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OPINION

Innovation in , Challenges, and Opportunities: An Opinion Paper

Janina Isabel Schweiger1, Kai G. Kahl2, Jan Philipp Klein3, Valerija Sipos3 and Ulrich Schweiger3

1 Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of , University of Heidelberg, Mannheim, Germany 2 Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hoch- schule Hannover, Hannover, Germany 3 Klinik für Psychiatrie und Psychotherapie, Universität zu Lübeck, Lübeck, Ger- many

sychotherapy as a field tends toward con- in psychotherapy. servativism, and the rate of innovation and development of new evidence-based P INTRODUCTION effective treatments has been slow. This paper explores important barriers to innovation like The implementation of psychotherapy in the dodo bird verdict and the habit of starting general healthcare has been one of the signif- the development of therapeutic methods from icant innovations of the twentieth century and techniques. The paper looks at the opportuni- has revolutionized how the health care system ties for translating basic science in deals with mental disorders. Psychotherapy is into psychotherapeutic techniques. Metacog- an essential focus of training in clinical psy- nitive therapy stands out from other psycho- chology and physicians aiming for board cer- therapies by its development from basic sci- tification in psychiatry or psychosomatics in ence. The paper describes the development of many countries. Despite this transformative the techniques detached mindfulness and at- impact, the rate of innovation and development tention training, how they were derived from of new evidence-based effective treatments has basic science and tested for their suitability in been slow, and it has been noted that compared the therapy of patients with anxiety disorders. with medication psychotherapy use is on the By this process, metacognitive therapy may be decline in the US (Gaudiano & Miller, 2013). an important model for the innovation process This opinion paper examines some of the bar-

First published in Frontiers in Psychology, 19 March 2019 https://doi.org/10.3389/fpsyg.2019.00495

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riers to innovation that we believe have slowed apeutic alliance is a good predictor of outcome progress. It discusses alternative ways of fos- in therapy (Cameron et al., 2018), a meta-anal- tering innovation and uses the development of ysis of the relationship between therapeutic metacognitive therapy by Wells and colleagues alliance and treatment outcome in eating dis- as an example of a strategy that overcomes bar- orders showed that the association between al- riers and discusses how MCT fits into current liance and outcome is weaker than the asso- assumptions about innovation. ciation between early symptom improvement and later alliance (Graves et al., 2017). Thus, it would seem that early symptom improve- BARRIERS ment affects the later alliance. We might pre- The Therapeutic Relationship and the sume that the most effective treatments give Dodo Bird Verdict rise to the strongest alliances. What is lacking are experimental studies that actively manip- One of the widespread assumptions in psy- ulate therapeutic alliance, and so the evidence chotherapy is that a good therapeutic relation- remains restricted to longitudinal predictor ship is the critical mechanism of successful analyses that can do little more than implying psychotherapeutic treatment (Wampold, 2015). causal relations (Fluckiger et al., 2018). Despite It is assumed that the relationship is more sig- the lack of experimental evidence, the preva- nificant than the underlying model of causali- lent assumption is that a good working alliance ty and the manipulation of its causal variables is “a thing” that resides in the interpersonal and is the universal change mechanism unit- harmony between two persons, providing a pa- ing all psychotherapy approaches. This way tient with a healing experience that appears to of thinking postulates that creating expecta- be part of a stable, benign relationship. Relat- tions through explanations of the disorder and ed to this is the presupposition that some the treatment involved and the enactment of therapists “have it” while others do not, mean- health-promoting actions are further common ing that there are good and bad therapists, as factors. The presumed equivalence of all ther- categories. Unfortunately, this explanation falls apies after correction for the therapeutic rela- short of the alternative but little-tested as- tionship has resulted in the dodo bird verdict sumption that a good therapeutic relationship (Luborsky et al., 2002). Based on the finding is an emergent phenomenon produced by pro- in meta-analyses that a broad spectrum of fessionalism, plausible models, and experience psychotherapeutic treatments in depression is of change already early in therapy. similarly effective, Cuijpers has claimed that there is a possibility to minimize the number Consistent with the assumption that the al- of existing therapies (Cuijpers, 1998). However, liance is, in fact, an emergent factor of effective results of meta-analyses support differences therapy, the working alliance in pure Internet between (Budd and Hughes, therapy is remarkably good (Heim et al., 2018). 2009; Tolin, 2010). The continued of the therapeutic re- lationship as the primary underlying factor of While the patient-rated quality of the ther- psychotherapy effectiveness is a barrier because

