Psychotherapy: Does it Work? Why Does it Psychotherapy: Does it Work? Why Does it Work?Work? Psychotherapy: Does it Work? Why Does it Psychotherapy: Does it Work? Why Does it Work?Work?

Bruce E. Wampold, Ph.D., ABPPDepartment of Counseling PsychologyDepartment of PsychiatryUniversity of Wisconsin-- Madison

&

Research InstituteModum Bad Psychiatric CenterVikersund NORWAY

Does it work?Does it work?Psychotherapy v. No-tx Psychotherapy v. No-tx Eysenck, science, and behaviorismEvidence from RCTs:

◦ Smith and Glass (1977)◦ Effect size: ◦ g = (mean Tx - mean Control)/SD

es = .80Accounts for 13% of variance in outcomesAverage treated person does better than

80% of untreated persons

Psychotherapy worksPsychotherapy worksNNT = 3 – three patients need to be treated

to obtain one additional successAspirin 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 safeEffects in practice comparable to

benchmarks created by RCTsElite club: Medicine and psychotherapy

Effect sizesEffect sizesd r %

variancennt Description

.2 .10 1.0% 9 small

.3 .15 2.2% 6

.4 .20 3.8% 5

.5 .25 5.9% 4 Medium

.6 .29 8.3% 4

.7 .33 10.9% 3

.8 .37 13.8% 3 Large

Tx v. No Tx

How does it work?How does it work?TreatmentCommon factorsInteraction of specific and

common factors– the contextual model

Specific Treatment EffectsSpecific Treatment EffectsPsychological 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 groupsInference: Specified treatment

differences will exist

Treatment DifferencesTreatment DifferencesTreatment 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)Wampold et al. (1997)All direct comparisons across

disordersEffects homogeneously distributed

about zero– No evidence to reject the null hypothesis

Upper bound◦d = .2◦% variance < 1%◦NNT = 9◦SMALL

Effect sizesEffect sizesd r %

variancennt Description

.2 .10 1.0% 9 small

.3 .15 2.2% 6

.4 .20 3.8% 5

.5 .25 5.9% 4 Medium

.6 .29 8.3% 4

.7 .33 10.9% 3

.8 .37 13.8% 3 Large

Tx A v. Tx B

Depression Depression (see (see

http://www.div12.org/PsychologicalTreatmentshttp://www.div12.org/PsychologicalTreatments

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 therapyBehavioral/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 CT for Depression (Jacobson et al. 1996)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 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 resultsJacobson 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”

PTSDPTSD

PE, Stress Inoculation Training v. Supportive Counseling (Foa et al.)

PE, SIT scientifically designed treatments

PE, SIT > Supportive CounselingConclusion:

◦Exposure, cognitive change needed.

Supportive CounselingSupportive Counseling“Patients were taught a general problem-

solving 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 PTSD in Adult Female Childhood Sexual Abuse (Completer Sample)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 PTSD in Adult Female Childhood Sexual Abuse Childhood Sexual Abuse (Intent to treat)(Intent to treat)Measure Tx A Tx B Effect size

% not ptsd 27.6% 31.8%

Clinician PTSD 53.1 47.2 -.22

BDI 12.9 10.8 -.18

Spielberger TAI 46.2 46.4 .02

TSI Beliefs 2.7 2.4 -.41

Dissoc. experiences

12.4 11.5 -.09

Cook Hostility 21.6 17.1 -.54

Qual of Life 39.5 39.0 .03

PTSD Dropout RatePTSD Dropout RateTx A Tx B

Enrolled 29 22

Completed 17 20

Dropped out 12 2

% dropped out

41% 9%

WL chose tx 5/10 dropped

0/9 dropped

PTSDPTSD“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.”

