This article considers the implications of psychotherapy research for psychotherapy training in psychiatry. Recent surveys conducted in Canada and the US indicate that psychiatrists continue to spend a substantial amount of time providing psychotherapy. In a survey of Canadian psychiatrists, Leszcz and colleagues found that 92% spent almost one-half of their clinical time engaged in psychotherapy (1). A survey of the office practices of US psychiatrists conducted by Olfson, Marcus, and Pincus indicated that 79% of their patients received psychotherapy in 1995 (2). Although the percentage had decreased from 89% in 1985, it remained substantial. Weissman and Sanderson reported that the US Medical Expenditure Panel Survey found the demand for psychotherapy in the general population unchanged at approximately 3.4% between 1987 and 1997 (3). The demand among psychotherapists with an MD actually increased. According to current practice as reported in these surveys, the need for training in psychotherapy remains strong.
This article is directed to 3 groups of readers. First are administrators responsible for developing and approving psychotherapy training programs. This group includes university or hospital directors of resident training, directors of continuing medical education (CME), and members of curriculum committees. Second are teachers and supervisors who directly provide psychotherapy training. Third are the consumers; that is, those who receive psychotherapy training and provide psychotherapy to patients. This group includes residents and licensed clinicians who participate in CME training.
Scientific journals continually publish a large volume of research articles on psychotherapy. Adair and Vohra have described the difficult challenge that all researchers face in keeping up with the current literature (4). The difficulty for providers and consumers of psychotherapy training is even greater: many are primarily clinicians who often do not have the resources to monitor new publications comprehensively. Even when research articles are available, however, they are often not read and thus do not inform psychotherapy training. There are several reasons for this. Researchers usually write for other researchers, not for administrators, teachers, or trainees. Articles are often difficult to understand because they are laden with jargon. Much research is regarded as artificial and not applicable to clinical settings (for example, randomized clinical trials [RCTs] of therapy efficacy). Much psychotherapy research focuses on brief therapies and neglects long-term therapies that are still provided by many private practitioners. In addition, research reports are usually written tentatively, with many qualifications and limitations that do not inspire confidence in clinicians, teachers, and trainees.
Another problem is the lack of research on training and supervision. There is no body of research literature comparing the effectiveness of different approaches to training and supervision. Training models are based on tradition, not research. For example, didactic course work, supervised treatment of cases, and personal psychotherapy is the time-worn model of most psychodynamic therapy training (5). A more fundamental problem is the lack of training for effective supervision. Because most training programs devote little attention to the topic of supervision, there is little to study. Most supervisors must rely on their personal experiences as a guide to conducting supervision.
Either a relatively simple or a relatively complex approach can be taken in addressing the implications of psychotherapy research for training and in making recommendations for curricula. The simple approach would provide lists of therapies that have the most evidence of efficacy for particular problems, provide references from the research literature, and emphasize teaching those approaches in training programs.
The more complex approach would also attend to evidence of efficacy. However, instead of focusing on current lists of therapies, problems, and references, this approach would direct readers to reviews of the research literature summarizing the specific evidence of efficacy. The more complex approach would also present limitations and controversies associated with the evidence. This approach would require familiarity with basic research methodology and evaluative criteria, which would have to be covered as part of the training. It would emphasize general themes emerging in the field rather than simply listing specific findings. It would convey tentative rather than definitive observations about the evidence.
A simple approach is tempting. Learning to be a skillful psychotherapist is a challenging task that takes time, effort, and hard work, even when trainees feel confident about the usefulness of psychotherapy. Highlighting ambiguities, doubts, and uncertainties can be problematic, particularly if this is done in a way that leads to expectations of poor outcome, weak motivation, or diminished morale. Most trainees desire direct reassurance that they are learning both effective techniques and how to provide them skillfully.
