Behavior Therapist (April 2009)


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Article published in The Behavior Therapist criticizing the common factors perspective

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Behavior Therapist (April 2009)

  1. 1. O ABCT rssN 0278-8401 ASSOCIATION FOR BEHAVIORAI. A N D C O G N I T I V ET H E R A P I E S VOLUME ]2, NO. 4 . APRIL 2OO9 theBehavior Therapist Contents Reseorch orum F Jedidiah Siea,lonathan Huppert, and Dianne L. Chambless ResearcbForunt The Dodo Bird, Treatmc.ntTechniclue,ancl Disseminating Empirically Supported Treatments o 69 The Dodo Birrl, S t u d e n tF o r u m Tl'eal-rnenTFcIrnirlu e. I Sarah E. Et,nns,Atrdrea R. Penq, Anranda Kras, Emily B. Gale, and ChristopherCanrybell antl Disseminating Supervisirrg antl Me.ntoring Undergraduates: Empirical ly Supporterl A (lradu;rte Sfllc-lcnt Pcrspec-tive . 77 Treatments Origins J crIirI j rrh Sir :v, [/ri.rrrcr.s of' ]: n n s.t'It,urt i, t . i t,t' Dcrek D. Rat,dnnd lanres K. Luisalli Antccedentsto a Paradigrn: Ogden l,irrdsley Jrrrrallrarr IJrrpplt. 7'1rc l). lleltren arrclB. F. Skirurer'sFounding of "Behavior Therapy" . 52 [,]niu: r.si4' of J e nuu.Le aurI f)iarrnc L. rn, y C hirnrl rless, [ ] nit: ersi,t1'of' Pent us I tn nio . Clossified as n a rcacnrprcsirlcntirrl !r)lunll ir th, Bebat r,'t IF l /ttra1,isr, Ritymr)n(l DiGitrst'p1te ubscncJ At ABCT I I t l r a t e l f t r r t s o . l i s s e r t t r n uc c r p i r i t i r l l y t r p - t tn s Ncrv Mcmbers . 86 Welcome., porte(l trcatments(EST;),and cspecially cogni- tive-bchavioral treatments, havebcen limited by pcrccptions"that all psychotherapies are cffeccivc[the Dodo l]ird verclictl, and . . . that common faccors, therapisr, and relarionship vari- Canlidates are sought for Editor-Elecr of the Behatior T'huapist, ablesaccountfirr thc majority oi rhe varianccin Volun.rcs to 36. The officialterm fbr the Erlitor isJanuary l, 201l, rcr 31t tl-rerapy olrtcomc studies" (2007, p. tt8). He D e c e m b c r3 1 , 2 0 I ) , b u t t h e E d i t o r - E l e c s h o u l d b e p r e p a r c cti o b e g i n t called for dialogue with proponents of those handling manuscriptsapproximately1 year prior- viev"'s, an effort to trnclcrstand in their persl>ectivc Candidates should scnd a lettcr of intent and a copy of their CV to and convey the alternative. Ultimately, "either Philip C. Kcndall, Ph.D., PubiicationsCoordinaror, ABCT, 301 Seventh rve rebut theseconclusions, concluctneq' research Avenue, l(rth Floor, Neq''ork, NY 10001 or email teisler(q, to shorv they are wrong, or tr'e acceprthem and Candidatesn'ill be aske,lto preparea vision lctrer in support of their change " (p. our rnessage I t9). The airnof tl-ris ar- candidlcy.David Teisler, ABCT's Director of Conrmunications. s'ill pro- ticleis to providesomehistorical conrexrin rerms vidc you rvith morc details on the selectionprocessas lvell dutics and of prcvit.rusattempts to respond to these con- responsibilities the Ecliror.Letters of supporr or recommendationare of tentions and to present an update on recent re- discouraged. Ho*,ever, candidatesshould have securedthe support of searchbearing directly on the Dodo Bird verdict theirinstitution. and the :rssertionsregarding varianceaccounted Questions about the responsibiiities and duries of the Ediror c.rr abour for by activeingredients (e.g.,rechnique). rhe selection process can be directed to David Teislerat the above email address lt (212) 617-1890. or Letters of intent MUST BE RECEIVED BY August 3, 2009. ' Vision letters u.ill be required b,v September 1,2009. rontinred onp. 7 1 Apfil . 2009
