|A Look at the Evidence|
Top 10 Research Findings of the Last 25 Years
By: Jay Lebow
How much does empirical research direct the way therapists actually practice? Most surveys indicate that clinicians regard other sources of information, such as supervision and their personal experience of therapy, as being far more important than formal research studies in influencing how they work with their clients. That's unfortunate because the last quarter-century has produced an astonishing amount of meaningful research demonstrating not only the overall effectiveness of psychotherapy, but the positive impact of specific therapeutic methods with particular disorders. To give you an idea of how far the marriage of research and therapy has advanced, here are my choices of the 10 most significant developments in the field that research has documented during the last 25 years:
1 Psychotherapy has been shown to be at least as effective as medication in treating such common psychiatric diagnoses as dysthymic disorder, generalized anxiety disorder, and chemical dependency. Metanalyses of psychotherapy studies, such as those conducted by Mary Lee Smith, Gene Glass, and Thomas Miller in the early 1980s, show that individual, group, and family therapies alike have large statistical and clinical effects. Furthermore, in a survey conducted by psychologist Martin Seligman for Consumer Reports in 1995, the great majority of respondents reported positively of their psychotherapy experience, showing unusually high levels of consumer satisfaction.
Perhaps the best single demonstration of the impact of psychotherapy was the Treatment of Depression Collaborative Research Program (TDCRP), a methodologically rigorous study initiated by Irene Elkin of the National Institute of Mental Health and her colleagues in the 1980s that compared psychotherapy and medication head to head in the treatment of people suffering from depression. In the study, two psychotherapies—Interpersonal Psychotherapy (a variant of psychoanalytic psychotherapy developed by Myrna Weissman and Gerald Klerman) and cognitive therapy (developed by Aaron Beck)—were shown to work as well on depression as medication, even though the study was done in the short-term format typical of medication-only studies. This superbly constructed research study left no doubt that psychotherapy has an impact comparable to that of medication in treating serious mental health problems.
2 Specific treatments have been identified for specific disorders. In the first 75 years of its history, psychotherapy consisted of a general set of principles applied to just about everybody, with only a secondary focus on matching treatment to the client's particular difficulty. The emergence of empirically supported treatments (ESTs) has moved one sector of psychotherapy away from that generalized focus toward specific treatments for specific problems. Today there are more than a hundred ESTs, each having a demonstrated impact on a problem or syndrome, ranging from adult substance use disorders, to childhood oppositional disorder, variants of depression and anxiety, eating disorders, and general health problems. Examples of particularly well established treatments include Beck's Cognitive Therapy and Wiessman and Klerman's Interpersonal Therapy for depression; David Barlow and Michele Craske's Panic Control Treatment for panic disorder; Edna Foa's exposure and ritual-prevention therapy for obsessive-compulsive disorder; Tom Borkovec's Cognitive-Behavioral Therapy (CBT) for generalized anxiety disorder; and 12-step and CBT treatments for substance-use disorders.
3 Brief, targeted interventions have proven effective across a broad spectrum of problems. Twenty-five years ago, psychoanalytic psychotherapy was still in its heyday and was, for the most part, not subjected to empirical testing—perhaps because it just wasn't clear how to test a modality that was so subjective and nebulous. During the last two decades, however, a number of upstart therapies have demonstrated that positive outcomes can be achieved in a shorter time than any self-respecting analytic psychotherapist would have dreamed possible. CBT, for example, began as a treatment carefully nurtured and tested in psychological/psychiatric research laboratories. The impressive outcomes achieved in empirical investigations, such as those conducted by Beck, Steve Hollon, and colleagues in the treatment of depression and David Barlow and colleagues in the treatment of panic disorder, have been so persuasive that CBT is now the most widely practiced of any specific school of treatment. Notably, we have begun to see carefully constructed therapies of other kinds—such as Emotion-Focused Therapy, an experiential therapy developed by Les Greenberg and Susan Johnson, and Multi-Systemic Therapy, a family therapy developed by Scott Henggeler—follow a similar pathway to becoming widely established.
4 The importance of common factors has been validated. Fifty years ago, Jerome and Julia Frank argued for the preeminent importance of "common factors" (the factors shared by all effective models) in treatment in their influential work Persuasion and Healing. In the past 25 years, research has forcefully demonstrated the truth of the Franks' hypothesis—particularly the significance of the therapeutic alliance. We now know that, in most cases, without a positive alliance, virtually any psychotherapy is ineffective. Related common factors, such as the generation of hope and positive expectation, therapist warmth and caring, and goal consensus, have also been shown to be central to treatment success.
5 The concept of a "magic-bullet" therapy has yielded to the integration of modalities. Empirical research during the past quarter-century has disproven the idea that there is any single method that will work for everybody. Under rigorous examination, no one therapy has ever been demonstrated to achieve results that are consistently better than those of any other. There are always some clients for which the approach under review simply won't work, though some other modality might well succeed. The finding that there's no perfect, single method and probably never will be has led therapists to expand upon the strategies and interventions of their favorite modalities in an effort to improve outcomes. As a result, over time, integration of methods has become widespread, replacing the theoretical and clinical purity of the past. For example, Paul Wachtel of the City University of New York has pointed to the value of incorporating behavioral and psychodynamic strategies in treatment, highlighting how work on one level can add to the impact of work on the other. Surveys show that most therapists now label themselves integrative or eclectic. "Pragmatic" might be a better description. Clinicians today tend to be far more focused on doing what works than on sticking rigidly to a sacrosanct model.
