Conclusions

Let a Hundred Flowers Bloom; Let One Hundred Schools of Thought Contend

Joel WEINBERGER AND STEFAN G. HoFMANN

So what can we conclude after reading 13 chapters on the art and science of psychotherapy? First, it seems that there is little doubt that the EST movement can be considered a revolution in psychotherapy research. Virtually no chapter failed to touch on it and, for most, it was a touchstone for the points made in the chapter. The authors differed, however, in their evaluations of the efficacy methodology underlying ESTs. All seemed to agree that there were some issues that needed to be addressed in this methodology. These ranged from thinking a little tweaking was in order to arguing that major flaws exist.

Litz and Salters-Pedneault are very favorably disposed toward efficacy studies. They believe that manuals need to be customized for patients seen in the real world. That is, they argue for flexibility. They provided examples from their work with PTSD and showed that manualized therapy can be sensitive to and respectful of individual differences. They addressed flexibility of therapist use of manuals and the combining of manualized treatments so as to obtain optimal results. Their chapter shows that manualized treatment is not without its art.

Nathan is also favorably disposed to efficacy studies. He discussed the apparent resistance to them and contrasted them with effectiveness studies. He presented a compelling case for efficacy research as well as an insightful analysis of resistance to it. He would supplement efficacy research with effectiveness studies. Specifically, he recommends using the results of efficacy studies to design effectiveness studies. Then, depending on results, he suggests alternating between the two "in bootstrap fashion." His model is the Onken/Hybrid Model of Behavioral Therapies Research.

Levy and Scott are a bit less favorably disposed to efficacy studies, seeing them as one tool in a multimethod toolbox. They discuss internal and external validity as the touchstones of the different methods available, with efficacy studies at one end (strong internal validity, relatively weak external validity) and case histories at the other (strong external validity, relatively weak internal validity). They provide an elegant review of different methodologies, describing the strengths and weaknesses of each and showing the values of each in a systematic research program. They apply their analysis to the study of Borderline Personality Disorder and show how each method can and has contributed to the understanding and treatment of this disorder.

Blaise and Hilsenroth are a bit further down the road concerning efficacy studies. They, like Levy and Scott, argue against its use as a gold standard for psychotherapy research and explicate their position in terms of internal and external validity. They review their own program of research, which uses what might be called, in Levy's terminology, naturalistic efficacy research. They study patients, as they appear in the clinic, without regard for particular diagnosis, in manualized short-term psychodynamic treatment. They describe their research program, which they term a "hybrid," in detail, as a more clinically real and externally valid alternative to efficacy research.

Westen is the most critical of efficacy research, detailing its weaknesses and offering alternative ways of studying psychotherapy. Contrary to Nathan, Westen would begin with effectiveness research and only when that yielded meaningful results would he design efficacy studies. Westen also argues that the correct control group for efficacy studies is the successfully practicing clinician, rather than a placebo or the overworked clinic that is now the modal "treatment as usual" (TAU). Even he, however, sees the value of efficacy research as part of an overall program of psychotherapy research.

Overall, the position on efficacy research as a generator of ESTs is that it has its place but ought not to be the exclusive mode of investigation of psychotherapy. All agreed on the value of empirical research; all agreed on efficacy research as a major player. The authors differed sharply in terms of how big a role it should play in the overall enterprise. For some (Litz & Salters-Pedneault; Nathan), it has pride of place, for others it is a flawed but useful research tool (Levy & Scott; Blaise & Hilsenroth; Westen) that needs to be supplemented by other methodologies (which are also flawed). Interestingly, no one advocated the exclusive use of ESTs or rigid adherence to manuals, although these positions were attributed to EST advocates. Either this volume did not include the individuals advocating these positions, the modal position in this area has changed, or this is not truly representative of the EST movement. We prefer to believe the latter. We believe that the debate more centers on the relative importance of the different methodologies and appropriate control groups than on a position of scientific exclusivity or rigid adherence. After all, methodological exclusivity and rigidity are not in the spirit of science.

A second major point was that the EST movement seems to suggest that each diagnostic entity must have its own unique EST. The alternative seems to be that efficacious interventions work for many if not all diagnostic categories and that all credible interventions seem to work about equally well. This outcome equivalence has been termed the "dodo verdict" and has led to the common factors movement (Weinberger & Rasco) and the advocacy of common principles of psychotherapy (Pachankis & Goldfried; Clinton, Gierlach, Zack, Beutler, & Castonguay). Clinton et al., Weinberger and Rasco, and Westen all pointed out that literally hundreds of ESTs would be required if separate, nonoverlapping ESTs were to be put into practice. No author argued for nonoverlapping treatment packages, however, and, although this might once have been the position of EST advocates, it seems no longer to be the case. On the other hand, it seems obvious that some unique aspects of a disorder might also require unique treatment strategies to target them. Unfortunately, however, there has been little cross-fertilization between nosology, psychopathology, and intervention. This is clearly an area of future research.

