Psychotherapy: A Relationship Based Model of Psychotherapy

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1 Psychotherapy: A Relationship Based Model of Psychotherapy 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

2 Overview Brief over of research evidence Model consistent with evidence Integration of common factors and specific ingredients

3 Does Psychotherapy 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

4 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

5 Effect sizes d r % variance nnt Description % 9 small % % % 4 Medium % % % 3 Large Tx v. No Tx

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

7 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

8 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

9 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

10 Effect sizes d r % variance nnt Description % 9 small % % % 4 Medium % % % 3 Large Tx A v. Tx B

11 Depression (see 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?

12 CT for Depression (Jacobson 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 cognitivebehavioral 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

13 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

14 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)

15

16 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) EMDR? Present Centered Thearpy

17 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)

18 Children Depression 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

19 If not treatment, then If not treatment, then. Common Factors

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

21 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

22 Effect sizes-- Alliance d r % variance nnt Description % 9 small % % % 4 Medium % % % 3 Large Alliance

23 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?

24 Psychotherapy Relationships that Work: Norcross Relationships that Work (2011) Factor # Studies # Patients Effect size d Alliance 190 > 14, Alliance-Child & Adolescents Alliance-Couple & Family Empathy Goal Consensus, Collaboration Positive regard, affirmation Congruence, genuineness

25 Common Factors Specific Factors Factor # Studies # Patients Effect size d Alliance 190 > 14, Alliance-Child & Adolescents Alliance-Couple & Family Empathy Goal Consensus, Collaboration Positive regard, affirmation Congruence, genuineness Adherence to specific protocol Rated competence Webb, DeRubeis, & Barber, 2010 NOT SIGNIFICANT

26 Therapist Effects Definition: Some therapists consistently attain better outcomes than other therapists 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)

27 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

28 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 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 (34,260,000 NKr)

29 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

30 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 Greater Severity

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

32 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

33 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 (McKay, Imel & Wamold, 2006)

34 Effect sizes Therapists Effects d r % variance nnt Description % 9 small % % % 4 Medium % % % 3 Large Therapists Effects

35 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

36 Alliance: Patient v. Therapist Contribution to Alliance 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.

37 Within or between? Better therapist

38 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

39 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)

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

41 An evidenced-based model of psychotherapy Integrating Common Factors and Specific Ingredients

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

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

44 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

45 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 Creation of expectation through explanation and some form of treatment Better Quality of Life Symptom Reduction

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

47 Conclusions Relationship factors critical Real relationship Explanation expectations Agreement about tasks and goals participation in treatment healthy actions Human evolved to heal through social means

48 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

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