Last week, my inbox started filling with emails from colleagues about a new study. Working with a real world sample, researchers compared dynamic therapy to cognitive therapy and found…

(drum roll please)

NO DIFFERENCE IN OUTCOME!

Long ago, psychologist Saul Rosenzweig dubbed the equivalence in outcome between competing brands of psychotherapy, “The Dodo Verdict.” 
(I’m the one on the right)

What’s surprising is all the attention the study has been getting.  After all, the “Dodo verdict” is one of the most robust findings in the treatment literature.  And yet, it remains a subject of controversy.  For obvious reasons, those who advocate that certain therapies are more effective than others dislike the Dodo intensely.  In fact, as I’ve reported several times on this blog, that group is forever claiming they’ve found the single study that proves it wrong.

Ultimately, however, the Dodo provides strong empirical support for something practitioners have long known: nothing works for everyone. To find the right path, therapists, and the people they serve, need choice.

Personally, I believe a much more important, yet under reported, finding of the study is the number of people who dropped out after a single visit with their therapist.  In this carefully controlled and executed study, 26% of people in both treatment conditions did not return for a second session.  Slightly more than half—50%–attended 5 sessions or less.  This after having endured a selection and recruitment process that retained only 5% of those initially screened for participation!

Beyond the impact on those seeking service (e.g., inadequate and ineffective care, longer waiting lists, etc.), unilateral client discontinuation and no shows, available evidence shows, “exact a significant financial burden in terms of staff salaries, overhead, and lost revenue, in addition to personnel losses resulting from low morale and high staff turnover.”

What can be done?

Three evidence-based ideas:

1. Setting aside time at the outset of treatment specifically aimed at making people feel welcome and comfortable has consistently been shown to improve attendance. Known variously as “role preparation/indunction,” it’s similar to how you would treat a guest in your home, either formally or informally explaining the therapeutic process, addressing any concerns/apprehensions/misconceptions, and creating an expectation of success.

2. Actively seek negative feedback about the therapeutic relationship.  Clients rarely report negative reactions until they’ve already decided to quit (Horvath, 2001).  Measuring and discussing the status of the working relationship has been shown to improve both retention and outcome.

3. Monitor progress. Not surprisingly, a felt lack of improvement is predictive of service discontinuation.   Clients whose therapists use measures to identify those not making progress or worsening stay longer and improve more than those who do not.

Learn more about how to create a culture of feedback and formally monitor the progress and the therapeutic relationship in this free article from the newly published book, Quality Improvement in Behavioral Health.  Loads of “how to” resources on the ICCE YouTube channel as well.  Check it out here.

What do the common cold and psychotherapy have in common?  Read on, the answers may surprise you…

• Lost productivity costs are roughly the same for the common cold and most common mental health problems;
• The common cold and most common mental health problems affect an amazingly large group of people each year. In the United States alone, citizens suffer 1 billion colds annually.  During the same time period, as much as 30% of the population have a “diagnosable mental or addictive disorder”;
• Both the common cold and psychotherapy are chronically under-researched and underfunded.

One other similarity.  Medicine has no cure for the common cold.   In a parallel fashion, the mental health profession has no cure—and has never offered a cure—for any of the 297+ diagnoses identified in the Diagnostic and Statistical Manual of Mental Disorders.

Everyone has their own pet remedy, of course.  For colds, your aunt recommends honey in tea with lemon; your uncle, liquids and vitamin C.   In mental health, new methods emerge every week.  One therapist advises confronting negative cognitions; another, emotions!   According to the organizers of the World Tapping Summit, 600,000 clinicians will be attending “10 full days of life-altering presentations” to learn how and where to tap people to better mental health.

Medicine’s failure to “cure” the common cold is understandable.  The causes are complex.  Over 200 different viruses can cause symptoms.  Even the most common—the rhinovirus—has 160 different strains!  It’s just not possible to predict which ones will show up in any given season or pack all them into a single injection.

Herein lies another similarity.  The cause of what are called “mental health problems” is equally, if not more complex.