  2. 2. Dodo Bird Verdict Aggregation 6' Evidence for the claim that all psy- chotherapies equally efficacious are derives from meta-analyses that combine various treatmenrs for various disorders (e.g., Luborsky et al., 2002; X/ampold et al., The author of The Worry Cure, and one of 1997). At most, thesemeta-analyses yield the most respected writers and speakers on smail effect sizesfor averagebetween-con- cognitive therapy, Robert L. Leahy, Ph.D., dition comparisons (e.g., / = 0.2I; provides simple, step-by-step guidance to Tampold et al.), and the authorsinfer that, overcome the symptoms associatedwith the overall, no two psychotherapies differ- are most common anxiety disorders. enrially cf{icaciousfor treating a disorder. S u c l r t , , n t l u s i o nh o w c v e ri,s h a s c .o n t l r c a , l Outsmart panic, agoraphobia, obsessive- fullu.ig-q-r .."to"ins thut b. compulsive disordeqgeneralized anxiery,social riients for all disorders not differ on aver- do anxiery,and post-traumatic stresswith the best ag_-e, particular treatment is superior to _n_o psychological treatment methods available ino!@see Beutlcr, today! 2diD ;()ramblcss, 2002; Crits-Christopli, Hardcover . $2.5.95 978-401,9-21,63-7 1997; Hunsley & Di Giulio, 2002; and many othcrs who have argueclthis point). E v c n o p e r r t i n gw i t l r t l r i s r ( a s ( ) n i n A , u s r m meta-analyses havc fbund diff-erences bc- twecn rrcatmentorientations (Luborskyet al.; Shapiro & Shapiro, i982; Smith t Glass, 1977; l)Tampold al.), cvcn when et taking into account allegiance. Further- morc, in responscto Vampold et al.'s mcta-anirlysrs, Crits-(.hristophsuggcstcd () tl-rataggregating various populations,dis- orders, and treirtments would likely ob- scure rcal differrnccs in I re:rt n)ent Availablewhereverbooksare sold, or outcomes.Moreover,half of the studiesex- amincd by rVampolcland colleagues evalu- order onlineat ated the trcatment of anxiety, and ncarly 70Vo compared cognitive to behavioral Join Robert l-eahy at therapics,characteristics the studiesthat of may minimizc the likelihood of finding substantial trearment differences. Crits- ICAN D@ITI SanL)iego Christoph demonstratedthat 14 o€ rhe 2L) May 1 - May 3, 2009 studies that J/ampold and colleaguesin- cluded that compared two treatments for specificdisorders grounded in different ori- HAY entations yielded large effect sizes. HOUST Similarly, Beutler, Chambless,ancl others (Chambless Ollendick,2001; Htrnsley& a Di Giulio, 2002) havecited multiple stucl- p a n i c - r c l a t c d m e a s u r e sa n r l i n d i c e s o f c l i n i - In addition ro combining variousrrcat- iesand reviewsthat questionthe Dodo Bird cally significant change. In contrast, for ments ancl disorclcrs, many mcta-analyses verdict. in u'hich tl-reDodo Bircl verdict is aclvarrced GAL), tlic t'o treatmcnts wcre equivalcnt As a further challengeto the Dodo Bird do not distinguish betr.veen prin-rarv and verdict, Siev and Chambless(2007) re- o n a l l r n e a s u r e s .F u r t h c r m o r c , t l - r e r a p i s t sn i secondary outcon)e measLrres (Wamlrold et centlycondLrcted meta-analyses comparing a l l s t t r d i e ss ' e r c c r o s s e cr v i t h t r c a t n r e n t c o n - l al., 1997).Rarl.rer,they derivc a singleeffcct CBT and relaxation (two bona fide treat- dirion, and most authors asscsscd lienr ex- c sizeiirr eachberween-conclitron comparison ments for anxiety disorders) panic disor- for prt t,rtiuns .rnJ rerirtgs ri l ' trceilncnr by averaging al.l outcome measurcs.Their der (PD) and generalizedarLxiety disorder credibilitl', rvhich wcre high ancl never dif- logic fcrrdoing so is: (GAD) In so doing, we comparedtwo spe- ferecl by treatment group. These method- Given assumprionrhat reserrrclrers th cific cognitive-behavioralinterventions in (lt(!)cuur(()tI( met5ures ltat .tr. 2:errtr.rn,' r - ological strengths bolster the likelihocrd the treatment of two anxiety disorders. The ro the psychok-rgical funcrioning oi the pa- results revealedthat for PD, CBT outper- that treatment techniqucs rrffected treat- tients involved in tlre stucly', is the effi'cr of it formed relaxationac postcreatment all on ment ei-fects. t h ( t r e J l m r n tO n t h c S . r r r tu u t L u n r L ( r - m April . 2009 7l