Although tempting, a simple approach has several disadvantages. The outcome of psychotherapy is multiply determined; therapist technique is but a single factor. Choosing a promising therapy from a list and attempting to conduct it skillfully will not guarantee success. Patient, therapist, and relationship factors are also influential and need to be considered in treating individual patients. To assume otherwise will lead to disappointments. Similarly, therapists following a simple model of treatment will be disillusioned when the inevitable limitations of particular techniques become evident. As the field continues to develop, a relatively simple approach will not help the therapist evaluate evidence for new or emerging techniques; to do so, one must be a well-informed consumer. It is the responsibility of training programs to produce such trainees.
In taking a relatively complex approach, this article highlights 8 themes that characterize the current psychotherapy research literature. Each theme represents a controversial issue that has implications for psychotherapy training and practice. Many of the themes are related to each other and represent different positions in regard to the controversial issues. Before presenting these themes, which are expressed as conclusions, their historical context is briefly considered.
Just 50 years ago, there were no controlled or comparative outcome studies of the psychotherapies. Nevertheless, in 1952, Eysenck published a review claiming that psychotherapy was not effective (6). He compared the outcome reports of 24 studies, most of which involved psychodynamic therapies, with the outcome reports of 2 control studies involving patients who had not received psychotherapy. Eysenck concluded that two-thirds of the patients improved substantially within 2 years, whether or not they received psychotherapy. Subsequently, there were many criticisms of his review. It was argued that patient samples and outcome criteria differed between the treatment studies and the control studies, that control patients actually received treatment, and that his interpretation of the treatment studies’ results was biased.
Although Eysenck did not appear to win the debate on academic grounds, he scored a victory on psychological grounds. People invested in the practice of psychotherapy seemed embarrassed, off-balance, and demoralized. In time, the debate set the stage for a counteroffensive that included controlled studies and new reviews. Probably the most influential review was that of Smith, Glass, and Miller (7). Using a new review method called metaanalysis, which involved calculating an effect size for each outcome variable and then averaging the effect sizes across studies, they summarized the results of 485 controlled studies. These authors concluded that psychotherapies in general are effective and that there is little difference in effectiveness among the different types of psychotherapies. These conclusions were regarded as inaccurate by a number of people, many of whom were advocates of behaviour therapy (8). They attacked the review methodology and the conclusions. Debate about the validity of metaanalysis and the conclusions one can draw from it has continued to the present time. Nevertheless, many metaanalyses continue to be published. In an extensive current review of the outcome literature, Lambert and Ogles (9) came to the same general conclusions as Smith, Glass, and Miller and acknowledged that the controversy has not subsided. Unfortunately, one of Eysenck’s legacies is a polemical climate that has too often led to attacks and counterattacks between vested-interest groups. The latest example is the debate concerning the value of creating lists of “empirically supported therapies,” discussed below as a controversial theme.
Another strong force that has influenced the type of therapies studied and practised in North America is health care reform, often referred to as the managed care movement. As third-party controller of health care funds, managed care companies have favoured short-term therapies. Further, decisions about which therapies to fund have frequently been influenced by practice guidelines. These are policy statements from major organizations about the proper treatment of certain disorders. The preference for short-term therapies has created pressure for researchers to study them and compete in determining which therapies meet criteria for empirical support. It has added fuel to the polemical climate that has characterized psychotherapy research and has resulted in what some believe to be extreme positions and simplistic claims that certain techniques are superior. Within the context of these developments, the major themes that characterize the current psychotherapy literature are considered next. Each is presented as a conclusion. Following this, implications for training are considered.