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it reduces the necessity of developing innova- content and processes of cognitive distortion in tive theories and techniques since new tech- patients (Beck, 1963, 1964). The primary in- niques only make a marginal difference. As- tervention derived from this observational ap- signing the therapeutic relationship to the role proach and comprised of correcting cognitive of the critical cause of change, instead of mod- distortions and deficiencies in schema con- eling it as an emergent phenomenon of change tent using Socratic dialogue. This fundamental creates inertia in research on psychopathologi- change technique of (CT) is cal mechanisms and complacency in therapists. derived from philosophy and is not rooted in or supported by . To the contrary, research shows that trying to replace Starting the Development of Therapeutic dysfunctional by more appropriate Methods From Techniques thinking may result in and New approaches have most often been de- have adverse paradoxical effects (Longmore & vised based on techniques, that is on the basis Worrell, 2007; Magee et al., 2012). Subsequent- of assembling combinations of treatment tech- ly, more techniques used initially in behavior- niques that appear to work. Such approaches al activation, assertiveness training, anxiety are often only loosely grounded in theoretical or mindfulness meditation have models, and the models of treatment mecha- been incorporated to form a more eclectic cog- nisms may develop after the treatments them- nitive behavioral therapy (CBT). selves. A second notable example of technique-driv- A top-down approach in the design of tech- en development is dialectical behavior therapy nology starts with an overview of the relevant (DBT). It is based on the assumption that pa- system (e.g., dysfunctional beliefs) but does tients with borderline personality disorder have not specify subsystems in sufficient detail or skills deficits in regulation (Linehan elucidate how they impact on functioning. For et al., 1991; Linehan, 2014). At the core of the instance, negative automatic and be- interventions are approximately 50 skills that liefs are purported to cause or maintain disor- are taught to patients to improve emotion reg- der in the . However, as pointed ulation. Again, theory informed the out by Wells and Matthews (Wells & Matthews, selection of these skills, but none was derived 1996), this approach does not consider broader from experimental psychology nor were they aspects of that are known to be as- individually tested. As packages, both CBT sociated with the disorder such as biases in the (Beck & Dozois, 2011) and DBT (Stoffers et al., regulation of and levels of control of 2012) can be considered as well supported by cognition. The cognitive-behavioral model has evidence. There were a few studies involv- not advanced along with recent developments ing component analysis (Jacobson et al., 1996) in and theory such that showing that in the case of CBT challenging the practice of therapy is only loosely tied to thoughts on the content level, the primary and an of mechanisms. Beck based elemental technique may not be the essential CBT on the description of problematic thought ingredient. The introduction of disorder-spe-

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cific treatment methods for depression, anxiety between RFT and the techniques proposed by disorders, and personality disorders beginning ACT is an ongoing point of discussion. For spe- in the 1960s was a big step forward for psy- cific , (see Zettle et al., 2016). chotherapy. These new methods led to a con- An essential aspect of starting from basic siderable extension of the field of activities of science is to direct therapeutic techniques at psychotherapy toward groups that are severely psychological mechanisms or processes and ill and were traditionally underserved. not at mental disorders which are broad con- While there is evidence that these treatments cepts summarizing symptom clusters. Focus- offer innovation and can work, it is important ing on a specific mechanism necessarily results to question whether the technique-driven ap- in a reductionistic approach. For example, MCT proach of combining a range of techniques is assumes that worry, rumination, and threat the most effective means of treatment devel- monitoring are part of a cognitive attentional opment. In particular, multi-component and syndrome (CAS) which is a core psychologi- highly eclectic treatment packages may hide cal process and a transdiagnostic factor across detrimental effects of specific components of most disorders. Putting worry, rumination, a treatment method (Castonguay et al., 1996). and attention to threat in the center implies In summary, these examples show that in psy- that psychological dysfunction such as anxiety chotherapy, the dominant technique-driven is a product of this mechanism, and there is no approach (as in other fields) has advantages need to directly address the emotion anxiety if but also creates serious problems. a technique can limit the CAS.

