What Leads to Optimal Outcomes in Therapy?

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If you were searching the web as a consumer, looking for the best Psychologist, would you know what to look for? 

If you said that you would look for someone experienced, it is a good guess, but years of experience don’t seem to make too much of a difference when it comes to improving therapeutic outcomes (Minami et al., 2009).

What may be important is that they are a Psychologist and not a Counsellor. In Australia, anyone can call themselves a Counsellor and open up a practice, even without having undergone training. However, if they are a Psychologist than they have to have completed at least four years of undergraduate training, plus a post-graduate degree or at least 2 years of formal supervision. Psychologists are also obliged to abide by the Australian Psychological Society’s (APS) code of ethics, whereas Counsellors are not.

If you said the company that they worked for or how much they charged than these are both good guesses too. However, private practice Psychologists are either self-employed and set their own price of their service, or are employed by a company that they work for, and have their price set for them. It is unlikely that all Psychologists within the same practice are equally effective, even if they are charging the same amount.

The current recommended rate for a 45-60 minute Psychological consultation in Australia is set at $238.00 by the APS, but all Psychologists have the discretion to vary this fee. What this often means is that services in more affluent locations with client’s who have a greater capacity to pay a larger amount will charge more (also due to higher rent), whereas services in poorer areas will often charge less.

More expensive Psychologists may believe themselves to be better Psychologists too, but this doesn’t mean that they are. The self-evaluations of therapists are often not very accurate, with a largely positive bias suggesting overconfidence in their general abilities. In a 2012 study by Walfish, McAllister, O’Donnell, and Lambert (2012), they found that out of the 129 therapists that were surveyed, 25% estimated that their therapy results were in the top 10% compared to the other therapists, and not a single therapist believed that they were worse than the average. If this sample is representative of the general population, this means that at least 50% of Psychologists don’t realise how bad they are, and may therefore not be aware of what they are doing wrong and what they need to do to improve.

What is known is that some Psychologist’s do consistently outperform other Psychologists (Wampold & Brown, 2005). In a 2015 study by Brown, Simon and Minami (2015), they looked at 2,820 therapists, with a combined sample size of 162,168 cases, and found that the lowest-performing therapists required as much as 3 times the number of sessions to produce successful outcomes as the average therapist, and as much as 7 times the number of sessions as the highest-performing therapists. This indicates that choosing the right Psychologist is a very important task. But,

What characteristics do the best Psychologist’s have, and what do they do that makes them so successful?

During my DPsych course, we were primarily trained in Cognitive Behavioural Therapy (CBT) by the University lecturers and tutors. I initially thought that it was extremely important to follow the CBT session structure, minute by minute, as set out by Judith Beck in her book ‘Cognitive Behavior Therapy: Basics and Beyond’ and that this would lead to the client’s learning these skills, applying them and getting better. But once I started my clinical placements I soon learned that the art of therapy didn’t always replicate or neatly fit alongside the science of Psychology.

I still do believe that if a client can successfully change their interpretations of situations to be more helpful, than they will feel better emotionally and physically and more likely to engage in helpful behaviours. However, I do not believe that this is the only way for a client to improve, or that this must be the way that I approach every client that I see and every session that I have. Once I discovered some of the limitations of CBT, I began to explore and do some further reading on my own with the aim of one day being able to help as many of my client’s as possible, improve as much as possible, rather than just the individual’s who are suitable for CBT.

1. Different Models of Treatment 

Different schools of Psychotherapy, from Psychoanalysis, Psychodynamic Psychotherapy, Humanistic Psychotherapy, Gelstalt Therapy, Narrative Therapy, Schema Therapy, Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), Acceptance and Commitment Therapy (ACT), Family Therapy, Interpersonal Therapy, Mindfulness Based Stress Reduction, Mindfulness Based Cognitive Therapy will tell you that their therapy is the way to go. If you would like to explore these different models of therapy, it is possible to find out more about these by searching them, or finding Psychologist’s that practice these methods through the APS find a Psychologist service. Each school will back up their claims with several theoretical underpinnings, as well as good quality research studies that show how effective their treatment is and how much individuals improve from the beginning of treatment to the end.

What they won’t often advertise is that no matter what school of therapy it is:

  • none of them will help every client
  • the drop out rates can be quite high
  • clients who do drop out prematurely tend to fare worse than clients who are able to complete treatment, and
  • other psychotherapy schools tend to produce similar results

So yes, therapy works, sometimes, for some people, under some conditions. Whilst one mode of therapy may not be generally more effective than another, goodness of fit does seem to be important, so do choose a Psychologist who has an approach or therapy model that seems to make sense or appeal to you.

A lot of client’s will also come wanting to learn particular strategies so that they can get better, which is virtually never done in Psychoanalysis, and is done often in ACT, CBT or DBT. But once again, outcome research suggests that specific factors or models of treatment fail to account for the majority of improvements across treatment, with as little as 15% of the overall outcome variance. Non-specific factors account for a much larger percentage (up to 85%) of the overall outcome variance (Hubble & Miller, 2004), so it is important to understand what these factors are in more detail if optimal outcomes are to be achieved.

