent resources
different approaches to studying the effectiveness of the based on considerable teaching and clinical experience that
psychotherapies; and knowledge of basic methodological and can help fill the gaps with reasonable suggestions. These
statistical weaknesses that affect the conclusions one can include publications by Cameron and colleagues (55–57).
make about studies. The objective is not to transform trainees Last but not least, trainees should be familiar with the contro-
into researchers but to provide trainees with a basic set of versial themes and implications highlighted in this article.
skills for understanding research literature that can be confus- Although they may heighten some uncertainties about the
ing. Trainees should be familiar with the EST movement, broad range of psychotherapies being taught, they will pro-
including its lists of treatments and disorders and its limita- vide a more realistic and enlightened perspective of the field,
tions. Similarly, trainees should be aware of good patient– commensurate with the goal of creating well-informed, com-
treatment matches from the aptitude-treatment literature. petent psychiatrists.
They should also be familiar with the empirically supported
relationships movement, including its lists and limitations.
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