OPPORTUNITIES MCT seems to be quite unusual as it ex-

Starting From Basic Science clusively developed and uses techniques that can be directly related to the parent theory, All methods of modern behavior therapy and it was developed by systematically test- refer to general learning theory (, ing the assumptions derived from this theory. , constructivism, and social cogni- MCT started with case studies demonstrating tive theory) or theory. the effects of manipulating attention focus, Only two refer to a specific psychological the- through the attention training technique (ATT) ory derived from general psychology: meta- as a means of enhancing cognitive control and cognitive therapy (MCT) (Wells, 2009) draws disrupting the CAS (Wells, 1990), and later on on and develops the of metacogni- the effects of attention enhancements -on ex tion as described by Flavell (Flavell, 1979). It posure (Wells & Papageorgiou, 1998). There is grounded in the self-regulatory executive is now a significant database supporting the function (S-REF) model, a detailed informa- probable efficacy of ATT (Knowles et al., 2016; tion processing model of cognitive and Fergus & Wheless, 2018) and full MCT (Nor- affective regulation (Wells & Matthews, 1996). mann et al., 2014). While there are a variety Acceptance and commitment therapy (ACT) of techniques intended to modify attention- refers to (RFT) (Hayes al focus and attentional processes in behavior et al., 2001). The exact nature of the interaction therapy literature, these were often focused

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on reducing anxiety through distraction, rath- related to a lack of progress in general psychol- er than based on a theory linking attention to ogy. Actually, there is a substantial amount of psychological causal or maintenance mecha- new in the field with obvious rele- nisms. An exception is presented by work in vance that awaits translation into psychother- the area of attention bias modification (ABM) apy techniques, e.g., knowledge about decision based on the finding that anxiety is associated making (Morewedge & Kahneman, 2010), hu- with “automatic processing” of threat-related man cooperation (Rand & Nowak, 2013), heu- information and in principle, such bias might ristics (Raab & Gigerenzer, 2015), or the theory be retrained (MacLeod, 2015). However, these of constructed (Barrett, 2017). The examples of ATT and ABM appear to be among development of MCT presents an example of a the few exceptions in the field. systematic approach to theory and testing that could be emulated in developing the full poten- tial of other psychological discoveries. Theory-Driven Construction of Psychotherapeutic Methods CONCLUSION In the case of MCT and of its individual tech- niques such as ATT, we see a paradigmatic shift Our opinion paper points to the necessi- with a predominant theory-driven develop- ty of rethinking innovation processes in psy- ment of therapeutic techniques. Furthermore, chotherapy. Psychotherapy is a significant the theory is firmly grounded in objective psy- achievement in modern health care. It needs chological science of attention (Wells and Mat- further evolution. To this end, it still needs to thews, 1996). However, we need an awareness overcome barriers and might benefit from a of the potential risks involved in this system of more rigorous theory-driven approach that is therapy development, and we require an on- informed by discoveries in psychological sci- going process of refining psychotherapy from ence. Metacognitive therapy is an example of a basic science perspective. Helpful tools may this type of approach in which an interface be- be qualitative studies examining the effects of tween cognitive psychology and applied psy- specific psychotherapeutic techniques, and sin- chology has been developed and exploited with gle case studies that focus on testing-isolated good effect. techniques. Essential principles of psychother- apy like “doing a few things well” or “less is AUTHOR’S NOTE more” (low complexity results in better skill acquisition, focus on key information results in The idea for this opinion paper arose during better decisions) may show their advantages in a lengthy discussion after a presentation by further enhancing the theory-driven approach Adrian Wells at the World Congress of Psychia- to therapy development. try in Berlin in October 2017.