  3. 3. sures that is importanr.. . . Focusing a on mainof GAD wassmallandnonsignificanr, Bona Fide Tieatments few of manyoutcome measules establish to d : 0.08, = .19,rhereby ! supporringrhe superioritycauses fishing and error rate Even advocates of a common factors ap- notion that treatments may differ depend- problems(Cook g Campbell,1919) and proach ro psychorherapy acknowledge that ing on the disorder studied. Finally, as evi- distracts researcher examining the from not all conceivable interventions are efflca- dent from the third graph, v"'heneffectsizes setof outcome measures,whichmight have cious. Instead, the Dodo Bird verdict ex- ($Tampold were derivedseparately primary and sec- [or produced negligible a effect size. tends only to bona fide treatmcnts, er al.,[)97 , p.210) ondary domains of treatment outcome, meaning those "intended to be theraperrtic" CBT outperformed relaxation for primary ( W a m p o l d e t a 1 . . ,1 . 9 1 ) 7 p . 2 O r ) . T h i s , dis- However, the average of all outcome outcomesof PD with a moderateeffectsize, tinction between bona fide and sham treat- measures doesnot accurately capturethe ef- d: 0.49,! < .002,whereas treatments the ments in evaluating the relativc efficacy of ficacy of the treatment for individuals suf- did not differ on secondaryoutcomes (i.e., dift'erent treatments, while having appeal, fering from a specificdisorder,and is likely depressionand generalizedanxiety), / : also introduces a number of tl-reorctical ancl artificiallyto attenuarethc magnitudc of 0.02,1t : .89. There were no diff-erences in c o n c e p t u a l c l i f f ic u l t i e s . thc cllcct size.I'hc cxtent to which ir trcat- prin-rary vcrsus sccondary' or.rtconrcsfirr $Tarnpold and colleagLres c.g.. Ahn & ( rncnt for a rlisortlcr(c.g., PD) alfcctsdo- GAD t,/s < 0.{)9,ps> .55).Hcncc,rhe clif- V/anrpolcl, 2(X)l; I'lcssrr & r':rnrPolcl, rnirins of comnron comorbiclity (..g., fcrcnce betwecnCBT and rclaxation PD fbr 2002) concludc rhil( trcirtmcnt ()Lttc()nte rleprcssion) criticalinfbrmrrtion, is not is but in thc prirnarydonr;rinof outconrels morc studics are lirtilc bccutrsccomlrarisons bc- of equal irnport in cvaluatins thc trcat- than two-and-a-half tirnes as large as onc t w c c n L r o n af i d e t r c a t m e n t s y i e l c l c l i n i c a l l y ment's efficacyas is thc exrent to u'hich it would conclude the basis the original, on of i n s i r n i f i c a n t c l i f f e r e n c c sa n d t l r o s c b c t w e e n rrllecrscore sympt()msr>fthe disorclcr: (c.g., allSrcgatedcflect sizc, rvhercls there wcrc bona ficlctrcltmcr)ts antl controls yicld un- panic syrnptoms anrl cliagnosricstrrtus). no diffcrcnccs bctrvcenrhe trcatrnents for intcrcsting rliffircncrs. This contcntiotr is Althorrgh it is trtrc that rcsearchcrs shoulcl GAI). s o n t c t ' l r i r t c i r c r . r l l L rh < t s ' c v c r ,b c c a t r s c c i L r c - , irrtir:r:latca priori the prin-rarydcpenclcnt 1'hc clivcrgcntinrplicirtions thcsc rc- of- g o r i z a t i o n a s a l . l o n al l c l t r r c a t n r c n t i s b t > t h a nlcasurcs, rcas()nxblc conccms trbour 1r()st sultsanclthosc<rf Wrrn"rpokl al. ( 199') rc- ct r r i t c r i o r rf o r i n c h r s i o ui n , a n t l l i r t i n r p l i c a r i o r t hoc reporting biascs(e.g., sclectively eln- llect basic cliflcrcnccs nrethoclological in o f , r h c r c s r r l t s o 1 -c l i n i c a l e x l . c r i ( n c c i t n ( l phasrzingsignificiint tinclings fitrn-ra l:rrgc irpproachcs treatr)1cnt