Issues in Religion and Psychotherapy

Volume 7 Number 2 Article 5

4-1-1981

The Effects of Psychotherapy: A Professional Update

Michael J. Lambert

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Recommended Citation Lambert, Michael J. (1981) "The Effects of Psychotherapy: A Professional Update," Issues in Religion and Psychotherapy: Vol. 7 : No. 2 , Article 5. Available at: https://scholarsarchive.byu.edu/irp/vol7/iss2/5

This Article or Essay is brought to you for free and open access by the Journals at BYU ScholarsArchive. It has been accepted for inclusion in Issues in Religion and Psychotherapy by an authorized editor of BYU ScholarsArchive. For more information, please contact [email protected], [email protected]. THE EFFECTS OF PSYCHOTHERAPY: A- PROFESSIONAL UPDATE Michael J. Lambert, Ph.D.· Presented at the AMCAP convention October 3, 1980

The following review attempts to summarize 2. It is not the result of "placebo effects" -- although research on the effects of psychotherapy and its some "placebo" and genuine treatments generate implications for the practice of psychotherapy. This "hope"and other emotions that increase successful review deals mainly with research on adult non­ coping and symptomatic improvement. psychotic outpatients. It is based on the assumption 3. It is not due to "spontaneous remission." The that controlled investigations will lead to replicable, effects of therapy clearly surpass no treatment or trustworthy, and significant findings. It is also spontaneous remission baselines. The assumed that it will result in findings that are specific­ "unsystematic" curative factors within society and -in the sense of identifying the actual causal the individual do not result in as rapid components in psychotherapy. The end result will be improvements as psychotherapy. to place the practice of psychotherapy on a 4. Deterioration. Despite controversy, it is clear that scientifically substantiated body of knowledge. a portion of patients are made worse by the In such a review, I recognize that few therapist's therapists who intend to help them. practice is based upon research, and further that the a) Most recent evidence comes from video self­ interpretation of research evidence is influenced by confrontation techniques. defensive processes on those rare occasions when b) Several reports now suggest these negative therapists do read research reports. For example, a effects occur in ser therapies with conservative recent well-controlled study indicated that therapists couples. are much more critical of methodology in studies that 5. The demonstrated effectiveness of those therapies contradict the therapy system with which they are which have proved successful has led to attempts identified. to specify the causal components of treatment. The I also recall Carl Rogers' comments about the search for causality can be catagorized into three apprehensiveness with which he undertook extensive main headings: evaluations of client. centered therapy. What if his a) Those variables related to the client (e.g., cherished beliefs and deep committments were not symptom severity). supported by the results of careful investigation? It is b) Those related to the therapist (e.g., empathic unusual to be open and to conclude as Rogers did: attitude). "The facts are always friendly." c) Those that are related to the treatment Recognizing that therapists may feel somewhat method or technique. threatened by information that comes from a base In general. outcome can best be predicted from other than their own experience, I realize that patient variables, next by therapist attitudes of the presenting a list of conclusions is not the most client centered variety, and finally by technique effective way to proceed. Given the time available and variables. This conclusion is illustrated in Figures 1 the scope of this presentation, however, little more and 2. than a list of conclusions can be offered. The An important speculation related to these figures is interested participant may wish to consult two the idea that therapist attitudelrelationship variables resources that provide clearer documentation of are least strongly related to outcome in the most and these conclusions (Bergin and Lambert, 1978; least disturbed patients. Lambert, 1979; Lambert, in press). The following conclusions were based upon these extensive reviews Prescriptive Psychotherapy of psychotherapy outcome literature. Although technique variables are not nearly as Let me proceed now with a list of conclusions that powerful as we would hope, the rest of this have implications for the practice of psychotherapy. presentation focuses on techniques and upon the idea General Conclusions of prescriptive therapy interventions. There are 1. Psychotherapy works, is effective, causes positive several empirical strategies for investigating personality change. prescription. For example, patients can be assigned to treatments on the basis of compatible and ·Brother lambert is an Associate Professor of incompatible personality traits, sex, racial Psychology at Brigham Young University, background, and the like. Research on these

19 AMCAP JOURNAL/APRIL 1981 exposure in fantasy. The success of these prescriptive Therapistrelatlonlhip 15'111 ---."e.;,....- treatments is dependent on patients who are willing to carry out the exposure procedures and a therapist Technique/treatment 5'111 who can properly influence motivation and Therapeuticexperlmce5'111 cooperation. RtCtnt &lrs. Emmelkamp, Kuipers, and Eggeraat