Starting the construction of psychother- apeutic methods from basic science is an ex- AUTHOR CONTRIBUTIONS ception rather than a rule. However, this is not

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All authors listed have made a substantial, Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., and Hayes, A. M. (1996). Pre- direct and intellectual contribution to the work, dicting the effect of cognitive therapy for and approved it for publication. depression: a study of unique and com- mon factors. Journal of Consulting Clinical Psychiatry 64, 497–504. doi: 10.1037/0022- 006X.64.3.497 CONFLICT OF INTEREST Cuijpers, P. (1998). Minimising interventions STATEMENT in the treatment and prevention of depres- sion. Taking the consequences of the ‘Dodo The authors declare that the research was Bird Verdict’. Journal Mental Health 7, 355– 365. conducted in the absence of any commercial or Fergus, T. A., and Wheless, N. E. (2018). The financial relationships that could be construed attention training technique causally re- duces self-focus following worry provoca- as a potential conflict of interest. tion and reduces cognitive anxiety among self-focused individuals. J. Behavioral Thera- py and Experimental Psychiatry 61, 66–71. doi: 10.1016/j.jbtep.2018.06.006 ACKNOWLEDGMENTS Flavell, J. H. (1979). and cog- We thank Prof. Dr. Heike Tost for her criti- nitive monitoring. American Psychololgy 34, 906–911. doi: 10.1037/0003-066X.34.10.906 cal comments to the manuscript. Fluckiger, C., Del Re, A. C., Wampold, B. E., and Horvath, A. O. (2018). The alliance in psychotherapy: A meta-analytic synthe- sis. Psychotherapy 55, 316–340. doi: 10.1037/ REFERENCES pst0000172 Barrett, L. F. (2017). The theory of constructed Gaudiano, B. A., and Miller, I. W. (2013). The emotion: an active account of in- evidence-based practice of psychotherapy: teroception and . Soc. Cognitive facing the challenges that lie ahead. Clin- Affective 12, 1–23. doi: 10.1093/ ical 33, 813–824. doi: scan/nsw154 10.1016/j.cpr.2013.04.004 Beck, A. T. (1963). Thinking and depression. I. Graves, T. A., Tabri, N., Thompson-Brenner, Idiosyncratic content and cognitive distor- H., Franko, D. L., Eddy, K. T., Bourion-Be- tions. Archive of General Psychiatry 9, 324–333. des, S., et al. (2017). A meta-analysis of the doi: 10.1001/archpsyc.1963.01720160014002 relation between therapeutic alliance and Beck, A. T. (1964). Thinking and depression. II. treatment outcome in eating disorders. In- Theory and therapy. Archive of General Psy- ternational Journal of Eating Disorders 50, 323– chiatry 10, 561–571. 340. doi: 10.1002/eat.22672 Beck, A. T., and Dozois, D. J. (2011). Cognitive Hayes, S. C., Barnes-Holmes, D., and Roche, B. therapy: current status and future direc- (2001). Relational frame theory. A post-Skinne- tions. Annual Review Medicine 62, 397–409. rian account of human and cognition. doi: 10.1146/annurev-med-052209-100032 New York: Kluwer. Budd, R., and Hughes, I. (2009). The Dodo bird Heim, E., Roetger, A., Lorenz, N., and Mae- verdict–controversial, inevitable and im- rcker, A. (2018). Working alliance with an portant: a commentary on 30 years of me- avatar: how far can we go with internet in- ta-analyses. and Psycho- terventions? Internet Interventions 11, 41–46. therapy 16, 510–522. doi: 10.1002/cpp.648 doi: 10.1016/j.invent.2018.01.005 Cameron, S. K., Rodgers, J., and Dagnan, D. Jacobson, N. S., Dobson, K. S., Truax, P. A., (2018). The relationship between the ther- Addis, M. E., Koerner, K., Gollan, J. K., et apeutic alliance and clinical outcomes in al. (1996). A component analysis of cogni- cognitive behaviour therapy for with tive-behavioral treatment for depression. depression: a meta-analytic review. Clinical Journal of Consulting Clinical Psychology 64, Psychology and Psychotherapy 25, 446–456. 295–304. doi: 10.1002/cpp.2180 Knowles, M. M., Foden, P., El-Deredy, W., and Wells, A. (2016). A systematic review of ef-

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