1. General Issues in Psychotherapy
Chapter 11
General Issues in Psychotherapy

2. Overview This is the first chapter in the section on psychotherapy
Psychotherapy is the most common professional activity of clinical psychologists
Upcoming chapters will focus on specific approaches; this chapter focuses on general psychotherapy issues

3. Does Psychotherapy Work?
Through the mid-1900s, most answers to this question came in subjective, non-empirical forms (few empirical studies)
Hans Eysenck (1952) concluded that therapy was of little benefit
His finding has since been overturned, but his study inspired decades of research on therapy outcome
After reviewing some of the early empirical studies on psychotherapy outcome, Eysenck concluded that most clients got better without therapy and that in general, psychotherapy was of little benefit. His scientific methods have since been criticized and his claims overturned.

4. Who, When, and How Should Researchers Ask?
Tripartite (“three party”) model - Hans Strupp
Client
Therapist
Third parties (society, family, insurance company, others)
Ratings by any of these three parties can be informative, but also biased
Some clients may be overly eager to see positive results, especially after investing significant time and money, and therefore overestimate therapy’s benefits. Other clients’ opinions about psychotherapy may be negatively influenced by the very factors that brought them to therapy in the first place.
Therapists witness only a fraction of clients’ lives, and they may feel that negative evaluations reflect poorly on their own therapeutic skills.
Society tends to bring a perspective that emphasizes the client’s ability to perform expected duties in a stable, predictable, unproblematic way.

5. Who, When, and How Should Researchers Ask? (cont.)
Immediately after therapy?
Follow-up?
After months? Years?
Before therapy ends?
At certain points, or at every session?
Shrewd researchers may choose multiple answers to the question of when, either within or across psychotherapy studies. But it is evident that the time at which the researchers answer this question may influence the results they see.

6. Who, When, and How Should Researchers Ask? (cont.)
Questionnaires?
Interviews?
What questions should be asked?
Behavioral observation?
Who, when, and how researchers ask about psychotherapy can influence results

7. Efficacy vs. Effectiveness
Efficacy—the extent to which psychotherapy works “in the lab”
In controlled outcome studies
Therapists’ methods are controlled or manualized
Clients are selected for diagnostic criteria
Better internal validity than external validity
Most recent studies of psychotherapy outcome are efficacy studies. They maximize internal validity—that is, the ability to draw conclusions about the cause-effect relationship between therapy and outcome—by controlling as many aspects of therapy as possible.

8. Efficacy vs. Effectiveness (cont.)
Effectiveness—the extent to which psychotherapy works “in the real world”
Greater variability in therapists’ methods
Greater variability in clients’ issues and diagnoses
Better external validity than internal validity

9. Efficacy vs. Effectiveness (cont.)
Results of efficacy studies
Overall result: psychotherapy works
Hundreds of meta-analyses and thousands of individual studies support this finding
Average person receiving therapy is better off than 80% of comparable others who don’t
Benefits last and exceed placebo effect
Psychotherapy works (Lambert, 2011; Wampold, 2010a). For example, a primary finding of a landmark meta-analysis of 475 psychotherapy efficacy studies (Smith, Glass, & Miller, 1980) was that the average effect size for psychotherapy was .85, indicating that “the average person who receives therapy is better off at the end of it than 80 percent of the persons who do not” (p. 87).

10. Efficacy vs. Effectiveness (cont.)
Results of effectiveness studies
Not as many studies as efficacy studies, but similar results: psychotherapy works
Consumer Reports study is example of a large scale effectiveness study
Therapy had positive effects
Results lasted over time
Some methodological concerns
Sampling bias
No control group

11. Alternate Ways to Measure Psychotherapy Outcome
Neurobiological effects of therapy
Via fMRI, PET neuroimaging, etc.
Therapy changes the brain
Medical cost offset
Indirect measure of therapy outcome
Successful therapy reduces later medical costs
A review of more than 90 studies on this issue found that, on average, clients receiving therapy spent fewer days in the hospital and saw their medical costs reduced by 15.7%, while comparable clients in control groups spent more days in the hospital and saw their medical costs increased by 12.3% (Chiles, Lambert, & Hatch, 1999). Additionally, psychotherapy has been found to reduce the need for emergency room visits (Carr, 2008).

12. Which Type of Psychotherapy is Best?
Supporters of various kinds of therapy have often claimed theirs is superior
However, comparative outcome studies have consistently reached the same finding: a virtual tie
Different therapies are equally effective
This finding was nicknamed the “dodo bird verdict” (from Alice in Wonderland)

13. Which Type of Psychotherapy is Best? (cont.)
How could various therapies be equally effective?
Common factors—shared, fundamental elements of therapy (rather than specific techniques) are “active ingredients”
Therapeutic relationship/alliance
Hope
Attention
Three-stage sequential model of common factors
Support, learning, action factors (in that sequence)
Support factors: a strong therapist-client relationship, therapist warmth and acceptance, trust
Learning factors: changing expectations about oneself, changes in thought patterns, corrective emotional experiences, new insights
Action factors: taking risks, facing fears, practicing and mastering new behaviors, working through problems

14. Which Type of Psychotherapy is Best? (cont.)
The dodo bird verdict has not gone unchallenged
Some researchers (e.g., Dianne Chambless) argue that for specific disorders, some therapies are demonstrably better
Outcome studies using manualized treatments for specific disorders can lead to a prescriptive approach to psychotherapy
Certain therapies are “treatments of choice” for specific disorders
This controversy continues today

15. What Types of Psychotherapy Do Clinical Psychologists Practice?
Eclectic/integrative therapy was most popular orientation until 2010
Cognitive is now #1
Psychodynamic therapy has declined since 1960s
Orientation
1960
1973
1981
1986
1995
2003
2010
Eclectic/Integrative 36 55 31 29 27 22
Cognitive —  2  6 13 24 28
Psychodynamic/Psychoanalytic 35 16 30 21 18 15
Behavioral  8 10 14
Humanistic/Rogerian/Existential/Gestalt  7 12  4 2

16. What Format of Psychotherapy Do Clinical Psychologists Practice?
Individual therapy is most common by far
A sizable number of clinical psychologists also practice group, family, marital
Psychotherapy Format
Percentage of Clinical Psychologists Who Practice It 
Individual 98
Couples/Marital 48
Family 34
Group 20

17. The Future of Psychotherapy
Experts expect the future of psychology to include a rise in
Cognitive and behavioral therapy
Culturally sensitive therapy
Eclectic/integrative therapy
Evidence-based therapy

18. Eclectic and Integrative Approaches
Both involve multiple approaches
Eclectic therapy involves selecting the best treatment for a given client based on empirical data from studies of the treatment of similar clients
Integrative therapy involves blending approaches in order to create a new hybrid