For example, Medicine.net—the website that claims to “Bring Doctors’ Knowledge to You”—reports, “The exact cause of most mental illnesses is not known.”   It then goes on to state, however “many of these conditions are caused by a combination of genetic, biological, psychological, and environmental factors.”

Really?

A combination of genetic, biological, psychological, and environmental factors? 

What else is left?  Vermicious knids?  Morgoth, Master of Sauron, from The Lord of the Rings?  Or, the evil machinations of escapees from Area 51?  In other words, the cause of mental and emotional ailments is…complicated!

One final similarity.  Colds respond to the very same curative condition that forms the basis of effective psychotherapy: Empathy.

With a large sample, researcher David Rakel and colleagues found that the duration and severity of the common cold varied depending on patients’ experience of physician-provided empathy.

The formula?

More empathy = Shorter, less severe colds + changes in the immune system

Perhaps what’s important about our pet remedies is not so much the remedy, but the care that accompanies it?

The central role empathy plays in effective therapy will come as no surprise to most clinicians.  As the graph below illustrates, it tops the list of curative factors—especially when compared to other aspects of treatment that get a lot of attention, such as technique and adherence to protocol.

What is both surprising and distressing is how little growth occurs in therapist empathic abilities over the course of their careers.  Hard to believe, but true.  A study by Chow and colleagues show that significant improvement is possible.  By measuring a therapist’s empathic response to a challenging clinical scenario and then providing targeted feedback and an opportunity to practice, significant improvement occurred and even generalized to novel situations.  See the video below for a summary and in-depth discussion.

Across modalities, the therapeutic relationship has consistently been found to be a robust predictor of treatment outcome.  Most practicing clinicians understand this finding and work hard at establishing and maintaining a collaborative working alliance.

Here’s a less well known, but sobering statistic: clients report tensions or actual breakdowns in the therapeutic relationship in 19% to 42% of sessions.  These figures rise to 41% to 100% of sessions when trained observers are used to identify “ruptures” between clients and therapists.

Given the frequency of such occurrences, therapy really is about constantly re-pair-ing—a continuous process of getting back “in touch” with and connected to the person seated opposite us in the consulting room.  Findings from a number of studies (1, 2, 3, 4) emphasize the value of therapists openly acknowledging and exploring ruptures, all the while maintaining an open and non-defensive stance.  Failing to do so, the data make clear, leads to higher dropout rates and poorer outcomes.

Given the frequency of such occurrences, therapy really is about constantly re-pair-ing—a continuous process of getting back “in touch” with and connected to the person seated opposite us in the consulting room.  Findings from a number of studies (1, 2, 3, 4) emphasize the value of therapists openly acknowledging and exploring ruptures, all the while maintaining an open and non-defensive stance.  Failing to do so, the data make clear, leads to higher dropout rates and poorer outcomes.

Of course, admitting a mistake presumes knowing one has been made.  It’s easier said than done.  Clinicians’ experience of the quality of the therapeutic relationship frequently differs from those they treat.  And while a significant body of evidence documents the benefits of systematically monitoring the status of the alliance via simple measures like the Session Rating Scale, little is known about what therapists actually do with such information to inform and improve outcome. That is, until psychologist Chris Laraway entered the picture.

Dr. Laraway’s thorough and engaging study not only provides a systematic review of the alliance and feedback literature, but also the first empirical model for how feedback can be used to resolve ruptures in the therapeutic relationship.  What’s the secret?  The entire study is just a click away—or for those interested in the “Cliff note” version here.  Thanks to Chris for allowing me to make it available.

Not being a computer nerd, I’d never come across these expressions.  My 14-year-old son was the first person I heard use the terms.  He was referring to a problem I was having with my desktop computer.  To be sure, I’m no Luddite.  Still, “computer” will always be a second language for me.

With a restart and few clicks of the mouse, he resolved my issue.  When I asked him to explain what had caused the problem–hoping either to avoid or be able to resolve a similar occurrences in the future–he quipped, “Dad, it’s an RTFM problem, most likely in the PEBKAC.”

