Some Benefits Of The Evidencebased Therapy Ebt Approach

The examples presented so far illustrate that the evidence-based approach is fraught with more pitfalls than might at first be apparent. Qualitative and quantitative data analyses to date have provided few categorical assertions that do not require caution and careful interpretation. In psychotherapy, the evidence-based approach should therefore be seen as more of a method to aid the asking of questions than as a source of answers. It is a method fraught with its own problems. We can, however, begin to draw together and examine criteria for the evidence-based approach.

The American Psychological Association Task Force (American Psychological Association, 1995; see also Crits-Cristoph, 1996) proposed a set of criteria for evidence-based therapies (or 'empirically validated treatments' in their parlance), which are a useful starting point. The Task Force proposed that for a treatment to be well-established it should:

(1) Have at least two good between-group design experiments demonstrating efficacy in one or more of the following ways:

A. Superior to pill or psychological placebo or to another treatment

B. Equivalent to an already established treatment in experiments with adequate statistical power (about 30 per group). OR

(2) Have a large series of single-case design experiments (N >= 9) demonstrating efficacy. These experiments must have:

A. Used good experimental designs and

B. Compared the intervention to another treatment as in 1)A.

These overall criteria were additionally qualified by a requirement for the use of treatment manuals, that the client groups should be very clearly described and that the benefits should be found by at least two different teams.

The Task Force also spelled out criteria for 'probably efficacious treatments' as follows:

(1) There should be two experiments showing the treatment is more effective than a waiting-list control group. OR

(2) One or more experiments meeting the Well-Established Treatment criteria above but only from one team rather than two or more. OR

(3) A small series of single-case design experiments (N >= 3) otherwise meeting Well-Established Treatment Criteria but again only from one team rather than two or more.

These APA guidelines provide a useful starting point for categorising evidence into different types and grades. However, the use of the term 'experiments' throughout may seem either odd or even aversive to many psychotherapists, as if their patients were being treated as rats running through mazes (although therapy, in imitation of life, may seem like that sometimes!). The criteria reveal the influence of the American behaviour therapy tradition with its focus on quasi-experimental single case designs (for example, so-called ABA, ABBA, ABCA designs) but, apart from the language, the criteria overlap with the Cochrane review criteria that were summarised earlier. That is, the best quality evidence from a 'good between-group design' is considered to come from a randomised controlled trial, although the APA guidelines give more weight to single-case quasi-experimental designs than do the Cochrane criteria.

A second clear benefit of the evidence-based approach is the continued examination of the therapeutic relationship, client variables, therapist variables, and other common factors in relation to therapy process and outcome. The traditional approach to such common factors is best summarised in the series of handbooks that have been edited over the years by Garfield and Bergin (for example, Garfield & Bergin, 1978, 1986; Lambert, 2004) and which have exhaustively detailed research into therapist factors, client factors, and therapy factors. Work on therapist factors was best exemplified by research into client-centred therapy (Rogers, 1957) and the proposed trinity of warmth, empathy, and genuineness (Truax & Carkhuff, 1967), which every therapist was supposed to possess. However, the early optimism that characterised this work eventually led to the realisation that even 'ideal' therapists had patients with whom they did not get on well and that the presence of these therapist factors in themselves was not sufficient for therapeutic change. As Stiles, Shapiro & Elliott (1986, p. 175) concluded: 'The earlier hope of finding a common core in the therapist's personal qualities or behaviour appears to have faded.'

Work on client variables has in the past been characterised by the examination of athe-oretical lists of sociodemographic and personality variables (see, for example, Garfield, 1978), from which it has been possible to conclude very little. In a re-examination of this issue, Beutler (1991) concluded that there still has been no development in our understanding of client variables. Following a summary of some of the major variables that might be examined, Beutler (1991, p. 229) also pointed out that: 'There are nearly one and one-half million potential combinations of therapy, therapist, phase, and patient types that must be studied in order to rule out relevant differences among treatment types.'

Fewer than 100 methodologically sound studies have been carried out to test these possible interactions! There are, however, some promising leads from investigations of client attitudes and expectations that provide a more sophisticated view of such variables. For example, Caine and his colleagues (Caine, Wijesinghe & Winter, 1981) found that the type of model that clients had of their problems (for example, medical versus psychological) and the direction of their main interests ('inner-directed' versus 'outer-directed') predicted drop-out rates and outcome in therapy.

Work on specific therapy factors has also run aground on the problems of finding any differential effects (for example, Stiles, Shapiro & Elliott, 1986). Some of these problems were outlined earlier, when the pattern of outcome equivalence of psychotherapies for a range of disorders was outlined. As we hope this book will demonstrate, there are beginning to be advances in this area, which should continue in the future, for example with the use of so-called 'dismantling', in which one or more of the putative 'active' ingredients of a therapy are dropped in some of the conditions, and the manualisation of therapies combined with measures of treatment adherence, which ensure that something like the therapy in question is actually taking place. However, as the NIMH Collaborative Depression study demonstrated (see above), the fact that some therapists did extremely well and some not so well irrespective of the type of therapy demonstrates that therapy factors will only emerge in interaction with other therapist and client variables rather than as main effects. A specific example of this point comes from the Sheffield Psychotherapy Project carried out by David Shapiro and his colleagues. The analyses of this project published initially showed an advantage for prescriptive (cognitive-behavioural) therapy over exploratory (psychodynamic) therapy in the treatment of stressed managers. However, a later reanalysis (Shapiro, Firth-Cozens & Stiles, 1989) found that this advantage was true for one of the principal therapists involved in the study, but the second therapist was equally effective with both types of therapy. In an interesting conclusion, Shapiro, Firth-Cozens & Stiles (1989, p. 385) turned the initial question of which brand of therapy is better than which other brand on its head, as follows: 'The present findings are broadly consistent with the clinical lore that each new therapist should try different approaches to find the one in which he or she is most effective.'

