1. Psychology 6104
How Effective is Psychotherapy?
Incorporating a BPS Approach to Psychotherapy
Dr. Kim Vaughn
October 2014
Jacqueline Flowers
2. • What is Psychotherapy?
• Is Psychotherapy Effective?
• Are the Benefits of Psychotherapy Clinically Significant?
• Do the Benefits of Psychotherapy Last?
• How does the Effectiveness of Psychotherapy Compare to Medication?
• Does Psychotherapy Work for Everyone?
• Do All Therapies Work Equally Well?
• How Do We Explain the Effectiveness of Psychotherapy?
• Lambert’s Four Factors
• Wampold’s Therapist Competence
• Measuring Therapist Competence
• If Therapies are fairly Equivalent what about…
• What else accounts for the effectiveness of therapy?
• Reducing Treatment Failures
• by Broadening Treatment Options
• by Monitoring and Outcome Assessment
• By Evidence Based Practice
• A Biopsychosocial Model
• The Focus of the BPS Approach to Therapy
• A BPS Treatment Approach
3. What is Psychotherapy?
According to the Canadian Counselling and Psychotherapy Association
Definition of counselling: Counselling is a relational process based upon the
ethical use of specific professional competencies to facilitate human change.
Counselling addresses wellness, relationships, personal growth, career
development, mental health, and psychological illness or distress. The counselling
process is characterized by the application of recognized cognitive, affective,
expressive, somatic, spiritual, developmental, behavioural, learning, and systemic
principles. Who are Counsellors? Canadian Counselling and Psychotherapy Association. (2014). Retrieved from
http://www.ccpa-accp.ca/en/theprofession/whoarecounsellors/
On the American Psychological Association web page they define psychotherapy
as follows:
“Psychotherapy is a collaborative treatment based on the relationship between an
individual and a psychologist. Grounded in dialogue, it provides a supportive
environment that allows you to talk openly with someone who’s objective, neutral
and nonjudgmental. You and your psychologist will work together to identify and
change the thought and behavior patterns that are keeping you from feeling your
best.”
4. Is Psychotherapy Effective?
• The evidence supporting the effectiveness of
psychotherapy is extensive
o Meta analyses of studies on the effectiveness of
psychotherapy show effect sizes ranging from 0.75
and 0.85
o Wampold (2001) concluded that “a reasonable
and defensible point estimate for the efficacy of
psychotherapy would be .80 (Melchert 2011)
5. Are The Benefits Of Psychotherapy
Clinically Significant?
• Lambert and Archer (2006) concluded that
approximately three quarters of patients who
undergo treatment show positive benefits,
and 40-60% return to a state of normal
functioning. (Melchert, 2011)
• The average client receiving psychotherapy is
better off than 79% of untreated clients.
Although psychotherapy does not work
perfectly or for all clients, it is, simply put,
remarkably effective. (Campbell et al, 2013)
6. Do The Benefits Of Psychotherapy
Last?
• There tends to be some decay in the
psychotherapy benefits over time for most
psychotherapies, though the decay is far less
than for psychotropic medications…the
benefits of some therapies have actually been
found to increase over time. (Melchert 2011)
7. How Does the Effectiveness of Psychotherapy
Compare with Medications?
www.apa.org/psychotherapy
"Psychological interventions have generally been
shown to be equal or greater in effectiveness than
medicines for a range of psychological disorders except
for the most severe conditions such as schizophrenia
and bipolar affective disorder" (as cited in Hunsley et al, 2014)
DEPRESSION STUDIES -
Taken collectively, these meta-analyses
suggest that pharmacotherapy and
psychological treatment have comparable
success
rates in treating depression, with better
results at follow-up for psychological
treatment. These results provide substantial
evidence that both psychological treatments
and antidepressant medication work for
many depressed adults, thus providing
those suffering from depression a viable
choice of treatment options. There is also
evidence that combining the two
treatments can yield greater effects than is
obtained with either treatment on its own.