“RTFM problem?  In the PEBKAC?”

“Yeah,” he said with a laugh, then walked away.

Consulting Google, I quickly learned what the terms meant: Read the F%$&ing Manual as the Problem Exists Between the Keyboard and the Computer.  Swallowing my pride (and a fair bit of irritation), I had to admit my son was right.  I had not read the manual.  I didn’t want to read the manual.  I WANTED MY PROBLEM SOLVED!  As a result, I’d spent an increasingly frustrating hour, first tinkering, then on the phone with less than helpful customer service representative.

So, what’s this got to with psychotherapy?

Over the weekend, the twittersphere lit up with posts about a story in the New York Times: Effectiveness of Talk Therapy is Overstated.  The article reported on a new study which had found that psychotherapy was “25% less effective…than previously thought.”

The response to the story was swift, questioning, for the most part, motives and methodology:

• Who published this study and why?
• What kind of therapy was studied?  
• Why the emphasis on quantitative studies?
• Why is the media always so negative about therapy?
• Is this the whole picture?
  

The reaction is understandable.  The headline and story are enough to give any practicing therapist pause.  More so because, as I reviewed in a presentation at the Evolution of Psychotherapy conference, they are already working in an challenging practice environment.  Rules and regulation are on the increase.  Incomes are on the decline.  They know the value of the work they do.  They can see it in the people they treat.  Instead of recognizing the value of the services offered, the effectiveness of the field, it’s methods, and practitioners are called into question.

The interaction with my son still fresh in my mind, I wondered, “Could this be a RTFM problem located in PEBKAC?”

Said another way, “Had anyone actually read the study?!”  Despite assurances that “the facts are always friendly” from the likes of Carl Rogers, we know therapists don’t read research, for example.  How do we know?  RESEARCH!

In truth, the study is a merely an empirical call for more openness and transparency in publication of psychotherapy research.  Inflated estimates of effectiveness help no one.  Not practitioners.  Not clients. Not the field.

The very same factors that lead the media to highlight the most attention-grabbing aspects of a news story, influence what gets submitted, reviewed, and published in scholarly journals.  Sad, but true.  To get the full picture–to determine “what really works”–results from all research–whether published or not–must be tracked and reported.  Not surprisingly, when you get beyond the headlines, the story is almost always less dramatic and more nuanced.

Additionally, the research article contains some real gems!  For example:

• Psychotherapy was found clearly superior to a variety of placebo and no-treatment controls, including treatment-as-usual, pill-placebo, and non-specific control conditions.
• Consistent with research reported on this blog, no differences in outcome were found between treatment approaches!
• No differences in outcome were found between psychological treatments and anti-depressant medication.
• Finally, the effect of psychotherapy plus medications was superior to anti-depressant medication alone.

What’s not to like?

And while we’re on the subject, consider another study.  Click on the link and give it a read.  I’m sure there will be no headline in the New York Times, despite the fact that it’s the largest psychotherapy outcome study in history!   What are the results?  RTFM!

Previously, I’ve blogged about results from a Swedish study examining the impact of psychotherapy’s “favorite son”–cognitive behavioral therapy–on the outcome of people disabled by depression and anxiety.  Like many other Western countries, the percentage of people in Sweden disabled by mental health problems was growing dramatically.  Costs were skyrocketing.  Even with treatment, far too many left the workforce permanently.

Sweden embraced “evidence-based practice”–most popularly construed as the application of specific treatments to specific disorders–as a potential solution.  Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) specific to mental health practice.  Topping the list?  CBT.

A billion crowns were spent training clinicians in the method; another billion using it to treat people with diagnoses of depression and anxiety.   As I reported, the State’s “return on investment” was … zilch.  Said another way, the widespread adoption of method had no effect whatsoever on outcome (see Socionomen, Holmquist Interview).   Not only that but many who were not disabled at the time they were treated with CBT became disabled along the way, bringing the total price tag, when combined with the 25% who dropped out of treatment, to a staggering 3.5 billon!

