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Psychotherapy as a field tends toward conservativism, and the rate of innovation and development of new evidence-based effective treatments has been slow. This paper explores important barriers to innovation like the dodo bird verdict and the habit of starting the development of therapeutic methods from techniques. The paper looks at the opportunities for translating basic science in psychology into psychotherapeutic techniques. Metacognitive therapy stands out from other psychotherapies by its development from basic science. The paper describes the development of the techniques detached mindfulness and attention training, how they were derived from basic science and tested for their suitability in the therapy of patients with anxiety disorders. By this process, metacognitive therapy may be an important model for the innovation process in psychotherapy.
The implementation of psychotherapy in general healthcare has been one of the significant innovations of the twentieth century and has revolutionized how the health care system deals with mental disorders. Psychotherapy is an essential focus of training in clinical psychology and physicians aiming for board certification in psychiatry or psychosomatics in many countries. Despite this transformative impact, the rate of innovation and development of new evidence-based effective treatments has been slow, and it has been noted that compared with medication psychotherapy use is on the decline in the US (Gaudiano & Miller, 2013). This opinion paper examines some of the barriers to innovation that we believe have slowed progress. It discusses alternative ways of fostering innovation and uses the development of metacognitive therapy by Wells and colleagues as an example of a strategy that overcomes barriers and discusses how MCT fits into current assumptions about innovation.
The Therapeutic Relationship and the Dodo Bird Verdict
One of the widespread assumptions in psychotherapy
is that a good therapeutic relationship is the critical mechanism of successful
psychotherapeutic treatment (Wampold, 2015). It is assumed that the
relationship is more significant than the underlying model of causality and the
manipulation of its causal variables and is the universal change mechanism
uniting all psychotherapy approaches. This way of thinking postulates that
creating expectations through explanations of the disorder and the treatment
involved and the enactment of health-promoting actions are further common
factors. The presumed equivalence of all therapies after correction for the
therapeutic relationship has resulted in the dodo bird verdict (Luborsky
et al., 2002). Based on the finding in meta-analyses that a
broad spectrum of psychotherapeutic treatments in depression is similarly
effective, Cuijpers has claimed that there is a possibility to minimize the
number of existing therapies (Cuijpers,
1998). However, results of meta-analyses support differences between
psychotherapies (Budd and
Hughes, 2009; Tolin, 2010).
While the patient-rated quality of the therapeutic
alliance is a good predictor of outcome in therapy (Cameron
et al., 2018), a meta-analysis of the relationship between
therapeutic alliance and treatment outcome in eating disorders showed that the
association between alliance and outcome is weaker than the association between
early symptom improvement and later alliance (Graves et al.,
2017). Thus, it would seem that early symptom improvement affects
the later alliance. We might presume that the most effective treatments give
rise to the strongest alliances. What is lacking are experimental studies that
actively manipulate therapeutic alliance, and so the evidence remains
restricted to longitudinal predictor analyses that can do little more than
implying causal relations (Fluckiger
et al., 2018). Despite the lack of experimental evidence, the
prevalent assumption is that a good working alliance is “a thing” that resides
in the interpersonal harmony between two persons, providing a patient with a
healing experience that appears to be part of a stable, benign relationship.
Related to this idea is the presupposition that some therapists “have it” while
others do not, meaning that there are good and bad therapists, as categories.
Unfortunately, this explanation falls short of the alternative but little-tested
assumption that a good therapeutic relationship is an emergent phenomenon
produced by professionalism, plausible models, and experience of change already
early in therapy.
Consistent with the assumption that the alliance
is, in fact, an emergent factor of effective therapy, the working alliance in
pure Internet therapy is remarkably good (Heim
et al., 2018). The continued perception of the therapeutic
relationship as the primary underlying factor of psychotherapy effectiveness is
a barrier because it reduces the necessity of developing innovative theories
and techniques since new techniques only make a marginal difference. Assigning
the therapeutic relationship to the role of the critical cause of change,
instead of modeling it as an emergent phenomenon of change creates inertia in
research on psychopathological mechanisms and complacency in therapists.
Starting the Development of Therapeutic Methods From
New approaches have most often been devised based
on techniques, that is on the basis of assembling combinations of treatment
techniques that appear to work. Such approaches are often only loosely grounded
in theoretical models, and the models of treatment mechanisms may develop after
the treatments themselves.
A top-down approach in the design of technology
starts with an overview of the relevant system (e.g., dysfunctional beliefs)
but does not specify subsystems in sufficient detail or elucidate how they
impact on functioning. For instance, negative automatic thoughts and beliefs
are purported to cause or maintain disorder in the cognitive model. However, as
pointed out by Wells and Matthews (Wells &
Matthews, 1996), this approach does not consider broader aspects of
cognition that are known to be associated with the disorder such as biases in
the regulation of attention and levels of control of cognition. The
cognitive-behavioral model has not advanced along with recent developments in
cognitive psychology and theory such that the practice of therapy is only
loosely tied to an understanding of mechanisms. Beck based CBT on the
description of problematic thought content and processes of cognitive
distortion in patients (Beck, 1963,
The primary intervention derived from this observational approach and comprised
of correcting cognitive distortions and deficiencies in schema content using
Socratic dialogue. This fundamental change technique of cognitive therapy (CT) is
derived from philosophy and is not rooted in or supported by experimental
psychology. To the contrary, research shows that trying to replace
dysfunctional thought by more appropriate thinking may result in thought
suppression and have adverse paradoxical effects (Longmore &
Worrell, 2007; Magee
et al., 2012). Subsequently, more techniques used initially in
behavioral activation, assertiveness training, anxiety management or
mindfulness meditation have been incorporated to form a more eclectic cognitive
behavioral therapy (CBT).
A second notable example of technique-driven development is dialectical behavior therapy (DBT). It is based on the assumption that patients with borderline personality disorder have skills deficits in emotion regulation (Linehan et al., 1991; Linehan, 2014). At the core of the interventions are approximately 50 skills that are taught to patients to improve emotion regulation. Again, learning theory informed the selection of these skills, but none was derived from experimental psychology nor were they individually tested. As packages, both CBT (Beck & Dozois, 2011) and DBT (Stoffers et al., 2012) can be considered as well supported by evidence. There were a few studies involving component analysis (Jacobson et al., 1996) showing that in the case of CBT challenging thoughts on the content level, the primary and elemental technique may not be the essential ingredient. The introduction of disorder-specific treatment methods for depression, anxiety disorders, and personality disorders beginning in the 1960s was a big step forward for psychotherapy. These new methods led to a considerable extension of the field of activities of psychotherapy toward groups that are severely ill and were traditionally underserved. While there is evidence that these treatments offer innovation and can work, it is important to question whether the technique-driven approach of combining a range of techniques is the most effective means of treatment development. In particular, multi-component and highly eclectic treatment packages may hide detrimental effects of specific components of a treatment method (Castonguay et al., 1996). In summary, these examples show that in psychotherapy, the dominant technique-driven approach (as in other fields) has advantages but also creates serious problems.
This has been an excerpt from The Neuropsychotherapist Volume 7 Issue 6 – for the complete article and more interesting content, please subscribe to our website.