to olltconrL'clata,irntl rrcilrmcnt or-rtcon)c rescar<-h (antl mcrlL- setol rnostlynonsignilicrrnt fintlings) olrrlrr n,:ithcr slrtrulcll.c pcrccivcd as statisrical a n a l y s c sr h a t s y n t h c s i z c n r L r l t i p l cs L l c l ls t u ( l - n o t p r c tl r r d t r ( r i l r L l l c r f r t l r nr n v c s t i g a t i r r t ' s slight of hanci. Rathcr,in conductingor in- ics). Tir illusrratc, considcr the histon' o{- sccondary (lutcorncs. Combining mersllrcs tcrpretllu] rlrese datlr,one nrust ct>nsrcler a tWlratis thc qr.rcstion? brhavit>ral trcatlrlents for obscssivc-corn- of prim:rrl,an.l sccon,lrtry oLltcorncs fi)rccs firnclanrent:tlisstrc: It is our contcntion that rarcll' clocsthc rc- ; r u l s i v c r l i s o r d e r ( ( ) C l ) t . F o r r y y c a r s : r g r >b c - , cirn t>lrscurc rn:rsk cntircl]' mc:rningfirl or hirvioral rlrcrapists trcatc<l OC[) u ith difiirencesin trcatmcrrtcfflcts (scc (-rits- searchcr, clinician, or consunler carc r c . l a x : r t i o n .A s c x p o s u r c a n d r c s l r o n s e 1 . r c - Chrisroph,1997). rvhcthcr,on averalle,trcatmcnts fbr all dis- vcr)rion (ERP) rl,as clcvciqrcd, clinicians ,lis- Mcta-analytic data comparingCBT anrl orrlers ircross all clomains do not difitr. covcrccl rhat it q'as f:rr more elflcacious than rclaxation firr PD ancl GAD that verc nor Rathcr, tlic consunrcr(to take one, for ex- rclaxation, rvhich is now consiclcrcd a publishcdin Sicv rurcl Cliambless (2(X)7)il- amplc)wishes know what trc:rtmentwill to placebo in rhe trcarment of OCD. f)ocs rhc Iustratcthc importarrcc consitlering of not best alleviatc the distrcsscauscclby l-risor c l i s c < l v c r t 'h r r t o n c t r c i r t m c n t o u t p e r f i l r r r t s a only disordcrsscparatc-ly, prinrary irnd but her s1'nrptonrs (cL thc fundamcntal psy- sccond r('n(lcr that very contparison invalitli' sccr>ndary outconrc mcasurcsscparately, xs chotherapy(luestionof Paul, who articu- In firct, in a rcccnt srirve)' of 1>sychologists rvell.Three graphs zlrcl)rcsentcdin Figure 1 latccl the importance of asking not only rvho trcat :rnxictl' clisorclcrs and rvho prc- tlrat prtrgressivcll illrrstrate u'lt1' mct.r- s'hethcr psvchorheral)y rvorks,but "What dominanrly favor a CBT approach, nrorc analysesthat aggrcgatc effcct sizes rcross tfelrtmcnt, by whom. is mosc cffc'ctivcfor c l i n i c i a n s e n . l o r s c d L r s i n gr e l a x a t i r ) n f o t r c : r t clomains ancl outcrrtnc mcasurcs nliry bc this incliviclr.ral rvith that spccificproblem, O(-D, than enclorscd using ERP (|rcihcit, misleacling.As clepictecl the first graph, in and under *'hich sct of circumstances?" Vye, Swan, c' Cacly, 2004). Surely those the combined effect size comparing CIIT {1967, p. I I l; ernphasis the originall). in rVhcn the presenting problern is PD, the clinicians consider relirxatir>n to bc a bona and relaxation fbr PD and GAD acrossall fidc trcatmcnt. Horv can it then become d o m a i n s a s / : O . l 9 , p = . 0 7 , t h en . r a g n i - w best answcr to that question(if the oprions something othcr than a bona fide treatment tude of n'hich is consistent u,ith the uppcr areCBT and relaxation) that CBT is likely is whcn zr rcsclirchcr uscs iti /an-rpoltl ancl limit of betrvecn-treatncnt dilferencesrc- to reduceprin-rarypanic-relatcdsyml)toms colleagr-res' concern rlrat comp:rrisons he- ported l.