Therapists and Treatment Effectiveness

Having just endured a round trip flight from California to NY, I had the chance to catch up on some reading, so I have a great deal to comment on.  I'll begin with an article that appeared in the current (May/June 2005) issue of the Psychotherapy Networker magazine entitled "The Messenger is the Message: The Effectiveness of treatment still depends on who delivers it" by Jay Lebow (p. 91).  On what is the claim of this title being based?  We learn that a large-scale study of therapists' self-reported attitudes has been conducted by David Orlinsky, a psychology Professor at the University of Chicago. Lebow describes the study as follows:

"..a large scale international research project to determine what therapists bring to the therapeutic encounter, personally and professionally, and what their experience of the therapeutic process is at different stages of their careers."  He goes on to describe the "extensive questionnaire to explore everything about the therapists surveyed, from their employment setting, years of experience, orientation, and training to their views of themselves when they started their careers, how those views have changed over time, the kind of clients they see, their satisfaction with their work, and their satisfaction with their lives."

While this is undeniably a worthy and fascinating topic for research, the conclusions that have been drawn by Lebow from this study are highly unwarranted.  From this self-reported data, he reports that Orlinsky and his colleagues came up with four practice patterns:  Effective practice, challenging practice, distressing practice, and disengaged practice.  Hold on a minute!  How did the authors make the leap from a self-reported therapist survey to the determination that a positive self-report from a therapist is related to "effective practice?"  Are therapists who feel good about themselves, their practices and who lead relatively stress-free lives the best therapists?  I do not see any convincing data to support this notion and nothing described in the survey would support the claim in the title of the article that "the effectiveness of the treatment depends on who delivers it".

Lebow recognizes that the above could be an objection, playing devil's advocate and asking if therapists can be trusted to report accurately about experiences.  He argues that the answer is "yes" because a "long line of research studies" has shown that therapists honestly report.  Nevertheless, the finding that therapists honestly report is not sufficient to draw the conclusion that their sincerity is an accurate representation that their therapy is effective.  Those are two entirely separate matters that this author appears to be falsely conflating.  A therapist can sincerely believe that she is an effective "healer".  Yet this belief may or may not have any connection to whether or not the therapy done was actually effective.  Lebow admits that "Research has shown that therapists see therapy somewhat differently from how clients and observers do", yet this does not seem to deter him from interpreting the results of this study to mean that the effectiveness of the treatment depends on the therapist who delivered it.  I do not see any evidence that this was even assessed for in the study described.  What it comes down to is that a person can be content, honest, well-intentioned, sincere and self-fulfilled, and yet be off base in his/her perception of how effective the therapy has been for the client.  What we do know is that it is all too easy for therapists to engage in confirmation bias, as all human beings do and that there are studies showing that therapists do not necessarily learn well from experience.

What Lebow is overlooking is the fact that there are plenty of efficacy studies done on approaches such as CBT that do control for the therapist relationship and yet show the superiority of one approach over the other (See the reviews of various studies in David Barlow's 2002 edited volume, Anxiety and its Disorders for some examples).  Even though it might seem attractive to certain clinicians to see their interpersonal skills and connection with the client as being the primary healing factor, the evidence is just not there for this and the study described here does nothing to add to it. This is not to say that the client-therapist connection plays no role in the outcome of a therapy; of course it could have an impact as a non-specific treatment effect, but the claim that "the effectiveness of treatment depends on who delivers it" is not warranted.  There are therapies currently available that have been shown to have effects above and beyond the therapeutic relationship and therapists who care about their clients would do well to study and employ them in practice.

Comments

I think I found a reference to this (Orlinsky doesn't show his CV on the uchicago site), a semi-opaque page on some kind of "International Project on the Effectiveness of Psychotherapy and Psychotherapy Training":
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(c) David Orlinsky’s recent formulation of a comprehensive evidence-based model of therapist effective and ineffective practice patterns, measurable using the Collaborative Research Network’s (CRN) Development of Psychotherapists Common Core Questionnaire, which is available in 16 languages.
"Research Instruments"
http://www.experiential-researchers.org/instruments.html

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Sounds interesting, but, as you point out well, what justifies the cliff-diving conclusions of the author in the Networker?

Sometime the business-side seems to take over with some of these people. Note the 'Project' is directed by the "Center for the Study of Experiential Psychotherapy" and has a sort of methodology page up at http://www.experiential-researchers.org/methodology.html

-- I liked the "Proposed Criteria for Demonstrating Empirical Support for humanistic and Other Therapies" -- thinking, hmmm, how about *testing* empirical support first . . .

WSS