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Therapy Clients/Patients and Therapists: Your Responses Invited

January 21, 2011

Last weekend, I attended the annual conference of the Society for Social Work Research (SSWR) in Tampa, Florida. One of the most interesting and provocative sessions I attended was a roundtable session and discussion on Evidence Based Practice versus Practice Based Evidence (note: Allen Rubin was not present at this session, as listed on the program but all the others listed were). The common factors approach to psychotherapy and the DoDo Bird Verdict were being discussed.  The DoDo Bird Verdict is basically the idea that there are no major differences between various therapies and thus, it makes no difference which interventions are chosen and that the most important common factor in therapy is the quality of the relationship between the client and therapist. This notion is based on the results of a number of published meta-analyses that have purported to statistically demonstrate this. However, this is highly debatable and controversial because the methodology of these meta-analyses has repeatedly been called into question and there are, of course, a number of studies that do show robust differences between specific interventions for specific types of problems. Nevertheless, that is the point of view that was being presented by proponents of Practice Based Evidence and the DoDo Bird Verdict. It is called that after the DoDo bird in Alice in Wonderland,  who said “Everybody has won and all must have prizes.”

One of the findings in common factors research is that clients do better with theoretical approaches that are consistent with their own worldview and hence, therapists should present explanations about why a particular approach being offered that are consistent with the client’s worldview, even if that explanation lacks scientific support and there are better supported explanations that are not consistent with the client’s worldview and even if the therapist is aware that the explanation is not the scientifically correct one (this is my understanding — proponents can feel free to correct me if I have gotten anything wrong in my paraphrase).

One of the panel participants, Bruce Thyer, offered and challenged the following quotes, from an article published in the journal, American Psychologist, by psychologist Bruce Wampold, who is one of the most prominent proponents of the common factors approach. Without further comment, I would be very interesting in hearing responses anyone reading this has to the following quotes from that article:

I argue here that the truth of the explanation is unimportant to the outcome of psychotherapy.  The power of the treatment rests on the patient accepting the explanation rather than on whether the explanation is “scientifically” correct…What is critical to psychotherapy is understanding the patient’s explanation of it (i.e. the patient’s folk psychology) and modifying it to be more adaptive.”  (Wampold, 2007, p. 974, American Psychologist (November). Psychotherapy The Humanistic (and Effective Treatment.  (pp. 857-984)

I hypothesize that effective explanations in psychotherapy must be different from presently held explanations for a patient’s troubles but not sufficiently discrepant from the patient’s intuitive notions of mental functioning as to be rejected…Effective therapists are skilled at monitoring acceptance of the explanation and will modify the delivery of an explanation as necessary.  (Wampold, 2007, p. 975, American Psychologist (November). Psychotherapy The Humanistic (and Effective Treatment.  (pp. 857-984)

I will offer my own comments and opinions later, but would very interested in any reactions readers might have to this, particularly if you are, or have ever been a therapy client or if you are a therapist. How would you feel about a therapist taking this approach with you? Would you rather hear the scientifically correct explanation that best approximates what we currently know according to evidence or the explanation that is most compatible with your own belief system, even if not scientifically correct and even if it went against evidence? I would be very interested in any reactions anyone has to these statements.

  1. Not only would I rather hear the scientifically plausible explanation, I’ve discussed various popular but wrong ideas about psychology with my therapist (catharsis, orthomolecular therapy, popular depictions of mental illness). But in a sense that is compatible with my belief system, because I’d rather hear what’s currently believed to be true than what I might want to hear. And I’ve been wrong about things in the past, believing A when B or C was actually closer to the truth.

    Skepticism, to me, is the ability to recognize you might be wrong.

  2. While such an approach might seem respectful of patients, I think it is really patronizing and demeaning. And perhaps lazy on the part of the therapist. Professionals should expect the best of clients, i.e. that they can understand the reasons for using science-based interventions, and take the time to explain their importance.

    I’m writing here because this issue reminds me of exposure therapy. While it is highly effective, I know from experience that it the last thing you want to hear your therapist suggest if you have a major phobia. This therapy also doesn’t rely on a good therapist-client relationship, or even having a therapist. It can be done with a manual.