>y X/ampoldct al. ( 1997), anrl equal by approxinr'ately half a standard deviation tveen bon,t flcle treirtnrents and shar.ns ,rre to eFfecr lound by Luborskyet al. (2002) more than is relaxation. Cast as a binomial riggccl and sorrctimes trninfirmativc is ri'cll in their revieu' meta-arralyses. second of The c l l i ' t r s i z cJ i s p l r y . l t l r i s r e p r u s c n tx n i r ) - s raken- Certainly trcatnrents shclLrld c com- b graph dcnronstrates thilt, wlren ct>nsiderecl crclrsein thr- rarc of success frorn l[J9Z to parc.l ro rcal trcattncnts iurrl not trilrrmccl scparrately disorcler (:Llbeit aggrcgatecl by 62c,/c, r,,'isc . Tlte consr-rrner fering from PD srrf cloln, thrcc-leil!cd horses. Ar rhr sanrc acrossdomains), CBT outperformed relax- u'ill chooseCBT. t i m e , t o c o n c l u c t c o m p o n c n t a n a l y s t - st h a t a t i o nf t ) rP D , d : 0 . 1 1 , 1 < . 0 1 .I n c o n t r a s r , eva.luirte particular rechniques often pre- the becrveen-treatment ellect sizein the do- sente(ltu8etlrer as fJrrs ()l'a l;rrgrr treirt- menr package, certain trearmenr elemcnts I The binomial elfect sizedisplay is a meansof deprcting an eflcct sizeas a relativesuccess r.rre.Basedon musr be excluded. This is part of the bincl. tltc assumptionthat the rate oftrcatrrtent success 5092 overell, the binr-rrial effect sizcdispl,ryis uscti is A r e l u t e c l c o m p l i c a t i o r - rs t c r r s f r ( ) m t h e t o t r a n s l a t e n a s s o c i a t i ob c t q ' e e n r e a t m e n ta n d o u t c o m ei n t o t h c L r r o n o r t i o o f s u c c e s s c n u n c r r c a t - a n t n is s t u c l r ' - o r c l i s o r d e r - s p e c i f i c l a s s i f i c a r i o no f a c ment grollp rclative to another. 7? I he B eba rtor T lterapis t
  4. 4. treatment as bona fide. Although outcomes than do specific techniques has Figure 1. Betwecn-groups effect sizes Wampold al. (1997)formulatean opera- et been stated by many (e.g., Levant, 2004; comparing CBT and Relaxation(a) com- Messer & $7ampold, 2002; $7ampold, bining disorders and all outcome [Iea- G tional definition of bona f.ideto identify par- ticular studies for inclusion in their 2001), although with voices of opposition sures,(b) lor PD and GAD separatel.v, but combining all outcome measures, meta-analysis, there is little conceptualjus- (Beutleg 2004; Huppert, Fabbro, & a n . l r c t d i s t i n g u i s h i n gh c t w e e n p r i n r r r y tification for some resultant distinctions. Barlow, 2006). The claim that technique and secondary outcome measures PD fbr For example,accordingto tVampold et al.'s accountsfcrrapproximarcly l07o to I17o of guidelines, whereasrclaxationis now con- the variance of therapy outcome, whereas d) sidereda placebofor OCD, it is a bona fidc' expecrancy, relationship factors, and com- ( ) . 11 treatment for GAD becausestudies havc demonstrated that relaxation works as well mon factors accolrnt for closer to 4O7r'. is frequently demonstratecl a pie chart(e.g., in Lambert & Barley, 2001; 2002). Ht>*'evcr, U 0 . ' 1i - __l asother treatmentsfor GAD (and therefore l N rhc historyt>fthis chart rnaygivc thc rcacler 0.I i ther:rpists expcctrclax:rtion bc thcralreu- to F O pause. C)riginally publishcclin 19136 by o: ol tic), br,rt firr OCD (uncl U not thcrcfirre {stucll'1 u o)1 I L thcrapists nos' .lo not cxpc(t rcl:rxation ttr l-:Lrnbcrt, Shapinr, ancl Bergin in tlrc U o.I be tl'rerapcutic). othcr s'r>rrls, In rcsearchcrs l!undhook oJ Ps1'tbotl,uafl antl Btlr,t ior expcct somc trcatmcnts to u'ork bccausc Cbange 1rd edition), tlre pie chart rc1>rc- o they have found them to clo so, anclothers scntcda summary of L:rmbert's readingof PD/GAD to rvork lessrvell becausctlrcy have fbuncl the litcrarurefrom the prcvious20* ycars; thcrn to do so.ltlcrcinlicsanothcrdilficulty, it rvzrs an empiricaldctcrmination. nor L)nc rvitlrV/arrrl.oltl cr:rl-'s clirssiflcation trc:tt- of lroPt tlrirt s()nlel)rogrcss u',-,trlrl has Ltcc'rt tb) lrcnts irsbonafl.le: It is cirrrrlarto cliscount nraclc rlre 20 yearssince,espccially in *'ith t).5 thc srrpcrior tllicacy of a trcatr.trcnt thc on rcgarcl trn<lerstanciing ilttors, to rnccl nrtxlcr grotrncls that "I kncs' it u'rrr-rlcl n'ork bet ators.and l)roccsses