CllenU5% A.I HighlyDllturbed

-1'--"~-- Theraplstexperlmce5'lll

-..,..'-'~ Therapeutlcrelatlonohiplll'l1l figure 1. The relative contribution of client, Technique/treatment ll'lIl therapist and technique variables to psychotherapy outcome. Cllmt35%

Clim': Included here would be such variables as age, sex, socio­ economic level, IQ, marital status, diagnosis, motivation, ego strength, interaction with enviromental factors, therapy readiness, degree of disturbance, duration of symptoms prior to seeking treatment. Someofthese are overlapping variables, but each considered separately interacts with treatment variables to produce outcome. B. ModeratelyDisturbed Thtrllpist rtlllfionship VAridlts: Include therapist offered conditions such as empathy, genuineness, warmth and respect. Thtrapist trptritnct: May include unspecified variables including perhaps poise, confidence, good judgment, accurate expectations, personal maturity and even relationship skills. Cllent15% Tt,hniqut 1",,1 trtQtmmt Wlrillblts: Include specified procedures which are c1ear~ delineated and distinguishable from other procedures. Included would be diverse methods such as assertive training, EMG feedback, gestalt therapy, cognitive Therapeutlnelatlonohip15'111 behavior therapy. In general it represents the conclusions drawn from comparative studies. Error trnn: Represents unaccountedcomponentsofoutcome such as measurement error (e.g. Since most outcome measures have ..,..~- Theraplotexperlence5'lll reliabilities which do not exceed .80, 35% errorcould be due to ""'--.JL...t::::: Technlque/trument5'1lt this level of reliability).

C.SlightlyDisturbed strategies does not support this practice at this time. It is more common to assign patients with certain problems to therapists offering a specific treatment technique. Overall, this practice is not supported by research. There are, however, some notable --r-- Technlque/treatment3ll'l1l exceptions. Since the possibility of prescriptive assignment seems to be one of the goals of controlled research let us focus on research conclusions in those exceptional cases where prescription seems possible. Clientlll'lll Conclusion 1. Curren/ rrsrarch conlinurs /0 support /hr rzposurr hypothrsis: Sys/rma/ic rzposurr /0 {rar producing _L---- Therapistexperience5'111 stimuli rrducrs or rlimina/rs {rars in grnuinr phobic patients. ""'--.1""1:::::: Theraplltrelatlonohlp5% Substantial evidence indicates that phobias are significantly reduced by exposure techniques such as systematic desensitization, behavioral rehearsal Figure Z. The hypothetical contribution of client, modeling, and flooding. When contrasted with therapist, and technique variables to relationship therapy, insight oriented psychotherapy, psychotherapy outcome in patient etc., systematic exposure procedures are clearly more populations that differ in degree of effective. psychological disturbance. Even greater prescription is possible when we consider that exposure in oioo is more effective than lA ignores theeffectsofdrugson psychoticdisorders.

