Evidence And Psychotherapies

One of the classic and most destructive uses of evidence was in Eysenck's (1952) claim that psychodynamic psychotherapy was no more effective than leaving people to recover spontaneously. Apart from the controversy that Eysenck sparked, he also led to a generation of psychotherapy researchers determined to improve the science of psychotherapy outcome research, subsequent summaries of which argued that Eysenck had considerably overestimated rates of spontaneous recovery and under-estimated psychotherapy change (for example, Luborsky, Singer & Luborsky, 1975; Smith & Glass, 1977). These research efforts focussed primarily on analyses of the immediate outcome of therapy and, by-and-large, led to the conclusion that all therapies were equally effective because of the operation of 'common factors' such as the therapeutic relationship. Although there is some truth in such a conclusion, and there is no question of the importance of a positive therapeutic relationship in relation to outcome (Hubble, Duncan & Miller, 1999), the chapters in this book will testify that such a conclusion must be significantly qualified in relation to specific disorders and different individuals.

One of the issues that any account of the psychotherapies must deal with and explain is the continued development of new psychotherapies; perhaps the focus on common factors may partly explain this continued development, but nevertheless it provides an enormous challenge if the evidence base is to keep pace with the rate of development even simply in terms of the number of new approaches. Herink (1980) documented over 250 varieties of therapy. This number had increased to about 400 by the early 1990s (Norcross & Goldfried, 1992) and the latest estimates put the number at about 500. Indeed, somewhere in California there is probably another therapy being christened at this very moment. The question that must be asked of this diversity is whether 500 different therapies need to operate by 500 different mechanisms, or whether, alternatively, there exist common factors that can offer some unification of the diverse theories and practices that occur under the label 'psychotherapy'. These common factors might apply irrespective of whether or not the therapies or therapists are effective, so a more specific question must also be asked: 'Does the good cognitive therapist share anything in common with the good behaviour therapist or the good dynamic psychotherapist?' There is, in fact, a growing belief that, whatever the brand name, good therapeutic practice cuts across the artificial boundaries that therapies place around themselves in order to appear distinct from their competitors.

Some of the impetus for the exploration of integrative approaches to psychotherapy has arisen from the failure of many studies of the effectiveness of different therapies to find significant differences in outcome, as noted above. Stiles, Shapiro & Elliott (1986) have labelled this the paradox of 'outcome equivalence contrasted with content non-equivalence'. That is, it is clear from analyses of the content of therapy sessions that therapists of different persuasions do different things in therapy that are broadly consistent with the type of therapy to which they adhere (De Rubeis et al., 1982; Luborsky et al., 1985). Stiles, Shapiro & Elliott (1986) further argue that outcome equivalence applies not only to areas such as depression but also to areas where 'clinical wisdom' might suggest otherwise; for example, such wisdom would suggest that behavioural and cognitive-behavioural methods are more effective than other forms of therapies for the treatment of phobias. However, the evidence for this proposal arises from analogue studies with sub-clinical populations (primarily students), but they argued that it is less clear-cut from clinical trials.

The current book will provide an important update on issues such as whether or not all therapies really are equal and whether it really does not matter what the content of therapy is because outcomes are very much the same. We hope to show that, although this conclusion has some truth, in particular in its focus on the need for a positive therapeutic relationship, at the level of specific psychological disorders that range from simple phobias to severe psychoses there is evidence of differential effectiveness of therapies - that some things help and that some things do not.

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