(Hunsley et al. 2014)
However, mood-stabilizing medication appears to
prevent relapse in relatively few patients, as 70% to
85% of patients relapse within 5 years; additionally,
30% to 50% of patients do not adhere to their
medication treatments and/or continue to experience
significant residual symptoms while on the medications
(Szentagotai & David, 2010). Although psychotherapy
alone cannot successfully treat this disorder, increasing
evidence suggests that, as an adjunct to mood-
stabilizing medication, it can significantly reduce relapse
rates and improve overall functioning and well-being in
youth, adults, and older adults. (Hunsley et al. 2014)
Bipolar Disorder
8. Does Psychotherapy Work for
Everyone?
• 25% of patients are early responders – showing a
dramatic improvement within the first few weeks of
therapy
• 5-10% of patients experience a steadily declining state
of health that fails to respond to the most effective
therapies and therapists
• 15-25% of patients neither improve or decline during
therapy
• The severity and complexity of the patients mental
health state are widely variable and therefore the
effects of therapy are also variable
(Melchert, 2011)
9. Do All Therapies Work Equally Well?
The Dodo Bird Verdict
• The researchers Lambert and Wampold are
known for their research into the “common
factors” model explaining the effectiveness of
psychotherapy.
Rosenzweig introduced the metaphor of the Dodo Bird,
after the feathered creature in Lewis Carroll's Alice in
Wonderland, who declared following a race that
“everyone has won, and all must have prizes.” The “Dodo
Bird verdict” has since come to refer to the claim that all
therapies are equivalent in their effects
Rosenweig suggested that a few common factors such as
the therapeutic relationship, showing respect for the
client(s), and giving hope, were the reason that
psychotherapy was effective. (Lillien et al, 2012)
10. How Do We Explain the Effectiveness of
Psychotherapy?
15%
30%
15%
40%
Lambert’s (1992) estimates regarding the
factors explaining the effectiveness of
psychotherapy
Specific Techniques
Common
Expectancy
Extratherapeutic Change
Common Factors + Extra-therapeutic Changes
There is controversy over which elements of therapy most contribute to its effectiveness.
11. Lambert’s Four Factors
• Specific Techniques (15%) – the effectiveness of
particular treatment or techniques for particular
disorders
• Expectancy (15%) – expectations that one will improve
as the result of being in treatment
• Common Factors (30%) – factors found across
therapies, such as empathy, warmth, acceptance and
encouragement to take risks
• Extra therapeutic Change (40%) – factors associated
with the patient ( e.g., severity of psychopathology and
level of ego strength or the patient’s environment (e.g.,
availability of social support)
(Melchert, 2011)
12. Wampold’s Therapist Competence
Intrapersonal
component
•Avoids negative or hostile
behaviors toward client
•Doesn’t allow dysfunctional
personality characteristics
to influence care
Interactive
component
•Able to develop a
collaborative relationship
with patients
•Able to get patients to
process emotion
effectively
Interpersonal
skill
•Selective response to
patients needs
•Open and clear
communication
•Communicates openness
and empathy
Type of Treatment
Provided 0 - 8%
Unexplained Patient
Characteristics 22%
Therapist
Competence 70%
(Wampold, 2001)
13. While therapist competence is a factor in the effectiveness of
psychotherapy, the therapist may not be as competent as they
think…
• In one study in which therapists were asked to gauge their
effectiveness, nearly one quarter of the sample believed
that 90% or more of their clients improved. Half the sample
reported that none of their clients deteriorated while under
their care (Walfish, McAlister, O’Donnell, & Lambert, 2010).
Our self-distorted view was revealed in an outcome study
showing that the least effective therapists rated themselves
as being on par with the most effective therapists (as cited
in Beihl, 2011).
