Researchers identify factors responsible for change in psychotherapy

Although still somewhat of a novelty in Thailand and other developing nations of the world, the use of psychological therapies to resolve interpersonal issues and alleviate emotional suffering has exploded in recent years. In 1996 researchers reported that the number of professional therapists had increased by 275% since the mid 1980s.

Today people in the developed nations of the world seeking help with mental health problems need not look far. Mental health services are currently provided by numerous categories of professionals, including psychologists, psychiatrists, psychoanalysts, social workers, licensed professional counselors, marriage and family counselors, psychiatric nurses, alcoholism counselors, addiction specialists, members of the clergy, and any number of others who profess competence in the area.

A similar trend has been seen in the growth of therapy models and techniques used to treat mental health problems. It has been estimated that there are more than 200 therapy models to choose from, each one claiming particular effectiveness and curative power embodied within their various rituals and procedures. Studying growth trends in psychotherapy techniques during the 1980s, researcher Sol Garfield predicted, “…that sometime in the next century there will be one form of psychotherapy for every adult in the Western World.”

Before long, the appearance of rival therapies generated an interest among researchers to identify the most effective therapies, and to weed our therapies demonstrating little or no utility. The ensuing 40+ years of therapy outcome research, taken as a whole, produced a very surprising conclusion: Although therapy clearly works, no specific system of therapy has emerged as consistently more effective than the others. Luborsky, Singer, & Luborsky dubbed this the “Dodo Bird Verdict” borrowed from Alice in Wonderland. “Everyone has won and all must have prizes.”

This finding eventually led to efforts to identify elements common to various forms of psychotherapy that might account for their general effectiveness. As early as 1936, psychologist Saul Rosenzweig suggested the notion that the effectiveness of different therapy approaches might be attributable to common elements, as opposed to their theoretical foundations.

In their recent book, The Heart and Soul of Change, building on the work of Dr. Michael Lambert of Brigham Young University, psychologists Mark Hubble, Barry Duncan and Scott Miller, identified four factors they believe to be the “active ingredients” of effective therapy. They consist of 1) client/extratherapeutic factors, 2) relationship factors, 3) placebo, hope, and expectancy, and 4) model/technique factors.

According to these investigators, characteristics of the client and his/her life circumstances are the primary contributors to the therapeutic outcome. Each client brings to therapy a number of personal resources, such as a sense of responsibility, persistence in the face of adversity, supportive family members, religious faith, an education and work history.

Chance factors that periodically affect clients’ life circumstances would also be included here, such as landing a new job, the establishment of new supportive friends, winning the lottery, and the readjustment of life stresses. According to Lambert, client and extratherapeutic factors are, by far, the most potent contributors to change in psychotherapy, accounting for 40% of the outcome variance.

Relationship factors are those that result from the quality of the relationship or “alliance” between the client and therapist. These are identified as “caring, empathy, warmth, acceptance, mutual affirmation, and encouragement of risk taking and mastery.” These factors are believed to account for 30% of the therapy outcome variance.

It is a widely known fact that the client’s hope and expectancy also contribute to favorable treatment outcomes. When a person enters treatment with a credible professional, he generally expects a favorable treatment outcome. Drug researchers, aware of this fact, routinely utilize inert substances, known as “placebos,” to control for such factors in clinical drug trials. This expectancy, in itself, can contribute to a patient’s feelings of relief, and a sense of well-being. Lambert places the contribution of these factors to treatment outcome at 15%.

Model/technique factors consist of the set of beliefs and procedures promoted by the particular treatment approach. Lambert suggested that these characteristics, like those of expectancy, account for only 15% of the outcome variance.

The surprising conclusion offered by this body of research and its implications have yet to be fully absorbed by professionals in the mental health field. Some theoretical camps continue to squabble about the differences among various techniques. Controversies over theoretical models seem minor, however, compared to the relative importance of the more salient common factors in affecting treatment outcomes. During the coming years it will be interesting to see to what degree practitioners modify the way in which they provide mental health services, in response to the compelling findings produced by these clinical investigations.