thcrapy,anclin (-Ll'l- in U t) I ' 'lb P'os tcr." if that asslrrnption rlcrivctlfron'r obser- in lrartictrlar. takc one str-rdy cxccl)- as t'ation of- thc sanrc sr.rPcrir>r n,hatothcr groundsis rclaxation lxrnaflclc trc:rtmcntfirr onc anxietyrlisorclcr a ctllctcr'. M ( ) r c { ) ' (irl . t l r i s r c l s , , r r r r 15 t-, , r r t t t . , , t r i 1 anclnot tional in tcnr-rs suchl)rr)grcss, (2(X)(r)slrr>rvccl of Clark rr al. that (.BT targcting corc co.t4nitit>rrs conccmsof incliviclr,r:rls atid socialanxic't1' clisorclcr rvith was nrorc cffer'tivc than exposurcthcrapy (rvitl-r purcly bc a eI iti, il lnothcrl' Consiclcring tlracViLnipolcict al. PD PD/GAD GAD havioral r;rtionale plus t>1-habituation) rclax- () aggrellatcacross disor.lcrs irr)(ltrcittrncnts. atiun. Clark et al. rc1>ortthc cficcts ot this posesa particular theorcticaldiflicLrlty. technique,alliance,anclcxltcctancy(seepie Is it reasonable inclurle cornparisons to of- (c) chart in Figure 2). Not only were therapist CBT and relexation GAD (asthcy do), for cffectsnot large or signiticant,but therc but not for OCD2 Wampold ct al. use the were no diffcrcncesbetwccn the ts'o tre:rt- , ,5 notion oibona ficletreatrncntto cusurcthirt ment conditionsin ratingsof alliancc(/ : the pirtient and thc thcraprst have positive .17), credibility(! : .261,or expectancy (fi o.a expectancics about outcomes,as expectan- : .22), suggestingthat thcse mechanisms ciesarc proposcdto bc 'ln essential common 10. were not responsiblc frrr rhe dif{ircntial factor relatcd to olrtcomc. I{orvever, if a treatmcnt outcome bctwecn CBT and ex- ior tlrerapistirnd a p:rtient cxpect ERP to work posure.Similar data fiom another rescrrrcl.t bettcr thirn rclaxation fbr OCD, for cxam- 0.r ple, then they are correct in tl-reirexpccta- Sroup suggest that thesc CBT techniques for socialanxiety disorder may be more ef- rion, but it does not mean that expectancy fective chan exposure alone (Huppert, PO / zUeAD is driving the trcatmenc cffccr. Are the ef- Lecllel',& Foa, 2007). At the sarne time, fectscauscdby cxpcctancl,, do peopleex- or treatment technique did not account for pect more from rrearments that work J07o or B0o/o the variance,and it is un- of better?Finall.r', Vampold et al.'scriterion of iikely that any treatnent will reach sucli a bona tr(irrment comperisons creates threshold. Figure 2. Brcakdorvn of Clark et al. s the potential trap thar if consensus were Hon'large are techr-rique effectslikcly to ( 2 0 0 6 )d a t a b y t e c h n i g u e t h e r a p i s r , reachedthar exposure-based CBT is the bei' Even Lambert'spie chart indicates rhat unkno*'n treirtment oi cl'roiccfbr OCD, then onc up to l5o/,:of treatment eff-ects rnay be due could not establish its cfficacl', irs there to tcchniclue,v,'hereas Vampolcl (200i) CBT vs. ExposureAlone Effects could not be a bona ficlc trcatrnent with suggesrsU!2. Befbre speculating abour s'hich to cornprire exposr.rrc-Lrirsecl CBT. their magnitude,one nceds consider to how best to determine technique effects. One Relationship and Therapist Variables, Therapist method may be to compare active therapy Common Factors, and Technique th to placebo.Overall, CBT for anxiery disor- ffi other - The norion that the therapeuticrela- factors ders has in tzrctshown significant supcrior- tionship,therapisr, and/orcommon fhctors (cf ity to placebo Hofmann & Smits,2008), Treatment I contribute significantly more ro treatment with an irverageeffect size fbr the magni- procedures April . 2009 73