AMCAP JOURNAL/APRIL 1981 20 · (1978) compared cognitive restructuring and anxiety. prolonged exposure in t/it/o in a cross-over design with (b) Riley and Riley (1978) presented the results of a twenty-one agoraphobics. Assessments were made at controlled study that compared the effects of the beginning of treatment, at cross-over, at the end "directed masturbation" in combination with sensate of treatment, and at the follow-up one month later. focus and supportive psychotherapy versus sensate Cognitive restructuring consisted of relabeling, focus and supportive therapy in the management of elimination of irrational beliefs, and self-instructional female primary orgasmic failure. Fifteen married training. Prolonged exposure in t/it/o resulted in patients participated in the sensate focus/supportive significant improvements on most variables. There psychotherapy treatment, while 20 married patients was not one variable on which cognitive participated in this combined treatment plus the restructuring resulted in more improvement than in directed masturbation. After treatment, both t/it/o exposure. Some improvement, however, did partners were questioned about success or failure of result from the cognitive approach. The success the treatment because it was considered that this obtained through cognitive restructuring seemed to would give a more reliable assessment of outcome. depend upon the imaging ability of the patient. The Eighty-five percent of the patients who experienced better the patient's ability to imagine the situation, the directed masturbation program, and 47 percent of the more easily he could overcome it. The authors the combined treatment group, became coitally suggest that the relatively poor results for cognitive orgasmic on at least 75 percent of coital occasions. therapy compared to past research was caused by its The results suggest directed masturbation is an application to a patient population that is more effective and necessary component in the disturbed than the college student groups upon which management of primary female orgasmic failure, This past research was based. result could be contrasted with secondary female Limitations. a) Exposure treatments are less effective dysfunction where communication between partners with more complex phobias; b) Some patients who is more important to attend to in treatment. improve on target fears, generalize these Limitations. The above conclusions, while based upon improvements to other fears; c) Some patients a large, diverse body of research, have several improve without systematic exposure; and d) Some important limitations. patients who are continuously exposed to phobic a) The studies so far conducted have been directed objects fail to improve. toward test anxiety, speech anxiety, Conclusion 2. Currtnt research continues to support the use heterosexual/social anxiety and sexual dysfunctions. of some exposure techniques with performanet anxiety problems The subjects studied have not in general been such as test anxiety, spttch anxiety, and sexual dysfunctions. "patients." Thus, the generalization of results to Substantial evidence suggests that behavioral persons who are socially/vocationally incapacitated is rehearsal, systematic desensitization, and cognitive not well substantiated. restructuring methods are much more effective at b) The results with sexual dysfunctions seem to reducing performance anxiety than insight and hold up for persons with liberal sexual altitudes who have relationship oriented methods. a relatively conflict-free marriage, and who are free Rutnt Examples. (a) Goldfried, Linehan, and Smith, from more complex psychological conflicts. The early (1978) compared two procedures for reducing test success ra tes reported by Masters and Johnson seem anxiety with a waiting list control. The first was to be highly inflated by the sample studied, and the systematic rational restructuring where the subjects rather unclear criteria for "success." were asked to imagine test-taking situations and then c) The criteria for success in other performance realistically re-evaluate them. The second was a anxiety problems provide results that are impressive prolonged exposure condition where the same items on a self-report basis but unimpressive when actual were given without the instruction to cope performance on tests (GPA, actual speeches and cognitively. Questionnaire measures of anxiety similar, more rigorous criteria) is considered. indicated that greater anxiety reduction was found in Conclusion 3. The treatment of physical disorders that the systematic rational restructuring condition, interact with psychological problems IRaynauds Disease, followed by the prolonged exposure group. The migraine and tension headaches, asthma, etc.) are more efftetit/ely waiting list control showed no changes. The subjects treated with therapies that "engage the body" rather than insight, in the rational restructuring condition reported a verbal methods. Evidence indicates that systematic decrease in subjective anxiety when placed in an desensitization, systematic relaxation training to a analogue test-taking situation as well as in social lesser degree, hypnosis, and autogenic training, are evaluative situations. This rl!sult adds to the useful methods of dealing with many psychosomatic increasing belief that the cognitive reappraisal of disorders. anxiety-provoking situations can offer a markedly Rmnt example. Hock, Rodgers, Reddi, and Kennard effective treatment procedure for the reduction of (1978) evaluated the effectiveness of relaxation