Theme 1: There Are Few Differences in the Outcomes of Most Psychotherapies
Metaanalytic reviews have strongly supported this theme, which represents what has been referred to as “the dodo bird effect” (10,11); that is, everybody has won, so all shall have prizes. When differences among therapies have emerged, they have often been attributed to “the allegiance effect.” This refers to the strong relation between the theoretical orientation of the research investigator and the theoretical orientation of the treatment that emerges as most effective in comparative outcome studies (12). After statistical adjustments are made for the allegiance effect, the outcome differences among therapies usually disappear. The strongest opponents of this theme are the advocates of the empirically supported therapies (EST) movement. They claim that the therapies on their lists have evidence of superiority over other therapies for specific diagnoses (13). Other opponents are the advocates of aptitude–treatment interactions (ATI). This group believes that there are optimal matches between patients scoring high on a particular characteristic and specific therapies and patients scoring low on the same characteristic and other specific therapies. They contend that, when effect sizes are averaged across therapies in metaanalyses, these specific matches (interactions) become obscured. Opponents also attribute the small number of outcome differences in comparative studies to such factors as weak methodology; low power owing to small sample size; treatment of mildly disturbed, single-diagnosis patients; use of brief therapies; and overreliance on symptoms as outcome criteria (14).
Theme 2: Common Factors of Therapies are More Strongly Related to Outcome Than Unique Factors
Common factors are therapeutic factors that are present across therapies (for example, a helping relationship, a convincing rationale, and feedback concerning progress) (15). In contrast, unique factors differ across therapies (for example, interpretation of transference). Those who believe that there are few differences in outcome among most therapies, as indicated by metaanalytic reviews, often attribute this to the presence of common factors. In a series of studies of the actual process of therapies with distinct orientations (that is, psychodynamic, cognitive-behavioural, and interpersonal), Jones and colleagues found that they had much in common, particularly in regard to what appeared to be the effective ingredients of favourable change (16). Separate research has found it difficult to demonstrate that the unique theoretical base of different therapies accounts for their effectiveness—additional evidence for the greater importance of common factors. For example, a recent review of the literature found little evidence for the unique theoretical underpinnings of cognitive-behavioural therapy (CBT) (17). Similarly, a review of the literature found little evidence that eye movements were a necessary component of eye-movement desensitization and reprocessing therapy (18).
Theme 3: The Criteria for Empirically Supported Therapies Should be Used to Select Which Therapies Are Taught in Training Programs
Criteria for empirically supported therapies and lists of therapies that meet those criteria were originally championed by an American Psychological Association task force (19). Subsequent lists have been prepared (20,21). The criteria have emphasized RCT designs, treatment manuals, homogeneous diagnostic groups, and independent replications. Many advocates have been from the behavioural and cognitive- behavioural orientations, with associated treatments dominating the lists. To their credit, they have advocated an accountable, evidence-based approach to choosing treatment for specific problems. However, their approach has been viewed by many as premature and restrictive. Opponents of the EST movement, which have included both clinicians and researchers, have criticized the use of RCT methodology. While accepting the strong internal validity of RCTs (that is, having confidence that the treatment was responsible for the outcome differences), they have emphasized the weak external validity (that is, generalization to clinical practice) of RCTs. They have argued that clinicians usually do not accept patients randomly, treat patients restricted for age and sex, treat patients with minimal comorbidity, or use manualized, time-limited therapies (22). They have described RCT studies as tests of efficacy, not tests of effectiveness (that is, studies conducted in natural clinical settings). In the UK, difficulties have been reported in teaching general practitioners basic CBT skills (23) and in bringing about superior improvement with CBT, compared with nondirective counselling (24). These findings highlight the difficulty of transferring the practices of research clinics that conduct RCTs to primary care settings.
Opponents of the EST movement have also emphasized the importance of nondiagnostic patient characteristics, therapist characteristics, and patient–therapist relationship characteristics in affecting outcomes. To counter the EST movement, some opponents have created their own task force and compiled lists of empirically supported relationships (25,26). These lists highlight such relationship characteristics as the therapeutic alliance, goal consensus, self-disclosure, and group cohesion in group therapies. Opponents have also argued that RCTs suffer from dropouts, which undermines random assignment, and that they are but one of many methods to investigate the effectiveness of the psychotherapies. Alternative methods include naturalistic, correlational, process–outcome, structural modelling, and qualitative approaches, each of which can provide valid data about therapy outcomes.