And now, a new study–this time from Norway, Sweden’s neighbor to the west.  Norwegian researchers looked at how the effectiveness of CBT has fared over time.  Examining data from 70 randomized clinical trials, study authors Johnsen and Friborg found the approach to be roughly half as effective as it was four decades ago.  Mind you, not 10 or 20 percent.  Not 30 or 40.  Fifty percent less effective!  Cause for concern, to be sure.

So, what’s happening to CBT?  Is the “favored son” losing its effectiveness?

Naturally, the results published by the Norwegian researchers generated a great deal of activity in social media.  Critics were gleeful (see the comments at the end of the article).  Proponents, of course, questioned the results.

If the findings are confirmed in subsequent studies, CBT will be in remarkably good company.  Across a variety of disciplines–pharmacology, medicine, zoology, ecology, physics–promising findings often “lose their luster,” with many fading away completely over time (Lehrer, 2010; Yong, 2012).  Alas, even in science, the truth occasionally wears off.  In psychiatry and psychology, this phenomenon, known as the “decline effect,” is particularly vexing.

That said, while the study and commentary have managed to generate a modest amount of heat, they’ve shed precious little light on the question of how to improve the outcome of psychotherapy.  After all, that’s what led Sweden to invest so heavily in CBT in the first place–doing so, it was believed, would improve the effectiveness of care.  So today, I called Rolf Holmqvist.

Rolf is a professor in the Department of Behavioral Science and Learning at Linköping University.  He’s also the author of the Swedish study mentioned above.  I wanted to catch up, find out what, if anything, had happened since he published his results.

“Some changes were made in the guidelines some time ago.  In the case of depression, for example, the guidelines have become a little more open, a little broader.  CBT is always on top, along with IPT, but psychodynamic therapy is now included … although it’s further down on the list.”

Sounded like progress, until Rolf continued, “They are broadening a bit.  Still the fact is that if you look at the research, for example, with mild and moderate depression, almost any method works if it’s done systematically.”

Said another way, despite the lack of evidence for the differential effectiveness of psychotherapeutic approaches–in this case, CBT for depression–the mindset guiding the creation of lists of “specific treatments for specific disorders” remains.

Rolf’s sentiments are echoed by uber-researchers, Wampold and Imel (2015), who point out, “Given the evidence that treatments are about equally effective, that treatments delivered in clinical settings are effective (and as effective as that provided in clinical trials), that the manner in which treatments are provided much more important than which treatment is provided, mandating particular treatments seems illogical.  In addition, given the expense involved in “rolling out” evidence-based treatments in private practices, agencies, and in systems of care, it seems unwise to mandate any particular treatment.”

Right now, in Sweden, an authority within the Federal government (Riksrevisorn) is conducting an investigation evaluating the appropriateness of funds spent on training and delivery of CBT.  In an article on the subject in one of the countries largest newspapers , Rolf Holmqvist argues, “Billions spent–without any proven results.”

Returning to the original question: what can be done to improve the outcome of psychotherapy?

“We need transparent evaluation systems,” Rolf quickly answered, “that provide feedback at each session about the progress of treatment.  This way, therapists can begin to look at individual treatment episodes, and be able to see when, where, and with whom they are and are not successful.”

“Is that on the agenda?” I asked, hopefully.

“Well,” he laughed, “here, we need to have realistic expectations.  The idea of recommending that you should employ a clinician because they are effective and a good person, rather than because they can do a certain method, is hard for regulatory agencies like Socialstyrelsen.  They think of clinicians as learning a method, and then applying that method, and that its the method that makes the process work…”

“Right,” I thought, “mindset.”

“… and that will take time,” Rolf said, “but I am hopeful.”

But, you don’t have to wait.  You can begin tracking the quality and outcome of your work right now.  It’s easy and free.  Click here to access two simple scales–the ORS and SRS.  the first measures progress; the second, the quality of the working relationship.