PTSDPTSDTx 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? McDonagh et al. 2005

Present Centered TherapyPresent Centered Therapy RCT 1: PCGT v TFGT

Scnurr et al. 2003 Vietnam Vets

RCT 2: PCT v CBT McDonagh et al. 2005

Childhood Sexual Abuse

RCT 3: PFGT v TFGT Classen 2011

Childhood Sexual Abuse/HIV Risk PCGT TFGT No

Difference PCGT TFGT No

Difference PCGT TFGT No Difference

Drop Rate***

CAPS Total severity

Drop Rate *

CAPS Total HIV risk *

Anger/ Irratability**

PTSD Severity

CAPS B BDI Sexual revictimization

CAPS C STAI Substance Use PTSD

Checklist DES Risky Sex

General Health Q

COOK # of partners

SF-36 Physical

STAXI Avoidance

SF Mental QOLI Reexperiencing Interpersonal

Problems Depression Dissociation Sexual

Concerns Dysfunction

Sex Impaired Self-

references Tension

Reduction Posstraumatic

Growth Drop Rate

Present Centered TherapyPresent Centered Therapy3 TrialsComparable (or better) than

Evidence-based Treatment> 2 Research groupsManualizedMeets standards for evidence-

based treatment (Frost et al., submitted)

Consider EMDR◦Pseudo science, Mesmerism

Resick et al. 2008 PTSDResick et al. 2008 PTSDCognitive Processing Therapy Cognitive therapy onlyWritten Accounts2hr/wk, 6 weeks (writing 45-60

min)All 3 treatments showed

improvement

Post Traumatic Diagnostic Post Traumatic Diagnostic ScaleScale

PTSDPTSDProlonged 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 diagnosesOther 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)

ChildrenChildrenDepression 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

Meta-analysis of studies Meta-analysis of studies comparing 2 treatmentscomparing 2 treatments

Meta-analysis of studies Meta-analysis of studies comparing 2 treatmentscomparing 2 treatments9 comparisonsOverall effect not significantOnly 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….If not treatment, then….Common Factors

AllianceAllianceBond (i.e., relationship) Agreement on Goals Agreement on Tasks

Alliance and outcome Alliance and outcome correlationcorrelationHorvath et al. (2011) reviewed

190 studies, > 14,000 patientsCorrelation of alliance at early

session and outcomer = .27 d = .57 > MEDIUM

Effect sizes-- AllianceEffect sizes-- Allianced r %

variancennt Description

.2 .10 1.0% 9 small

.3 .15 2.2% 6

.4 .20 3.8% 5

.5 .25 5.9% 4 Medium

.6 .29 8.3% 4

.7 .33 10.9% 3

.8 .37 13.8% 3 Large

Alliance

Alliance and outcome Alliance and outcome correlationcorrelationHorvath et al. (2011) reviewed 190

studies, > 14,000 patientsCorrelation of alliance at early

session and outcomer = .27 d = .57 > MEDIUMNot 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 Psychotherapy Relationships that Work: Norcrossthat Work: NorcrossRelationships that Work Relationships that Work (2011)(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 Common Factors—Specific FactorsFactors

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 .14Webb, DeRubeis, & Barber, 2010

NOT SIGNIFICANT

Correlations v. RCTsCorrelations v. RCTsCorrelation does imply causation Issues with RCTs

◦Selection and Generalizability◦Blinding◦Distinguishability◦Active ingredients◦Therapist effects◦Outcome measures

Therapist Effects Therapist Effects Definition: Some therapists

consistently attain better outcomes than other therapists

Not due to contribution of patientsNot due to chance Generalizable to the population of

therapistsCompare to effects for other factors

(e.g., treatment differences)

Therapist Effects– The Therapist Effects– The EvidenceEvidenceClinical 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 reanalysisNIMH TDCRP reanalysisNested Design (CBT and IPT)Well trained therapists, adherence

monitored, supervisionElkin:

◦ 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 (40,198,715.15 SEK)

Random Effects ModelingRandom Effects ModelingTherapists considered a random factorTherapists nested within treatments

(multilevel model)Final observations, controlling for pretest at

patient and therapist level◦ Kim, Wampold, & Bolt, Psychotherapy Research, 2006

Random Effects ModelingRandom Effects ModelingTherapists considered a random factorTherapists nested within treatments

(multilevel model)Final observations, controlling for pretest at

patient and therapist levelTherapist slope fixed and random

◦ Kim, Wampold, & Bolt, Psychotherapy Research, 2006

Greater Severity

Greater Severity

Variance due to Tx: CBT v Variance due to Tx: CBT v IPT IPT

Variable Treatment

Therapist

BDI 0%

HRSD 0%

HSCL-90 0%

GAS 0%

Variance due to Tx and Variance due to Tx and TherapistsTherapists

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– Psychiatrist Effects– PsychopharmacologyPsychopharmacology