Theme 4: There Are Some Good Matches Between Specific Patient Characteristics and Specific Therapies
Evidence for good matches has come from the EST movement and ATI research. The former has focused on patient diagnoses and the latter on patient personality dimensions. Perhaps the strongest evidence for matches, as identified by the EST movement (21), involves the anxiety disorders and forms of CBT. Examples include CBT for panic disorder and generalized anxiety disorder, exposure for phobias, and exposure and response prevention for obsessive–compulsive disorders.
Evidence from ATI studies has most often demonstrated a match between a personality dimension and 2 or more distinct therapies. Researchers have emphasized the importance of making a priori, theoretically based predictions in ATI studies; this enhances the chances of finding a match as well as the credibility of the findings. Two examples that are frequently cited come from the work of Beutler and colleagues (27) concerning the personality dimensions of externalization and reactance. Externalizing patients responded better to skills- oriented, symptom-focused therapies, whereas internalizing patients responded better to insight-oriented therapies. Reactance refers to resistance to directives. High-reactant patients responded better to self-directive therapies, whereas low-reactant patients responded better to directive therapies (28). Another example concerns quality of interpersonal relationships. Patients with a history of relatively gratifying interpersonal relationships do better in confrontive, insight- oriented therapies, while patients with a history of relatively problematic relationships do better in supportive psycho- therapies. This match has been found in both individual and group therapies (29,30). The ATI approach may have particular promise with group therapies. A review of the group-therapy literature found that 83% of the ATI studies had significant findings (31).
Theme 5: Therapy Manuals and Practice Guidelines Should Be Used for Training and Clinical Practice
Psychotherapy researchers developed manuals to standardize the therapist’s theoretical and technical orientation. Reducing therapist variability can strengthen the internal validity of trials. The use of manuals spawned adherence measures, which are used to quantify the degree to which therapists follow manuals. For advocates of empirically supported therapies, the use of manuals is an essential criterion. Teachers and clinicians have had mixed reactions. Manuals vary considerably in length (for example, from 20 pages to book length) and in the degree to which they instruct therapists to comply or be flexible in providing the technique. There has been concern that manuals may contribute to therapist rigidity and less satisfactory outcome. This concern has spawned competence measures, which indicate how skillfully the therapist provides treatment. Evidence from a large-scale psychotherapy training study indicates that therapists trained with manuals became more adherent but less competent in providing therapy (32). Concern about the possible negative effects of using manuals has been greater among therapists from some orientations (for example, psychodynamic) than others (for example, cognitive-behavioural). Psychodynamic therapists follow a more patient-driven model, where uncertainty about how the session begins and what follows is part of the intended unpredictable process. If the therapist greatly determines the content or provides standard responses, the process is not considered to be psychodynamic. Thus, some manuals for psychodynamic therapy (33) have been designed to provide general guidelines and to encourage therapists to use their judgement regarding interventions (for example, the number and timing of interpretations). Adherence measures for such therapies must assess the degree to which general guidelines are followed. They should monitor not only what the therapist should be doing but also what the therapist should not be doing (34). Both psychodynamic therapy teachers and cognitive therapy teachers agree that training competent therapists takes considerable time and goes well beyond teaching therapists to adhere to manuals (35,36).
Many of the same issues affect the use of practice guidelines (37). Advocates believe that they usefully present state-of-the-art procedures for treating patients with specific disorders. Opponents argue that they prematurely bring about closure in areas of treatment that need development and that they soon become obsolete.
Theme 6: Brief Therapies Should Be Provided to Patients Before Long-term Therapies and Should Be Emphasized in Training Programs
The vast majority of psychotherapy research conducted in North America over the last 50 years has focused on relatively brief therapies; that is, of 20 sessions or less. For example, in Smith, Glass, and Miller’s review of 485 studies (7), the included therapies averaged 11 weeks’ duration. Surveys of therapies provided in outpatient clinics also indicate a predominance of brief therapies. There are several reasons for the high prevalence of brief therapies in clinics and research studies. First, there are strong economic pressures from third- party payers to cover brief treatments. Second, many patients expect and desire brief treatments. Third, therapists from some orientations (for example, psychodynamic) have been interested in applying their techniques innovatively in brief therapies (for example, early-transference interpretation). Fourth, considerable research evidence from dose–response studies indicates that many patients can accomplish important changes in brief periods of time. Studies by Howard and colleagues (38) and Kopta and colleagues (39) suggest that over 50% of patients experience significant improvement after 8 sessions and 75% after 26 sessions.
