verdict implies that we should âleave well enough aloneâ regarding research, that (perhaps the most egregious comment) anything goes in the consulting room, ...
Point/Counterpoint – A Forum for Discussion of Reviews and Books Reviewed
The Heart and Soul of Change: Delivering What Works in Therapy (2nd ed.) by Barry L. Duncan, Scott D. Miller, Bruce E. Wampold, and Mark A. Hubble (Eds.) Washington, DC: American Psychological Association, 2010. 455 pp. ISBN 978-1-4338-0709-1. $59.95 Original review: The Heart and Soul of the Dodo Author response: Some Therapies Are More Equal Than Others? Reviewer reply: Response to Barry L. Duncan
Some Therapies Are More Equal Than Others? Barry L. Duncan
In his review of The Heart and Soul of Change: Delivering What Works in Therapy, Thomas L. Rodebaugh candidly admits his allegiance to empirically supported treatments, which perhaps explains the myopic lens used to examine the book. The dodo verdict (“Everybody has won and all must have prizes”) still perfectly describes the state of affairs in psychotherapy—all bona fide approaches, in spite of vociferously argued differences, appear to work equally well. It is the most replicated finding in the outcome literature. Commenting on the dodo verdict’s ubiquity is hardly “stacking of the deck” when the findings that contradict it are less than would be attributable to chance alone. Importantly, saying that the dodo verdict persists in no way suggests that specific treatments for particular problems are not helpful. While we take a critical stance toward claims of model superiority and confirm the veracity of the dodo verdict across modalities and populations, we do not denigrate model and technique or specific effects, but rather propose that model/technique are essential components of a common factors perspective. We offered a way to understand how the alliance, expectancy, and model/technique are interdependent and overlapping.
Technique is the alliance in action, carrying an explanation for the client’s difficulties and a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of engendering the same response in the client. Indeed, one cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, one cannot have a positive expectation for change without a credible way for both the client and therapist to understand how change can happen. We attempted to unite the warring factions via a more sophisticated understanding of change (interconnected factors, not disembodied parts or a tiresome specific vs. common factors polemic) as well as the American Psychological Association’s (APA’s) more contextual definition of evidence-based practice. As the APA Task Force (APA, 2005) noted, the response of the client is variable and therefore must be monitored, with treatment tailored accordingly to ensure a positive outcome. Proponents from both sides of the common versus specific factors aisle have recognized that outcome is not guaranteed, regardless of evidentiary support of a given technique or the expertise of the therapist. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve outcomes regardless of the treatment administered. There are now nine randomized controlled trials showing the significant benefits of feedback (Duncan, 2010). Rodebaugh’s assertion that one must examine specific treatments for specific disorders to uncover differences between treatments ignores the many direct comparisons that have not yielded any differences for specific disorders, such as the Treatment of Depression Collaborative Research Program, Project Match, and the Cannabis Youth Treatment Project, to mention a few (see these program descriptions in The Heart and Soul of Change). Consider the study we didn’t cite (Siev & Chambless, 2007). Although it is hard to imagine many therapists who would solely offer relaxation training for clients with panic disorder, cognitive behavior therapy (CBT) beat relaxation training alone on primary measures (although a closer look at the five studies reveals that one showed significantly more positive results than did the other four and two found very little difference). But accepting this investigation at face value, namely, that CBT is better than relaxation training for treating panic disorder (but not generalized anxiety disorder) on primary measures only, hardly seems like any definitive overturn of the dodo verdict. Nowhere in The Heart and Soul of Change is there any suggestion that the dodo verdict implies that we should “leave well enough alone” regarding research, that (perhaps the most egregious comment) anything goes in the consulting room, or that there is little point to training. Quite the contrary. The book advocates for a shift toward research and training about what works and how to deliver it, and away from a sole reliance on comparative, “battle of the brands” clinical trials. For example, my colleagues and I recently explored the relationship of the alliance to outcome and found that it predicted outcome
above early treatment change and that ascending alliance scores were associated with better outcomes (Anker, Owen, Duncan, & Sparks, in press), a strong argument for continuous alliance assessment. The Heart and Soul of Change also calls for a more sophisticated clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches, there is indeed differential efficacy for the client in the room now—therapists need expertise in a broad range of intervention options, including empirically supported treatments, a point made by several authors. Dismissing the book on the basis that some therapies are more equal than others is reminiscent of another set of animals in another classic story. It’s time to transcend the polemics and instead focus on what works with the client in my office now.
References American Psychological Association. (2005). Report of the Presidential Task Force on evidence-based practice. Washington, DC: Author. Anker, M., Owen, J., Duncan, B., & Sparks, J. (in press). The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample. Journal of Consulting and Clinical Psychology. Duncan, B. (2010). On becoming a better therapist. Washington, DC: American Psychological Association. doi:10.1037/12080-000 Siev, J., & Chambless, D. L. (2007). Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders. Journal of Consulting and Clinical Psychology, 75, 513–522. doi:10.1037/0022-006X.75.4.513
PsycCRITIQUES 1554-0138
September 15, 2010, Vol. 55, Release 37, Article 8 © 2010, American Psychological Association