Next, read our latest article on how the field’s most effective practitioners use the measures to, as Rolf advised, “identify when, where, and with whom” they are and are not successful, and what steps they take to improve their effectiveness.

Finally, why not get some training in “Feedback Informed Treatment?”

The world seems to be in the midst of a pandemic of burnout, spread across all age groups, genders, professions, and cultures. Research specific to mental health providers finds that between 21 and 67 percent may be experiencing high levels.  Other related “conditions” have been identified, including compassion fatigue (CF), vicarious traumatization (VT), and secondary traumatic stress (STS), all aimed at describing the negative impact that working in human services can have on mental and physical health.

An entire industry of authors, coaches, and trainers has sprung up to address the problem, providing books, videos, presentations, retreats, and organizational consultation. There’s only one problem: currently fashionable approaches to burnout don’t work.  In fact, they may make it worse!

What can be done?  In an article published in the Psychotherapy Networker, my long time colleague and co-writer, Dr. Mark Hubble, and I review research on the field’s Top Performing therapists.  Once again, they have something to teach us, this time about “healing the heart of the healer.”  Click here to access a PDF of the article. 

What’s the difference between a trained therapist and a compassionate friend?  Look at outcomes and you are likely to be disappointed.  For example, meta-analyses of studies comparing professionals to paraprofessionals (or students) either find that the latter group achieve significantly better results or, at worst, the same!

A clearer difference can be found in area of ethics.  Unlike one’s BFF, a therapist is bound by their commitment to a code of professional practice.  Keeping confidences and doing no harm are two prime examples.  Most clinicians spend a semester or two studying ethics during their training.  Continuing education on the subject is mandated by most state licensing boards in order for therapists renew their license to practice.

Unfortunately, much of current ethics training is focused on staying up-to-date with laws governing the profession or minimizing the risk of malpractice suits.  Even the occasional focus on ethical “dilemmas” misses the point, narrowing the focus to the unusual and acting as though once resolved, we can go back to doing what we do.

As my colleague and friend, Dr. Julie Tilsen, observed, “We have detached ethics from the whole of practice, made it an ‘add-on.’  But, whether we realize or not, everything we do—and don’t do—is a matter of ethics. There is always an ethical standard in place, and that ethic typically reflects taken-for-granted values and understandings.”  She continues, “Any approach to practice is incomplete if it fails to articulate a stance on the ethics of the work—and by this I’m referring to the effects of what we do, in every moment of every encounter, with every person—whether or not a ‘dilemma’ presents itself.”

As readers of this blog know, becoming aware of the effects of our work is what Feedback-Informed Treatment (FIT) is all about as it directly answers the question, “How do we know when clinical practice is responsible and ethical?”  After all, ethical practice requires that our work is engaging and effective—from our clients’ point of view.

You are not going to believe me when I say it. Fifty percent. It’s true. Even in studies where carefully selected therapists who receive copious amounts of training, support, and supervision, and treat clients with a single diagnosis or problem, between 5 and 10% get worse and 35-40% experience no benefit whatsoever! That’s half, or more.

What happens to these people?

Well, if the therapist formally and routinely solicits feedback regarding the quality of the relationship and progress in care, drop out and deterioration rates fall, and outcome improves.

Still, a significant percentage of people do not improve—as many as 25%!  What can we do? The ethical standards for all of the professional mental health organizations require clinicians both monitor and end ineffective treatments as well as suggest helpful alternatives to clients (ACA [C2.d], APA [10.10]).  But what?

Enter Lynn D. Johnson, Ph.D., a psychologist whose work and thinking is always a step ahead.  I’ve known Lynn for decades, met him when I was a graduate student.  As I blogged previously about, it was Lynn who in 1996 first suggested routinely measuring outcomes.  He is also responsible for the creation of the original Session Rating Scale–a 10-item version that I later shortened to four.  For several years, Lynn pushed me to do research on top performing therapists, believing they held clues to improving the practice of psychotherapy in general.