Measuring Therapist Competence
14. If therapies are fairly equivalent in
effectiveness what about…
• Although most researchers agree that common factors play
key roles in psychotherapy, some doubt that all methods are
equally effective. Even Wampold has been careful to note
that his conclusion holds for only bona fide treatments; it
does not extend to all 500 or so therapies. For example, few
experts would contend that rebirthing therapy, premised on
the dubious idea that we must “relive” the trauma of our
birth to cure neurosis, works as well as cognitive-behavior
therapy for most psychological conditions. (Hunsley et al,
2002)
Jeane Newmaker was charged
with child abuse and neglect after
taking part in an attachment
therapy “rebirthing” session that
killed her adopted child Candace.
http://www.mentalfloss.com/blogs/wp-content/uploads/2011/04/candace20_350x249.jpg
15. So what else accounts for the effectiveness of psychotherapy if not the
specific technique or the competence of the therapist?
Although the therapeutic alliance is an important predictor of outcome, it only
accounts for about 7% of outcome variation. About 87% of outcome variability is
related to extratherapeutic-client factors—unique aspects of each client and his
or her environment—about which little is known (Wampold, 2001).
In an earlier slide we saw that 5-10% of patients experience a steadily
declining state of health that fails to respond to the most effective therapies
and therapists and15-25% of patients neither improve or decline during
therapy. By taking a holistic BPS approach to therapy we can reduce the
influence of these “extra-therapeutic client factors” on the outcome of
therapy.
What else accounts for the
Effectiveness of Psychotherapy?
Extra-therapeutic Client Factors
16. Reducing Failures by Broadening Of Treatment
Options.
In their review of the Dodo bird verdict, Stiles, Shapiro, and Elliott
(1986) concluded that the search for "winners" among treatments was
the wrong direction for psychotherapy research to take. Instead, they
argued that much more would be gained by examining differences
among techniques as they are used in the process of treatment. Rather
than determining the relative superiority of two treatments, they
suggested that much more would be learned by comparing techniques
that have been proposed to be useful in achieving intermediate, small
changes in a session of treatment for example, comparing a two-chair
technique with reflective listening for resolving decisional conflicts.(as
cited in Hunsley et al, 2002)
From the biopsychosocial metatheoretical perspective, the current research
literature suggests that there are a variety of therapeutic interventions
available to address patient needs and maximize their biopsychosocial
functioning. (Melchert, 2011)
17. Reducing Treatment Failures by
Monitoring and Assessing Outcomes
• There is evidence, however, that the ongoing monitoring of
treatment outcomes can reduce the number of failed treatments.
• Outcomes assessment is valuable because it generally focuses on
what is most meaningful to patients and other stakeholders. A BPS
approach to outcomes assessment would include both global and
generic measures of assessment. (Melchert, 2011) By monitoring
the patient and modifying the techniques and treatment plan
accordingly we may be able to identify when a treatment is failing
and also identify what techniques work well.
– Studies have shown that when feedback is obtained from the client
regarding treatment progress and the alliance, the likelihood of
improvement increases, and the likelihood of deterioration decreases.
(Beihl ,2011)
18. Reducing Failures by Evidence Based
Practice
Evidence-based practice is a trans-
disciplinary approach that aims to
improve accountability for health care
practices and promote lifelong
learning.(Spring, 2007)
EBP practice guidelines frame
treatment recommendations no-
mothetically. They specify the best
research-supported treatment for a
disorder, biopsychosocial condition,
or life problem. (Spring, 2007)
Consistent with ethical codes and professional standards, evidence-based practice
entails the monitoring and evaluation of services provided to clients throughout
treatment (from initial intake to treatment termination and maintenance of
gains.(Canadian Psychological Association, 2012)
http://www.psychotherapy.net/data/uploads/4ddbf47876130.jpg
19. A Biopsychosocial Model
• Stop searching for a reductionist, purely biological explanation for
psychological phenomenon. "It is implausible to expect any one
explanation (e.g., neurotransmitter dysregulation, irrational thinking,
childhood trauma) to fully account for mental disorders," he writes. "No
portion of the biopsychosocial model has a monopoly on the truth.“
(Deacon, 2013).