  5. 5. tude of the differenceof 0.33 for intent-to- latter. Note that this effectsizederivesfrom alsoCrits-Christoph& Gallop, 2006;Lutz, treat and 0.7) for completer analyses. data aggregatedacross studiesofa range of Leon, Martinovitch, Lyons,& Stiles,2007). However, there is variability in theseeff-ects, therapiesand treatments,similar to the ef- However, the questionof what makesther- with the strongestevidenr in the treatment fect sizescalculatedby Wampold and col- apists different from each other remains, of acute stressdisorder and OCD, and the leagues, and Luborsky and colleagues. and one answer may be technique. Some weakest in the treatment of PD. fhy Again, looking at specifictherapies and spe- therapistsare likely more adept than others might this be?It hasbeenshown previously cific populations, the verdict is nruch less ar using some techniques, formuiating that OCD is lessplaceboresponsive than is clear. For example, Lindsay, Crino, and treatment plans, encouragingtheir patients PD or social anxiety disorder (Huppert et Andrews( 1997)showedthat the alliance in to do difficult exposures, etc., even within al.,2OO4; Khan et al., 2001),and technique ERP and the alliance in relaxation were CBT. Of course, therapists also differ on effectsare most demonstrablein the disor- equal for patientswith OCD, but the differ- ability to form an alliance,but the therapist ders that have the smallestplaccbo effects. encesin efficacywere substantial.Similarly, who is ableto articulate scrongtreatment a In fact, for somc disorclers (c.g., major cle- Carroll, Nich, and Rounsaville (1997) rationaletailored to the partient's slrecific pression),significant tecl-rnicluc cffects arc shorvcd that irlliance was corrclatcd witlr presentirtion and to explainu'hy thc treat- st>mewhat difllcult to (lemonstrrte by com- olrtcome in a sr.rpportive therapy firr sub- ment citn hclp (or the thcrapistwho is ablc paring placeboto CBT (DeRubcisct al., stanceabtrse, but not CBT. In CBT for de- to provitican cxampleof an imaginirlexpo- 200)), althorrgh such effects are more pression, the data fiom DeRubcis and sure that direcly taps into an OCD pa- ;rrominentwhen examiningfbllow-updata colleagucs' studies havc consistently tient's fears)will likely bc cxpcriencecl by (e.g.,Hollon et al., 2001). Similarly, rhe in sl-rowed that the thcrapeuticallianccis better the patientasempathicancluncicrstanding. case of PD, lor rvhicl-rthc magnituclc of fbr paticnts rvhosc symptoms and cogni- Thus, techniclues may be part of thcrapist placcbo resl)onse also appcars to be high tions havc alreadychangedftrr the better effects(or vice versa),and not somcthing (l-ILrppcrt al.; Khan et al.),significant et bc- (c.g.,Tang& L)cRubeis, 1999);that is.early that can be truly scparatccl frt>n'r thcrn. twcen-trcatnlcnt clli'cts:lrc rnorccvidcntat iln;>rovenrent trcatnrcntleadsto :r nrorc in Jrrst as alliancc and thcrapist clfccts long-term fbllow-up (tsarlow, Gorman, positive alliancc. FIowever, in Cognitive sonretimcs may be accounte(l by tech- fbr Shear,& Woods,2000). In sum, it is diffi- Behavioral Analysis Systcm of Psycho- nicluc,so may othcr putzrcive common fac- cult to detcrmine the ovcrall cffect of tcch- thcralry,whcrc thc alliancc is an explicit tors (consider,firr cxrrmplc, how clatl on niquc without consiclcring disorcler ancl fircus of trciirment, alliance appetrrsto bc outconrc proviclecl during psychoeducation 1.r4rulation, conclrrsion :r reinfbrcecl otrr by prc.lictiveof outcome(Klcin ct al.. 2001). probably influcncc both therapist ancl pa- tliscussion the l)odo Birclvcrclict. of Ovcrall,alliancc may havethe grcatcst rela- ticnt cxpectancy).Indeed, thc notion of There arc t>thermcthods by wlrich one tionshipto olltcomeif the thcrapistrnnrkes conrmon ftrctorsitself l-ras broadenecl thc to may examinetcchniqrrc cffccts.For cxanr- it a ccntrlrlfocusof treatment.H()wever, in point that sornc u'oultl incluclethe tech- ple, Ablon and -fones(2002) showcclthat suchtreatments, clistinction thc betwcen al- nicltrc of exposure as a common factor cognitive therapy