Ehrenreich, Buzella, and Barlow, advocates of the efficacy approach, argued persuasively for a common set of techniques applicable to all emotional disorders, which they termed a unified treatment approach. Their chapter was a scholarly tour de force first demonstrating that the emotional disorders have much in common and that certain treatment techniques (altering cognitive appraisals, preventing emotional avoidance, teaching new adaptive responses to emotions) can be applied to all emotional disorders. If this chapter represents the current state of the EST movement, the debate may not be over whether each disorder requires a separate treatment but, rather, over how overlapping or common therapeutic principles are. Common factor and common principle advocates argue that these principles or factors can be fruitfully applied to most psychological difficulties. Thus far, the EST advocates have only argued for common treatment techniques for the affective disorders. This does not mean that they oppose common treatment for other groups of disorders. It means that the position awaits further empirical scrutiny.

The chapters identified a variety of common principles or factors. Different authors emphasized different principles. Some emphasized patient factors (Cinton et al.; Levy & Scott), some treatment factors (Clinton et al.), some promoted patient belief that therapy will be beneficial and patient adoption of a reality-testing approach to problems (Pachankis & Goldfried). Arkowitz and Engle described working with resistance, a common experience in clinical work that is too often ignored by researchers. Weinberger and Rasco identified specific factors that seemed to cut across treatment like expectancy, exposure, and mastery. Some authors called these principles of change (Clinton et al.; Pachankis & Goldfried) whereas Weinberger and Rasco preferred the term common factors. A rose by any other name No author seemed to dispute the idea that there were therapeutic factors that cut across different diagnostic categories and treatment modalities.

One factor identified by many authors was the therapeutic relationship (Blais & Hilsenroth; Clinton et al.; Pachankis & Goldfried; Ruiz-Cordell & Safran; Weinberger & Rasco). This seems to be the common factor or principle of change par excellence. Ruiz-Cordell and Safran offer a detailed exposition of how the Safran group has studied this variable. They look at how therapeutic ruptures are created and mended and describe their critical clinical importance. Blaise and Hilsenroth also describe an empirical approach to studying this variable. Both chapters address teaching budding therapists the ins and outs of the therapeutic relationship and provide data that show that clinicians can learn how to effectively use the relationship and that therapeutic outcome is improved by such training.

Common factors or principles lead to another issue triggered by efficacy research. The efficacy approach is an outcome rather than a process approach. This is enormously important, but if we want to learn what makes a therapy effective, there seems to be no alternative to process research. Pachankis and Goldfried make this point most forcefully, although Weinberger and Rasco make it too.

Another issue concerns the place of practicing clinicians in the empirical testing of psychotherapy. Many chapters referred to the failure of clinicians to embrace empirical findings (Clinton et al.; Nathan; Pachankis & Goldfried; Westen). It is clear that research needs to be made more clinically relevant or at least explained better to practicing clinicians. Clinton et al. offer the Systematic Treatment Selection model of Beutler and his colleagues. This approach makes the principles of change practically available to practicing clinicians so that they can "tailor a treatment plan in order to maximize outcomes for a particular patient." Presumably, this user friendly way of disseminating research results would be seen as helpful to clinicians and would be used by them. Another way to bring clinicians into the empirical fold is to involve them in the research process that designs the treatment approaches they are then asked to use. Nathan, Pachankis, and Goldfried, Weinberger and Rasco, and Westen all advocate learning from clinicians and including them in the research enterprise. Nathan proposes a collaborative model, a Practice Research Network, based on the work of Borkovec and his colleagues. A network of clinics would be established in which researchers and practitioners would work together collaboratively "on clinically meaningful questions." Pachankis & Goldfried propose obtaining audiotapes from practicing clinicians to learn how they deal with alliance issues. These would then be examined empirically. Weinberger and Rasco as well as Westen propose designing treatments, in part, based on what successful clinicians do and say. The logic is that their experience is worth a great deal. Clinicians can tell researchers much, both explicitly and implicitly (through videos of their work and their comments about them). After all, they deal with important clinical issues on a daily basis. Westen provides a detailed plan for how this could be accomplished empirically. It would be central to the way he would study psychotherapy. His model of psychotherapy would begin by studying what clinicians do, seeing what works, and then testing it more rigorously in efficacy type studies. He would compare what practicing clinicians do with currently available ESTs and then modifying treatments based on the results.