21 AMCAP JOURNAL/APRIL 1981 training, assertive training, and combined relaxation unipolar depressive syndrome. Patients who had a plus assertive training in increasing respiratory history of schizophrenia, drug dependence, character function and decreasing the number of recurrent disorder, and the like were excluded as well as asthmatic attacks. The study was carried out in an patients who had a medical history that suggested allergy outpatient clinic and the subjects were ten 17­ prior prescription of antidepressant medication or a year-old male asthmatic patients. The prior history of a poor response to tricyclic psychotherapeutic treatment was combined with antidepressants. medical treatment. A 5x4 analysis of variance was Patients were assigned to cognitive therapy (N = used to analyze the forced expiratory volume (FEY) 19) or anti-depressant treatment (N = 22) on a data, and a significant difference was found between random basis prior to inclusion in the study. the groups. A Newman-Keuls statistical comparison Therapists were, for the most part, inexperienced in led to the conclusion that both relaxation training by psychotherapy but experienced in the use of drugs itself and combined relaxation plus assertive training with depression. The majority were psychiatric increased respiratory functioning and reduced the residents. Treatment via cognitive therapy followed number of attacks. Assertive training alone failed to the training manual developed by Beck and lasted for improve respiratory function and had a tendency to a maximum of twenty 50-minute sessions over 18 increase the frequency of asthmatic attacks. weeks, but averaged 15 sessions for 11 weeks. Drug Limitations. Several variables make the seemingly treatment averaged 11 weeks in duration with one specific nature of treatment for these disorders 20-minute session per week. difficult to rely upon. Results suggest that both procedures reduce the a) The seemingly clear-cut relationship between symptoms of depression; but that the patient's self­ biofeedback, hand temperature increases and report, as measured by the Beck Depression improvement in Raynauds Disease and, migraine Inventory and clinician's judgment of improvement, headache appear less certain. Although it seemed that as rated by the Hamilton and Raskin scales, showed relaxation for tension headache and hand warming the cognitive therapy patients to be improved for migraine was a prescriptive difference, this is significantly more than drug patients at termination confounded by the fact that many patients improve and at three-month follow-up. This trend held up at without control over hand temperature. the six-month follow-up, but was not statistically b) A portion of patients who show clear control fail significant. In addition, there was a tendency for drug to improve. patients to drop out of therapy early. When these c) Lasting improvements seem to be related to dropouts are included in the analysis, cognitive continued use of relaxation over long periods of time, therapy was superior to drug treatment at six thus the idea that biofeedback causes a permanent months. In addition, 13 of 19 pharmacotherapy change is not true for a large numberof those who are patients re-entered treatment for depression, while treated. only 3 of 19 psychotherapy patientssought additional d) Placebo and expectancy effects cannot be ruled treatment. out as important contributions to positive outcome. Limitations. Their effects are in need of further exploration. 1) Cognitive and behavioral approaches are Conclusion 4. Cognitivt psychothtrapits which art rapidly relatively recent and have not been fully studied as rtplacing dynamic strattgit5 may bt uniqutly tfftCtivt with prescriptive treatments in depression. As with most unipolar dtprmion. Recent investigations tend to "new" treatments, original successes may be followed support the use of cognitive and cognitive/behavioral by a gradual loss in enthusiasm and eventual strategies with some depressed patients. In some disappointment. instances, their unique effects not only surpass 2) The effects attained may be limited to "least traditional dynamic therapies, but antidepressant disturbed" unipolar depression patients. medications. These therapy strategies tend to be time 3) Their prescriptive, almost "programmed" limited and highly structured and are best approach with depression needs to be replicated by represented in the work of Beck and his associates. others. In fact, this is currently taking place in a Rush, Beck, Kovacs, and Hollon (1977) recently world-wide study. reported a study investigating the effects ofcognitive REFERENCES therapy on the symptomatic relief of depressive Bergin A. E., and Lambert, M. J., The evaluation of therapeutic symptoms on a group of 41 outpatients. outcomes. In S. L. Garfield and A. E. Bergin eds. Th, Ho.dbookof The clients were carefully selected to include a Ps~cholh"opy o.d 8,ho.ior Cho.,t, New York: WUe~, 2nd Ed., homogeneous symptom pattern typical of neurotic 1978. EmmelKamp, P. M. G., Kuipers, C. M .. &. Eggeraat, J. B.. Cognitive depression. They were screened with the Beck modification versus prolonged exposure in vivo: A Depression Inventory, Hamilton Rating Scale for comparison with agouphobics as subjects. Btltao;or Rtsarrh ,nul Depression, and a clinical judgment consistent with ThtrRpy, 1978, 16. 33-41. continued on page 36

AMCAP JOURNAL/APRIL 1981 22 Lambert, M. J., H, Eff'ds of Psycholhtrapy, Vol. 2, Montreal, Eden Press, (in Press). Riley, A. J., and Riley, E. J., A controlled study to evaluate directed masterbation in the management of primary orgasmic failure in women. British Journal of Psychiatry, 1978, 133. 404-409. Rush, A. J., Beck, A. T., Kovac" M., &< Hollon,S., Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cogniliw TIt""py IInti RtsftIrch, 1977, 1. 17-37.

continued from page 22 Goldfried, M.R., Lienhan, M. M., Smith, J.L.. Reduction of test anxiety through cognitive restructuring. Journal of Consulling and Clinical Psy,hologh, 1978, 46. 32-39. Hock, R. A., Rodgers, C H., Reddi, C, Kennard, D. W., Medico­ psychological interventions in male asthmatic children: An evaluation of physiological change. Psychosomatic Mtdici",. 1978, 40. 210-215.

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