The notion of the importance of the alliance between therapist and patient arose early in the psychoanalytic literature. Freud (1912) viewed it as the healthy part of the transference, a proposal that was later extended by other psychoanalytic writers. Carl Rogers (1957) also focused on the importance of the therapeutic relationship, although the client-centred view is different to the psychoanalytic. The diverse influences on the origins of the concept and the growing awareness of its importance in cognitive-behaviour therapies (Safran & Segal, 1990) make it a cosmopolitan concept that has the advantage that therapists of different orientations can begin to talk to each other because of a shared language, but the disadvantage that they might mistakenly think they are talking about the same thing! Fortunately, this problem is surmountable. As Wolfe & Goldfried (1988, p. 449) stated: 'The therapeutic alliance is probably the quintessential integrative variable because its importance does not lie within the specifications of one school of thought.'

In order to understand the concept, the three factors proposed by Bordin (1979) provide a reasonable starting point; namely, that there should be a bond between the therapist and the patient, that there should be an agreement on goals, and that there should be an agreement on tasks. In addition, the work of Jerome Frank (1973, 1982) provides a more general framework from which to view both the therapeutic relationship and the whole question of common factors in psychotherapy. To quote: 'The efficacy of all procedures... depends on the establishment of a good therapeutic relationship between the patient and the therapist. No method works in the absence of this relationship' (Frank, 1982, p. 15).

Frank goes on to describe a number of shared components that help to strengthen the relationship with the patient and which help the patient to have more positive expectations. Two of these components are:

• A confiding relationship. The patient should be able to trust and talk to the therapist about painful issues without feeling judged. These issues may be ones that the patient is revealing for the first time. This feature of confiding is not of course unique to therapeutic relationships, but is a characteristic of any confiding relationship (Power, Champion & Aris, 1988). One of the problems that has been identified in poor therapeutic relationships is that the confiding and expression of negative feelings by the patient is responded to with hostility by the therapist; the outcome of such therapy is often unsuccessful (Henry, Schacht & Strupp, 1986) and, hence, the emphasis now is on the establishment of a positive therapeutic relationship between therapist and client.

• A rationale. Patients should be provided both with a framework within which to understand their distress together with an outline of the principles behind the therapy and what treatment might involve from a practical point of view. Failure to provide such a rationale may leave the patient mystified or anxious, with misconceptions about what might or might not happen and, as a consequence, the risk of dropping out of therapy prematurely. The cognitive-behaviour therapies are particularly strong on providing such rationales; for example, Coping with Depression and Coping With Anxiety booklets are typically handed to patients after one or two sessions of cognitive therapy as a homework assignment. Fennell & Teasdale (1987) reported that a positive response to the Coping With Depression booklet was a good indicator of positive outcome in cognitive therapy.

One of the points that must also be dealt with in therapy is the likelihood, as in real life, of the development of 'misalliances'. Some of these misalliances may be temporary and resolvable if dealt with, whereas others may for example require referral on to another agency or other drastic action. As a starting point from which to consider misalliances, we can consider again Bordin's (1979) three components of the therapeutic alliance, that is, the bond, the goals, and the tasks, all or any of which can be implicated in a misalliance. It is well recognised that it is more difficult to develop an alliance with some patients than others; thus, the extension of cognitive therapy into work with personality disorder individuals has helped to heighten awareness of the therapeutic relationship amongst cognitive therapists together with a re-examination of a number of related psychodynamic issues (Beck, Freeman & Davis, 2004; Linehan, 1993). Less intractable misalliances occur when, for example, the patient attends therapy in order to appease someone else such as a spouse or partner or professional such as a GP, or the patient expects physical treatment rather than psychotherapy, or is attending because of a court order, and so on. Through careful discussion of the relevant issues the therapist should be able to identify these types of misalliances. Even when a satisfactory alliance has been established the painful work of therapy can lead to 'ruptures' (for example, Gaston et al., 1995); for instance, a behavioural exposure session that goes wrong and becomes too anxiety provoking can lead to a setback in the relationship that needs to be addressed before the therapeutic work is continued.

These points on some advantages and benefits of the evidence-based approach highlight the fact that the development of criteria for different grades of evidence and the continued exploration of therapeutic relationship, therapist, client, common, and specific factors in therapy process and outcome is of major benefit to the area. Nevertheless, there are a number of important warnings that have been hinted at throughout this chapter, and to which we return in the next section.

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