Arkowitz and Engle provide a clinically rich and empirically informed treatise on how to work with resistance. Their conclusions could be fruitfully examined in more detail by clinical researchers. They, therefore, come from a more clinical perspective (albeit informed by empirical research). Shedler's chapter demonstrates that clinicians can provide highly useful data for researchers. Stricker advocates encouraging clinicians to engage in nonsystematic research of their own. He calls his model the "local clinical scientist." In this way, clinicians would know empirically what seems to work for them. This would make them better therapists and also better and more willing consumers of empirical research. Weinberger and Rasco endorsed this approach and suggested teaching it in graduate training. They also argued that researchers would do well to formally examine the findings of these local clinical scientists.

Shedler has written the only chapter that pertains to the clinical entities that researchers study. He and his colleague, Westen, developed an innovative way to identify and understand clinical entities. They have practicing clinicians Q-sort prototypical patients as well as patients that they currently treat. The Q-sort items are descriptive of patient characteristics and are written in jargon-free, experience near, language. Shedler reports reliable and valid results that hold across therapist theoretical orientation. These do not always (in fact, often do not) coincide with DSM-IV diagnostic categories. Thus far, the work has been restricted to Axis II disorders but could be expanded to Axis I as well. This work indicates that the diagnostic categories that researchers study may not represent nature carved at its joints. If the DSM-IV categories are at all artificial, it says much about the findings of outcome studies aimed at particular DSM-IV diagnostic categories. This work reinforces the notion that we should involve practicing clinicians more in our work and also argues for process research. Finally, it argues for the necessity of testing the validity of currently used diagnostic categories.

To summarize our major points: First, the chapters in this book indicate that efficacy research is a valuable, even revolutionary method for studying psychotherapy. It has led to much progress. It is not, however, the only method and it is not without its problems. The clinical as well as the scientific enterprise would benefit from a multitude of methods, all imperfect, that would, hopefully, triangulate on clinical "truth." Second, there are both specific and common factors or principles that underlie psychotherapeutic success. The field could benefit from a more detailed examination of these common factors or principles. We would then have a better idea of what principles hold generally and what is unique to a particular treatment or diagnostic entity. Process research would be of great benefit here. Third, we need to involve practicing clinicians more in the study of psychotherapy. At present, they do not make much use of empirical findings. Suggestions range from ways of making practicing clinicians better consumers, to collaboration between researchers and clinicians, to teaching clinicians to conduct informal research, to using clinician insights to design formal empirical research. Finally, researchers might want to revisit their conceptualizations of clinical entities. In order to study psychotherapy for a particular disorder, we need to be certain that it exists and that we understand its characteristics. Ideally, the knowledge gained by research on the psychopathology of a disorder could then be translated into clinically useful methods and therapeutic techniques (an approach that is in line with the current NIMH initiative of translational research).

The theme of this conclusion chapter is to "let a hundred flowers bloom, let one hundred schools of thought contend." By this we mean to argue for diversity of methodology, clinical, and theoretical orientation. Let the scientific enterprise sort it all out (without wasting energy by fighting unnecessary battles with one another). This quote was uttered by Mao Tse Dung in 1958. He was asking the intellectuals of China to constructively criticize the regime and suggest improvements. We chose this quote to indicate that openness to new and seemingly divergent ideas must be followed in practice as well as in word. No one would argue that openness and competition of ideas is in the interest of science and clinical success, just as no one would argue that constructive criticism of government combined with new ideas is in the interest of the body politic. But shortly after Mao uttered the above, he launched the Cultural Revolution, which had as its goal the exact opposite and resulted in horrific damage to the Chinese population.

Psychotherapy research is at a crossroads. There is conflict between practicing clinicians and researchers. There is conflict among researchers themselves. None of these conflicting groups (with small unimportant exceptions) would argue against empirical research or openness to ideas. We offer the Mao quote as an object lesson. We really should let all ideas contend in a scholarly, clinically useful, and open fashion. This should be carried out in practice, not just uttered as a maxim. We believe that this book is a fruitful step in this direction. Advocates of different points of view were contained amicably in one volume. We would hope that they will soon be amicably contained in journals, clinics, granting agencies, and the halls of academe. This will benefit science, psychotherapy, and the patients we all claim to serve and want to help.

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