techniquesaccountcdlor lianceand techniqueis blurred. As othcrs (Lambert a Ogles, 2004). Howcvcr, as a significantamount of changcin dcprcssivc have noted (Beutler, 2002; Crits-Christoph Weinbcrgcr (1995) notcd, common factors symptoms in the NIMH Tieatmcnt of et al.. 2006). if onc addresses alliance di- may not be so common after all. The extent Depression Collaborativc Research Pro- rectly in trcatment sessions, vcry focus thc of focrrson alliance dilfers between trcat- gram in both CBT and interpersonal psy- on alliancc bccomes treatnrent a teclrnique. ments, and so does thc amount, type, or chocherapy treiltment conditions.In addi- Therc is only one pilot stuc{yto date that at- quality ofexposure. And ifthe goal ofpsy- tion, Cukrowicz et al. (2001) reportcd claca tempts t() imlrrove allianceby using specific chotherapyresearch to determinc the best is suSgestingthat '*'hen a clinic changeclits alliance-enhancing techniques (Crits- ways to relievesuffering for the most peo- policy to conduct only ESTs,there was sig- Christoph et al.), and the resultsare equivo- plc, researchcrs needto continue to locuson nificant improvement in patient outcomcs. cal. The effects of alliance-enhancing the areas that aremost manipulable,such as Howard (1999) noted that individuals a in techniques certainareas in (e.g.,changein technique.In fact, Lambert'slatest research managedcare environmcnt who had spc- allianceand improvement in quality of life) is an excellentexample of high-quality re- cialty training in CBT for anxiety disorders are l.rrge,but che impaccon symptoms is search thac incegrates argumentsfor the the were more likely to retain their patients, small, and the resultsare dilficult to inter- importanceof techniquc,alliance,and tl-rer- and thosepatientswere alsolesslikely ro re- pret without a comparison group of new apist factors. In brie[ Lambert has im- ceivefurther treatment 1 year latcr. It is im- traineeswho may have learned to improve provcd rhc quality of treatmentoutcomcin portant to note that studies that simply alliance without additional techniques. therapy by providing therapistswith feed- examine orientation are unlikely to flnd However,the studyis seminal its atempt in back on parient progressand whether rher- such effects, as Drny prirctitioners who directly to improve alliance, and fi-rrther apists are off track with their parients' i J e n r i f yt h c r r p r i r r r a r y r i c n t a t i o nr sc o g n i - o . strch studies are needeclto evirluate the predicted crajectories(Lambert, 2001. tive-behavioral concinrre userelaxarionas to causalin-rpact allianceon outcome. of Notably, rhe feedback inclucles specific a treatment of choice for OCD and PD Therapist eflectshave been discussed on rechniques that may help puc them back on (e.g..Freiheir al.. 2Ot)ll. er and off for over 30 years. More recently, track. One may r'",onder alouclwhether use But what about the contribution of al- some have shown that differences between o[ other types of disorder-specific infbrn.ra- liance, common facrors, and therapist e[- therapistsin treatment ourcomemay be de- tion could fi-rrtherenhance the efficacy of fects? On average. studies yield ar creased with n-ranualized trearmenrs (Crits- suchinterventions. correlation .22 betq,een of measures al- of C h r i s t o p he t a I . , 1 9 9 1 ) , a l t h o u g h n o t Overall, many researchers-ourselves liance and ouccome (Martin, Garske, & eliminated (e.g., Huppert et al., 2001). included-attempr ro quantify the relative Davis, 2000), demonstrating that thc for- How large are therapist effecrsi' Overall, contributions of technique and other ef- mer accountsfor )7o of the variancein the they seem to range from 17c to 75Va(see fects.Frequentlysuch data are presentedso tbe Behaior Tberapist