Others have been more skeptical about what brief therapies can achieve. They have been more interested in evidence of clinically significant, rather than merely statistically significant, change. Clinical significance is based on normative information and requires that, after treatment, the patient’s problems are more characteristic of normal than of pathological scores of disturbance. In a large survey using the more stringent criterion of clinical significance, Lambert, Hansen, and Finch found that only 50% of patients achieved improvement after 21 sessions and 75% after more than 40 sessions (40). In a follow-up to the well-known National Institute of Mental Health (NIMH) collaborative study of depression, Shea and colleagues found that 16 weeks of CBT or interpersonal therapy or antidepressant medication were insufficient to achieve full remission and lasting recovery for most of the patients (41). In our research team’s recent clinical trial of 20 sessions of dynamically oriented interpretive or supportive therapy (29,42), less than one-half of the patients achieved both clinically significant and reliable change by the end of treatment. Although these levels were maintained through 1 year of follow-up, they did not increase. In regard to specific outcome criteria, change in brief therapies more often involves symptoms than interpersonal or personality change. High comorbidity of disorders (for example, major depression and personality disorder), which is seen in community clinics more often than in university-based research clinics, is also associated with less impressive improvements (43). In general, all these findings suggest that the effects of brief therapies are both encouraging and disappointing—the glass is both half full and half empty.
Although the modal form of long-term psychotherapy has been psychodynamic therapy with a planned duration of 1 year or more, Crits-Christoph and Barber (44) have noted that it may also represent recurrent brief therapies, maintenance therapies, or brief therapies that required more time than initially expected. Very few outcome studies of long-term psychotherapies exist. Those that have been conducted tend to be retrospective or prospective but lack comparison conditions and random assignment. Thus, the scientific evidence for their effectiveness is less extensive and strong, compared with the brief therapies. This indicates that their effectiveness is unproven, not that they have been shown to be ineffective. In fact, dose–response studies have demonstrated that some patients do not improve unless they receive long-term therapy. Several factors have discouraged research on long-term therapies. Economic conditions have highlighted the importance of learning about brief therapies, ethical concerns have precluded the use of certain long-term control conditions, and research studies of long-term therapy are considerably more expensive, time-consuming, and difficult to complete. Nevertheless, conducting studies of long-term psychotherapy is a much-needed research objective that granting bodies and researchers will, one hopes, pursue.
Many clinicians believe that patients with long-term characterological problems that have not responded well to brief therapies or patients who require improvements in functioning that extend beyond improvements in symptoms are appropriate for long-term therapy. Many teachers of psychotherapy also believe that long-term cases are excellent learning opportunities for trainees. Nevertheless, skeptics emphasize the unproven nature of long-term therapies and maintain that it is unethical for therapists to provide long-term therapy to patients with problems that respond well to brief therapies. They argue that choice of therapy should be a product of the patient’s informed consent regarding the cost- effectiveness of different therapies (45).
Theme 7: The Combination of Psychotherapy and Medication Results in Better Outcomes for Most Problems Than Either Treatment Alone
In a recent literature review, Thase and Jindal (46) conclude that there is growing evidence of the superiority of combined treatments for recurrent and severe major depression, schizophrenia, obsessive–compulsive disorder, and bipolar affective disorder, as exemplified by the Keller and others study (47). They argue persuasively that previous reviewers who found little evidence that the combination added benefits did not sufficiently take into account study design and statistical limitations. Thase and Jindal do not believe that there is at present sufficient evidence to support the routine use of combined treatments for milder depressive and anxiety disorders, particularly in light of the cost of providing both.