Antidepressants: Imipramine v. Placebo

30 minutes, biweekly3% due to treatment9% due to therapistBest psychiatrists got better

outcome with placebo than worst psychiatrists with imipramine (McKay, Imel & Wamold, 2006)

Effect sizes– Therapists Effect sizes– Therapists EffectsEffectsd r %

variancennt Description

.2 .10 1.0% 9 small

.3 .15 2.2% 6

.4 .20 3.8% 5

.5 .25 5.9% 4 Medium

.6 .29 8.3% 4

.7 .33 10.9% 3

.8 .37 13.8% 3 Large

Therapists Effects

Therapists make a Therapists make a differencedifferenceCharacteristics 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 questionBeginning to accumulate evidenceBtw: therapist effects inflates

treatment differences

Alliance: Patient v. Therapist Alliance: Patient v. Therapist Contribution to AllianceContribution to AllianceCounseling center consortium dataOQ pre and post, Alliance 4th session331 patients, 80 therapistsAlliance/outcome correlation .243% of variance due to therapistsWhat is correlation of alliance with

outcome◦ Within therapists?◦ Between therapists?

And the results….

Within or between?Within or between?

Better therapist

Therapist contribution to Therapist contribution to alliance is criticalalliance is criticalPatient contribution to alliance

not predictive of outcome Therapist contribution is

predictive of outcomeInteraction not significantAlliance is not a result of

outcome

Interpersonal skillsInterpersonal skillsVerbal 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)

ConclusionsConclusionsTreatment

◦Particular treatment not important◦Treatment IS important

Who delivers the treatment is primary◦Therapist who can form alliances

with patients◦Interpersonal skills

AN EVIDENCED-AN EVIDENCED-BASED MODEL OF BASED MODEL OF PSYCHOTHERAPYPSYCHOTHERAPY

Creation of expectation through explanation and some form of treatment

Real relationship, belongingness, social connection

Trust, Understanding,

Expertise

Patient

Therapist

Tasks/Goals Therapeutic Actions

Healthy Actions

Symptom Reduction

Better Quality of

Life

Relationship ElementsRelationship Elements

Initial formation of Initial formation of therapeutic bondtherapeutic bond

Humans evolved to discriminate between those who can be trusted and those who cannot

50 msContext, healing

practiceNonverbal

Trust, Understanding,

Expertise

Patient

Therapist

Real RelationshipReal RelationshipTransference-free genuine

relationship based on realistic perceptions (Gelso, 2009)

Social relations = well beingSocial isolation = pathologyPsychotherapy is uniquely

ENDURING

Real relationship, belongingness, social connection

Trust, Understanding,

Expertise

Better Quality of

Life

ExpectationExpectationExpectation influence on well beingPlacebo effectsCreated in interpersonal interactionExplanation of disorderAgreement about tasks and goals of

TxTreatment actions

Creation of expectation through explanation and some form of treatment

Trust, Understanding,

Expertise

Symptom Reduction

Better Quality of

Life

Specific ActionsSpecific ActionsIndirect EffectAgreement tasks & goals adherence

to protocolHealthy actionsNeed to develop and test protocols

Trust, Understanding,

Expertise

Tasks/Goals Therapeutic Actions

Healthy Actions

Symptom Reduction

Better Quality of

Life

ConclusionsConclusionsRelationship factors critical

◦Real relationship◦Explanation expectations◦Agreement about tasks and goals

healthy actionsHuman evolved to heal through

social means Treatment important, but is the

particular treatment?

IMPROVE QUALITY OF IMPROVE QUALITY OF CARECAREDisseminate Evidence-based

TreatmentsMeasure and manage outcomes

◦Use best therapists◦Help poorer therapists improve

Provide therapists feedbackProvide training

◦Common fctors◦Specific treatments

Thank YouThank You

Bruce E. Wampold, Ph.D., ABPPPatricia L. Wolleat Professor of Counseling PsychologyClinical Professor, PsychiatryUniversity of Wisconsin--Madison Director, Research InstituteModum Bad Psychiatric CenterVikersund, Norway

bwampold@wisc.edu