The late George Engel believed that to
understand and respond adequately to
patients’ suffering—and to give them a
sense of being understood—clinicians
must attend simultaneously to the
biological, psychological, and social
dimensions of illness. He offered a holistic
alternative to the prevailing biomedical
model that had dominated industrialized
societies since the mid-20th century. His
new model came to be known as the
biopsychosocial model.
(Borrell-Carrió et al., 2004 ) http://savvywillingandable.wordpress.com/2013/09/25/the-biopsychosocial-model-explained/
20. Focus of the BPS Approach
A biopsychosocial approach to behavioral health care
emphasizes a broad, holistic, systemic, and developmental
perspective to understanding treatment.(Melchert, 2011)
BPS Treatment is focused on
– Current and long term developmental functioning
– Health and wellness strengths across all domains
– Monitoring progress and improving resilience over time
– Collaboration with other professionals and third parties
– The role of risk, protective and compensatory factors in
treatment and behavior change.
21. A BPS TREATMENT APPROACH
S
B P
SYMPTOMS
B P
S
B P
S
Etiology
Treatment
Plan
Treatment
DIAGNOSIS
Consider the 26
biological, social and
psychological
components connected
to the symptoms.
Consider the biological,
social and psychological
factors connected to
the plan of treatment.
Consider the biological,
social and psychological
factors connected to
the treatment
Use an in depth intake
form that allows for
modification as more
elements of etiology
are revealed.
Consider what EBP strategy
will best address the needs
of the client
Implement the plan of
treatment considering the
BPS resources and
collaborations at your
disposal.
22. References
Beihl, H. Psychotherapy: Shifting from technique to client. (Fall 2011). BC Psychologist, 18-22.
Campbell, L. F., Norcross, J. C., Vasquez, M. T., & Kaslow, N. J. (2013). Recognition of psychotherapy effectiveness: The APA resolution. Psychotherapy,
50(1), 98-101. doi:10.1037/a0031817
Canadian Psychological Association. (2012). Evidence based practice of psychological disorders: A Canadian perspective. Report of the CPA Task Force on
Evidence-Based Practice of Psychological Treatments, Canadian Psychological Association (CPA).
Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. The Annals
of Family Medicine, 2(6), 576-582.
Deacon, B. J. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical
psychology review, 33(7), 846-861.
Hunsley, J., & Di Giulio, G. (2002). Dodo Bird, Phoenix, or Urban Legend? The Question of Psychotherapy Equivalence. The Scientific Review of Mental
Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work.
Hunsley, J., Elliott, K., & Therrien, Z. (2014). The Efficacy and Effectiveness of Psychological Treatments for Mood, Anxiety, and Related Disorders.
Canadian Psychology, 55(3), 161-176. doi:10.1037/a0036933
Lilien, S., & Arkowitz, H. (2012, August 2). Are All Psychotherapies Created Equal? Scientific American
Melchert, T. P. (2011). Foundations of professional psychology: The end of theoretical orientations and the emergence of the biopsychosocial approach.
Elsevier.
Spring, B. (2007). Evidence-based Practice In Clinical Psychology: What It Is, Why It Matters; What You Need To Know. Journal of Clinical Psychology, 63(7),
611-631. Retrieved October 10, 2014, from http://faculty.weber.edu/eamsel/Classes/Science and Profession (2010)/Papers/Spring 2007.pdf
Wampold, B. E. (2001). The Great Psychotherapy Debate: Models, Methods and Findings. New York: Lawrence Erlbaum.
Who are Counsellors? | Canadian Counselling and Psychotherapy Association. (2014). Retrieved from http://www.ccpa-
accp.ca/en/theprofession/whoarecounsellors/
Understanding psychotherapy and how it works. (2014). Retrieved from http://www.apa.org/helpcenter/understanding-psychotherapy.aspx
