The Great Psychotherapy Debate: Models, Methods, and Findings

Rating:
Summary: Client Relationship Trumps Technique: and science proves it
Review: Wampold provides us with an invaluable resource. This book is a remarkable scientific analysis of psychotherapy with significant implications for developments both in this, and related fields. Wampold scrupulously and extensively reviews decades of perplexing and sometimes contradictory research evidence on psychotherapy outcomes. His findings lead him to dispute the fashionable medical model's assumption that the benefits of psychotherapy can be reduced to specific aspects contained in a given treatment: and that it is sufficient or effective to run the 5 D's model of diagnosis, disorder, dysfunction, disease, and deficit against a client's symptoms.

Wampold's review of the literature convincingly argues that successful outcomes depend more upon general therapeutic effects, and is best predicted by a contextual model. It is a much-needed, very extensive reprise of the idea of the primary role of general or common factors in the efficacy of psychotherapeutic outcomes from the work of Saul Rosenzweig who in the 1930s wrote 'Some Implicit Common Factors in Diverse Methods of Psychotherapy'. Rosenzweig showed remarkable foresight when he argued that any competition to identify a therapy that was superior to its competitors was fated to end in a tie. He anticipated that the value of any therapy's unique features is secondary to, and much smaller than, the factors that they hold in common. Rosenzweig is most often remembered for his adaptation of Lewis Caroll to provide the (Dodo's) verdict on the therapeutic beauty competition, "Everybody has won and all must have prizes".

More recently, Frank & Frank wrote the interesting Persuasion and Healing (issued 1961 with a revision in 1991). Jerome Frank argues that the weight of development and research findings lead him to question whether "psychotherapy might be more closely allied to rhetoric and its close relative, hermeneutics, than to behavioral science!". Frank poses the provocative question, "Could the fundamental limitation of psychotherapy research be that researchers have been trying to apply to the realm of meanings methods created to elucidate facts?". Wampold's review provides some well-validated answers to this and other crucial questions.

Wampold analyses the literature and research findings on:
·the absolute efficacy of psychotherapy;
·the relative efficacy of treatments;
·the differential elements and ingredients offered in various therapies;
·the effects attributable to common factors such as the therapeutic alliance, therapist allegiance and adherence to treatment protocol;
·the effects produced by different therapists who use the same techniques and methods.
Wampold's analysis of the evidence for each of these lends support to a contextual model and discredits the evidence base for applying the fashionable medical model metaphor to psychotherapy. Wampold offers a very fine discussion of how the contextual and medical models compete on a theoretical level and he details the criteria for the acceptance and presentation of evidence and the appropriateness of meta-analyses. The quality of the reasoning enlists the reader and is both engaging and persuasive: that said, this is not an easy read, and the writing style reaches out more readily to the academic market than a general readership. Nonetheless, the text is useful to a more general audience and should be referenced more widely for its findings that contradict what passes currently for received wisdom in popular discussion.

Wampold's well-validated conclusion from analysing decades of variation in psychotherapy outcomes suggest this partitioning of contribution:
1. General effects (common factors that underlie all psychotherapies: >70%).
2. Specific effects (differential aspects that distinguish a particular treatment: <8%).
3. Unexplained variability (encompasses client differences: 22%).

Wampold's analysis illustrates that the best assessment of therapist competence will always be the quality of therapeutic outcomes. In a challenge to professional associations that insist on the pursuit of CEU's, Wampold demonstrates that clients respond more to the quality of the therapeutic relationship, than show improvement related to innovatory techniques and methods. "The evidence in this book has shown that specific ingredients are not active in and of themselves. Therapists need to realize that the specific ingredients are necessary but active only in the sense that they are a component of the healing context. Slavish adherence to a theoretical protocol and maniacal promotion of a single theoretical approach are utterly in opposition to science. Therapists need to have a healthy sense of humility with regard to the techniques they use."

Recent research indicates that the current dependence on cognitive-behavioural therapy (CBT) may be unfounded or at least unjustifiable in some contexts. Wampold strengthens this when he reports that the distinctive/specific ingredients of CBT for depression and anxiety are not demonstrably responsible for any successful outcome in these conditions. Wampold reports that despite strong official support for the streamlining of therapy to a recommended sequence of procedures administered as if from a manual of Standard Operating Procedures, adherence to treatment protocol is not reliably associated with successful outcomes. Wampold warns us: "Therapy practice is both a science and an art ... Treating clients as if they were medical patients receiving mandated treatments conducted with manuals will stifle the artistry."

This fine book is a resource for psychotherapists and also for those of us engaged in coaching individuals and groups for optimal performance. It is my personality type to be attracted to the new, bright, and shiny; but Wampold has convinced me to resist the siren call of unproven innovations and to focus my time and energy on the client relationship as the crucible for positive change.