Theme 8: Group Therapies Have Outcomes Similar to Individual Therapies
Reviews of comparisons between the effectiveness of individual and group therapies have provided consistent evidence of virtually equivalent outcomes (48,49). Because multiple patients can be treated in groups, a strong argument can be made for their greater cost-effectiveness. Despite such findings and conclusions, group therapies have been underused. Resistance appears to come from both patients and therapists, who typically experience greater loss of control, individuality, understanding, privacy, and safety in the group situation. Given the current economic strain in the health care field, it can be expected that pressure to use group therapies will increase.
Other controversial themes that characterize the field of psychotherapy research also have implications for training. Three additional examples follow. First is the theme that supportive therapy is a distinct form of psychotherapy that is effective for many types of problems (50,51). Second is the theme that integration of different techniques has become a recommended approach to the practice of psychotherapy; examples include cognitive behavioral analysis system of psychotherapy (CBASP) for chronic depression (52) and coping strategies therapy (CST) for bulimia nervosa (53). Third is the theme that transference and countertransference are important events to be recognized and dealt with in all types of psychotherapy, not just in dynamically oriented psychotherapies (54). Space limitations do not permit elaboration and consideration of the implications of these and other themes.
The implications of the themes that have emerged from the research literature suggest specific content for a curriculum in psychotherapy training. To be informed consumers, trainees require training in basic research methodology. This includes becoming familiar with the different methods of reviewing research literature, such as metaanalysis; an appreciation of different approaches to studying the effectiveness of the psychotherapies; and knowledge of basic methodological and statistical weaknesses that affect the conclusions one can make about studies. The objective is not to transform trainees into researchers but to provide trainees with a basic set of skills for understanding research literature that can be confusing. Trainees should be familiar with the EST movement, including its lists of treatments and disorders and its limitations. Similarly, trainees should be aware of good patient– treatment matches from the aptitude-treatment literature. They should also be familiar with the empirically supported relationships movement, including its lists and limitations. Rather than taking sides, trainees should be encouraged to develop a constructively critical perspective to both movements.
The extensive presence of brief therapies in the research literature and in clinics across North America indicates that they should definitely be prominent in the curriculum. They include brief dynamic therapy, CBT, and interpersonal therapy. Both individual and group forms of these therapies deserve attention. Accompanying these therapies are treatment manuals that can be constructively used in training. Limitations associated with the use of the brief therapies and their manuals need to be considered. Evidence for the effectiveness of long-term therapies, both individual and group, is not of the same type or as strong as the evidence for the brief therapies. Nevertheless, given the other types of evidence of their effectiveness, their potential usefulness in treating problems that are severe and recurrent, and the fact that many teachers find them to be a useful means of learning about patients and psychotherapy, long-term therapies should be included in the curriculum. A similar argument can be made for including couple and family therapies.
The combination of psychotherapies and medications is a natural and important topic for the curriculum of psychiatrists in psychotherapy training because they have general training in medicine and, therefore, a unique area of expertise among mental health professionals. Further, given their expected leadership role in many mental health teams, it is important that psychiatrists receive training in supervising, consulting, and making referrals.
It is important that the curriculum not be restricted to the acquisition of specific clinical skills. As indicated previously, the field of psychotherapy research is continually evolving in terms of both methodology and content. Teachers should be encouraged to integrate research evidence of effectiveness, reviews of the literature, and the latest studies that contribute new information about the psychotherapies with the teaching of clinical skills. Obviously, research does not address many areas of training. Hopefully, considerably more areas will be covered. In the meantime, there are some excellent resources based on considerable teaching and clinical experience that can help fill the gaps with reasonable suggestions. These include publications by Cameron and colleagues (55–57). Last but not least, trainees should be familiar with the controversial themes and implications highlighted in this article. Although they may heighten some uncertainties about the broad range of psychotherapies being taught, they will provide a more realistic and enlightened perspective of the field, commensurate with the goal of creating well-informed, competent psychiatrists.
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Manuscript received and accepted December 2003.
1. Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
Address for correspondence: Dr WE Piper, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1
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