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The Future of Psychotherapy - Page 9


There is a certain seductive appeal to the idea of having a specific psychological intervention for any given type of problem--the psychological equivalent of a pill for emotional distress. But, in fact, a closer look at the research literature on therapy clearly reveals that the whole idea of empirically supported treatments (ESTs) is critically flawed, especially as any kind of mandate for what should be done in therapy.

To start with, the criteria for the clinical procedures used to validate a treatment contain a fatal bias. Standard research design requires that the treatments being assessed not contain the inevitable improvisations of therapy as practiced in the real world. Instead, the approaches studied are all required to follow a script so that the "variable" presumably being examined--a precisely defined and structured form of treatment--can be strictly controlled. But while certain kinds of therapy can be scripted--cognitive-behavioral therapy (CBT) being the most prominent--most cannot. So it should come as no surprise that CBT and other behavioral approaches dominate the list of treatments that have received the imprimatur of the task force, amounting to about 80 percent of the list. Is this because these treatments are more effective? No, it is really because they are the easiest to duplicate and, therefore, have been the ones chosen to be researched. This privilege does not extend to some 250 other approaches around today.

Besides the issue of what determines whether a treatment is chosen for study in the first place, questions have also been raised about whether the specific methods associated with an EST really constitute its "active ingredient." One of the most provocative of the studies that raise doubts about this assumption was conducted by Louis Castonguay and Marvin Goldfried, two prominent cognitive-behaviorally oriented researchers who set out to compare the effects of the therapeutic alliance with the effectiveness of a highly structured cognitive approach with depression. Surprising to many who carry the banner for ESTs, their study concluded that the more emphasis a therapist placed on cognitive-behavioral techniques, the worse the treatment outcomes for clients. In their study of 30 depressed clients, Castonguay and Goldfried compared the impact of a treatment technique specific to cognitive therapy--the focus on correcting distorted cognitions--with two other, presumably, non-specific, treatment variables: the therapeutic alliance (agreement between therapist and client on treatment goals and methods) and the client's emotional involvement with the therapist. Results revealed that while the two so-called common variables were highly related to therapeutic progress, the technique unique to cognitive-behavioral therapy--eliminating negative emotions by changing distorted cognitions--was negatively related to successful outcome!

Although the American Psychological Association's intention in adopting ESTs was to demonstrate that psychiatrists had not cornered the market on empirically verifiable treatments, in effect, its task force has responded to the myth of the magic pill by propagating the myth of the magic method. In fact, the uncomfortable truth for advocates of these verified treatments is that there is no solid evidence demonstrating that specific treatment models have unique effects, or that any single therapeutic approach is superior to another. Of course, there have been studies that purport to show that a particular therapy is especially effective. CBT is an example of this. But studies have yet to show consistent differences in effectiveness among therapies developed to address a particular problem despite the Herculean efforts of legions of researchers to do just that.

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