6 Specific therapies have proven to be effective with the most serious psychological conditions, such as psychosis and borderline personality disorder. The evidence-based treatments for schizophrenia developed by innovators such as Carol Anderson, Ian Falloon, and Bill McFarland comprise a mix of individual skill building, family management, systemic family therapy, and psychopharmacology. Together, these interventions help the person with schizophrenia and his or her family learn to solve problems, negotiate with each other, handle crises, understand schizophrenia, and reduce the types of "expressed emotion" (a combination of criticism and high emotional arousal) that can lead to relapse. Unlike the dramatic confrontations sometimes engineered in the family therapy of the 1980s, these sessions are focused on helping the family cope with their problems in a calm, cooperative, sustained manner.
In her new treatment for borderline personality disorder, Dialectical Behavior Therapy (DBT), Marcia Linehan has combined mindfulness techniques, examination of thoughts, behavioral programs of self-care, and techniques from crisis management into a highly effective approach. The treatment for schizophrenia and Linehan's DBT for borderline personality disorder help clients once thought to be unable to benefit from psychotherapy not only avoid hospitalizations, but profoundly improve their lives.
7 New approaches incorporating acceptance, meditation, and mindfulness have emerged. Meditation and mindfulness have gained scientific legitimacy since being incorporated into such empirically supported treatments as Jon Kabat-Zinn's pioneering approach to treating pain, Zindel Segal's model for treating depression, and Marsha Linehan's Dialectical Behavior Therapy for borderline personality disorder. In fact, the rising tide of mindfulness training has introduced a major shift in psychotherapy, as some newer approaches—Steven Hayes's Acceptance and Commitment Therapy, for example, or Neil Jacobson and Andrew Christensen's Integrative Behavioral Couples Therapy—focus less on the traditional goals of personal change or elimination of problems and more on coming to terms with conditions or circumstances that can't be changed. Many therapies, no doubt influenced by the mindfulness trend, now have made self-acceptance, rather than self-overhaul, a framework for treatment.
8: The tracking of therapeutic progress has been shown to enhance outcomes. Research by psychologists Kenneth Howard, Michael Lambert, and their colleagues has shown the value to all therapists of simply tracking the client's perception of progress in psychotherapy. Howard has developed Compass, and Lambert has developed OQ, both practical systems for tracking change, session by session. In one large study published in 2003, Lambert and his colleagues found that many clients doing poorly in treatment could get back on course if they had a regular mechanism for providing feedback on their perception of progress (or lack thereof) to the therapist.
Psychotherapy researchers now have developed numerous assessment technologies and measures, which are easily obtained, often without cost, and can be handily applied by almost any therapist for almost any clinical problem. For example, Scott Miller and Barry Duncan's simple measure of progress and alliance, the Outcome and Session Rating Scale, can be obtained at no cost from their website (www.talkingcure.com).
9 Effective, multisystem treatments have been developed for high-risk, emotionally disturbed adolescents. A quarter-century ago, chronically violent, substance-abusing, antisocial youths were generally consigned to largely ineffective correctional systems. Since then, a variety of complex, highly coordinated, onsite approaches that focus on the interconnected systems involving the teen—family, school, peers, neighborhoods—have been developed by research groups led by Scott Henggeler, Howard Liddle, Jim Alexander, Tom Sexton, Jose Szapocznik, Patricia Chamberlain, and their colleagues. Their outcomes have been light-years ahead those of standard residential or therapeutic approaches.
By contrast, research conducted by therapists like Tom Dishion has shown that adolescent group therapy—a traditional intervention, still widely practiced—frequently leads to deterioration in these clients. Apparently, group therapy acts much like a school for deviance, providing youth offenders with better opportunities for learning more sophisticated and efficient forms of offending.
10 Behaviors that predict the ultimate success or failure of a marriage with uncanny accuracy have been identified. Probably no single body of basic research has affected practice as much as John Gottman's work on couples. In a series of ingenious studies, he's shown the high probability that certain behaviors—criticism, defensiveness, contempt, and stonewalling (what Gottman calls "The Four Horsemen of the Marital Apocalypse") will yield future marital failure. He's demonstrated links between certain types of positive interchange, such as respectful actions, encouragement, and lighthearted banter during disagreements, and the long-term success of a marriage. Today, no adequately trained couples therapist would fail to watch for these undermining behaviors and try to help the couple increase their positive interchanges.
A list of the "top 10" practically begs for a list of runners-up. You'll find my nominations for these here: Runners-up to the Top 10.
We're living in an age of research that can and should inform the practice of psychotherapy. There now are hundreds of psychotherapy investigators engaged in significant research, and that research is as likely to come from outside North America as from within. There's a great deal to attend to and therapists each year express more interest in what can be learned from this source of information. At this rate of progress, I can't wait to see what the "top 10" will be at the Networker's 50th anniversary!
Gottman, John M. "Psychology and the Study of the Marital Processes." Annual Review of Psychology 49(1998): 169-97.
Lambert, Michael J., and Benjamin M. Ogles. "The Efficacy and Effectiveness of Psychotherapy." In Michael J. Lambert, ed. Bergin & Garfield's Handbook of Psychotherapy and Behavior Change (5th ed.). New York: Wiley, 2004.
Lambert, Michael J., Nathan B. Hansen, and Arthur E. Finch. "Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects." Journal of Consulting and Clinical Psychology 69, no. 2 (April 2001): 159-72.
Lebow, Jay. Research for the Psychotherapist: From Science to Practice. New York: Routledge, 2006.
Nathan, P. E., and J. M. Gorman. "A Guide to Treatments That Work (2nd ed.)." Psychotherapy Research 13, no. 1 (March 2003): 128-30.
Jay Lebow, Ph.D. is a contributing editor to the Psychotherapy Networker, a clinical professor at Northwestern University, and senior therapist and research consultant at the Family Institute at Northwestern University. Contact:firstname.lastname@example.org. Letters to the Editor about this article may be e-mailed to email@example.com.