  3. SkepticalMary permalink

    My answer to the question, “Would you rather hear the scientifically correct explanation that best approximates what we currently know according to evidence or the explanation that is most compatible with your own belief system, even if not scientifically correct and even if it went against evidence?” is “Neither.”
    What I would prefer, as a scientifically oriented person who has had predominantly negative experiences as a therapy client, is honest discussion of what is and is not known. I don’t mean to imply that therapists are deliberately dishonest (although some might be); I suspect that many therapists really aren’t honest with themselves.
    I make a distinction between “plausible” and “correct.” I think in terms of the strength and quality of evidence, not in terms of “whether or not there is evidence.” If a therapist proposes an intervention or makes an assertion to me, I would like to know, “How do you know? What is the evidence? Why do you believe that?” Unfortunately, therapists in my personal experience of therapy are more likely to give responses such as, “Do you realize you’re asking me to give up my control?”, “I have my reasons,” or “Because I believe in balance.” (Those are real responses, not made up, from three different therapists.) I have done a lot of reading to try to make sense of my experiences with therapy and the profession of therapy. In that reading, I have found mostly assertions that are not backed up with evidence, beyond perhaps an occasional anecdote. In reading involving Evidence Based Practice, I have found mostly “pro forma” arguments with outline, “We have conducted a randomized, controlled clinical trial, and the statistical analysis shows …” But when I read actual research papers, a lot of details (that would be important to a consumer, especially one with some knowledge of scientific research) are left out. Examples:
    What were the outcome measures? It is not helpful to read “so and so’s inventory of such and such” if the consumer can’t get their hands on that inventory. How would I know if I fit the criteria for being in the study? Or even if the questions made sense to me. (Therapist questions often haven’t made sense to me – and when I ask for clarifications, the response is often not helpful.)
    What is considered clinically significant improvement, and why? Again, without having access to the instrument, I couldn’t tell whether that would be worthwhile for me.
    Are the people in the study like me? (e.g., age, gender, educational background, reasons for seeking therapy)
    What is the distribution of outcome/improvement measure for participants in the study? Typically, only averages are given. How many people show clinically significant improvement? How many get worse, either as measured by the outcome measure or in other ways?
    What are the details of the statistical analysis? (Warning: This gets technical.) For example: Is the analysis based on intent-to-treat? (If not, the results need to be taken with a ton of salt.) Have the model assumptions of the analysis been checked? If more than one statistical inference has been done, has the problem of multiple inference been taken into account? Has therapist been treated as a random factor?
    Have the authors taken into account possible sources of bias? One important one is the fact that it is impossible to have a fully blinded clinical trial of a therapy method – the therapists have to know what method they are using! Therapist differences in training/experience, therapeutic allegiance, amount of client feedback, etc. can also lead to misleading conclusions about the therapy methods.

    Based on my own experience (therapy experience and self-knowledge), I suspect that the “treatment” that would be most likely to help me would be a therapist who considered their role to be a good listener, to be accepting (as contrasted with “trying to understand me,” which typically seems to consist of trying to contort me to fit into a pre-existing, not very realistic, framework), to be patient, to give me space, to be respectful of my dignity, and to refrain from interventions without informed consent. But the therapist would also need to be able to handle complexity (those black and white statements don’t help) and be honest with her/himself.

    • Therapy Abuse Victim permalink

      Bravo to you!
      I am yet another victim of a “therapist” who represented himself as competent in using EMDR (about which I then knew nothing) to help clients to heal following significant trauma (in my case traumatic loss of a loved one). In fact, he combined EMDR with “parts therapy,” eventually and insidiously (without adequate informed consent or even communication about his “diagnosis”) leading to my being psychologically “raped,”–told I had “parts,” threatened if I did not go along with his “diagnosis and treatment approach,” and much, much worse.

      I am trying to collect similar stories in order to write a book warning the public that the “Sybil phenomenon” is still very much a (damaging and somewhat secretive) part of “therapy,” despite no longer being a “hot” topic in the public eye. I seek to inform the public and to warn the vulnerable to beware of “dissociationist” cult-like “parts” therapists.

      I do have connection with psychologists, psychiatrists, and attorneys who have been involved in the past (mostly during the furor of the 80s-90s) with dangerous, destructive, abusive, pseudoscientific “psychotherapy” practices. In addition, I have been a co-author on several scientific papers and have written a published book chapter.

      I wish to describe the stories of some victims OTHER THAN those already described so well–i.e., other than those whose damage related specifically to false memories of childhood abuse or ritual abuse/satanic cult material. This book would target the damage being done by covert “parts therapists.”

  4. Bruce Wampold: “I argue here that the truth of the explanation is unimportant to the outcome of psychotherapy.”

    He lost my interest from that statement forward. That’s how cults and cult-like therapies operate. Nothing matters but the clients reality and that reality is shaped by the therapist who seems to have no sense of reality. How’s that sentence for an example of b.s.?

    Practice Based Evidence one sure way to scramble the brains of a client.

    • Right, that’s the sentence that Bruce Thyer had challenged and its implications as far as informed consent is concerned and his doing so created quite a stir. What that says about a profession that would consider Thyer’s challenge, controversial, I shudder to think.

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