2. Non-Specific Treatment Factors

It is perplexing to think how the research findings are all so similar in the different schools of psychotherapy (Wampold,2001) until it is made clear that non-specific treatment factors are common across the various schools of psychotherapy. Hubble and Miller (2004) found that these non-specfic factors include:

  • A. The Expectancy of Treatment Effects (15% of overall outcome variance)   

An individuals’ belief that they can improve has a powerful impact on their actual improvement (Bergsma, 2008), with larger reductions in symptom severity at post-treatment often occurring in those with higher expectations of benefit at pre-treatment (Ogles, Lambert, & Craig, 1991; Rutherford, Sneed, Devanand, Eisenstadt, & Roose, 2010a).

It is why the difference between antidepressants and placebo in clinical trials is sometimes non-significant (Kirsch, 2002). It is also why antidepressant effects are larger when compared to another antidepressant (60% response rate) than when they are compared to a placebo (46% response rate) in a randomized controlled trial (Sneed et al., 2008).

Greater expectations can improve hope and increase goal-directed determination, which has been shown to predict treatment completion (Geraghty, Wood, & Hyland, 2010).

Greater expectations of treatment outcome can also improve distress tolerance, which has been shown to reduce distress and depression severity across treatment (Williams, Thompson, & Andrews, 2013).

Essentially, the more that you expect that a Psychologist can help you, the more likely it is that you will have hope, persist with treatment, and get better. 

  • B. The Therapeutic Alliance (30% of overall outcome variance)

Another important issue influencing treatment outcomes is adherence to the treatment interventions, recommendations and strategies. A study that treated war veterans with CBT for insomnia found that individuals with the greatest adherence to treatment recommendations reduced their insomnia severity scores significantly more than individuals with the least adherence (Trockel et al., 2013). Compliance with treatment recommendations can be improved through a positive therapeutic alliance, which plays an important role in the overall success of a psychotherapy treatment (Wampold, 2001).

When looking at cognitive therapy for depression studies, both therapeutic alliance and the emotional involvement of the patient predicted reductions in symptom severity, whereas focus on distorted cognitions actually had a negative correlation with overall outcome (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996). Because unguided self-help CBT interventions tend to focus more on cognitive restructuring than therapeutic alliance, these individuals are unlikely to improve as much across treatment as they would through face-to-face psychotherapy.

Individuals with insomnia already engage in more thought control strategies than normal sleepers, and their use can worsen sleep, anxiety and depression when used incorrectly (Ree, et al., 2005). However, therapist feedback and guidance can assist the individual, by helping them determine when to problem-solve through techniques such as constructive worry (Edinger & Carney, 2008), when to challenge thoughts through cognitive restructuring (Morin, 1993), when to distract themselves through techniques such as imagery (Harvey & Payne, 2002), and when they would be better to be mindful and accepting of the thoughts instead of trying to change or control them (Harris, 2008). Consequently, a positive therapeutic alliance improves outcomes, by providing professional input, and ensuring that the strategies are implemented effectively.

If therapeutic alliance can be established, developed and maintained (Cahill et al., 2008), patients are less likely to drop out of treatment and more likely to achieve clinically significant improvements (Miller, Hubble, & Duncan, 2008).

Regardless of the theoretical orientation or the experience of the therapist, the best outcomes are achieved when therapists are flexible to the needs of the patient and responsive to the feedback that patient’s provide, repairing any ruptures in the therapeutic alliance as quickly as possible (Cahill, et al., 2008; Miller, et al., 2008).

Other research suggest that it is important to meet relatedness needs, which are dependent upon the therapist displaying warmth and genuine involvement in the treatment, and the client feeling both a sense of caring and connection in the relationship (Ryan & Deci, 2008).

Essentially, the more that you can relate to the Psychologist, and feel that you are allies working towards a common objective, the more likely you are to improve.

  • C. The Client’s Life-Circumstances, Personal Resources and Readiness to Change (40% of outcome variance)

The biggest factor in determining whether or not treatment will be successful, and this may be surprising to some people, is the client. If their current life circumstances are unstable, unpredictable, and emotionally or physically unsafe then it will be difficult for the one hour of therapy every week or two to be sufficient to overcome all of the negative events that are taking place between sessions.

Likewise, some client’s are not good candidates for Psychological therapy, and it definitely isn’t for everyone. If someone prefers to not question things, has no (or very limited) insight, has significant cognitive disabilities or memory difficulties, is currently manic or severely delusional or psychotic, or is too emotionally labile or reactive in close interpersonal settings, then therapy can either have no effect or be potentially harmful.

Lastly, if a client does not believe that they have a problem, then there is not too much that can be done by a Psychologist to help them, even if their family or friends or partner or the legal system believes that a problem exists. Unless some type of intrinsic motivation, or personal reason for changing can be created in the client, positive change is unlikely to be possible.

Where change is possible is when a client is ambivalent about change, or they want to change but don’t know how, or they know how to rationally, but emotionally don’t feel that it is possible. Motivational Interviewing (MI) principles are often used by Psychologists whenever there is some ambivalence or reluctance by the client, and with clarification, psychoeducation and teaching of skills, leverage can be created to help the client change and grow.

Essentially, make sure that seeing a Psychologist is the right option for you. You need to be sure that:

  • you are wanting to change or improve something about yourself
  • you are willing to put in the time and effort that it requires
  • you are willing to explore things to develop and grow, and
  • now is a good time for you to begin the amount of treatment (both frequency and duration) that is being recommended for you.

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If you follow these recommendations when seeking out a Psychologist, it will not guarantee you a successful outcome, but it will definitely help. I wish you the best of luck with your search and therapeutic experience!

 

Dr Damon Ashworth

Clinical Psychologist

 

 

 

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