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The Outcome of Psychotherapy: Yesterday, Today, and Tomorrow

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The Outcome of Psychotherapy: Yesterday, Today, and Tomorrow Psychotherapy © 2013 American Psychological Association 2013, Vol. 50, No. 1, 88–97 0033-3204/13/$12.00 DOI: 10.1037/a0031097 The Outcome of Psychotherapy: Yesterday, Today, and Tomorrow Scott D. Miller, Mark A. Hubble, Daryl L. Chow, and Jason A. Seidel International Center for Clinical Excellence In 1963, the first issue of the journal Psychotherapy appeared. Responding to findings reported in a previous publication by Eysenck (1952), Strupp wrote of the “staggering research problems” (p. 2) confronting the field and the necessity of conducting “properly planned an executed experimental studies” to resolve questions about the process and outcome of psychotherapy. Today, both the efficacy and effectiveness of psychotherapy has been well established. Despite the consistent findings substan- tiating the field’s worth, a significant question remains the subject of debate: how does psychotherapy work? On this subject, debate continues to divide the profession. In this paper, a “way out” is proposed informed by research on the therapist’s contribution to treatment outcome and findings from studies on the acquisition of expertise. Keywords: psychotherapy, outcome, excellence, practice-based evidence, therapist variability The progress of science is the work of creative minds. Every creative In the decades preceding Psychotherapy’s appearance, practice mind that contributes to scientific advances works, however, within was mostly limited to physicians, and psychoanalysis and psy- two limitations. It is limited, first, by ignorance, for one discovery chodynamic approaches predominated (Frank, 1992; VandenBos, waits upon that other which opens the way to it. Discovery and its Cummings, & DeLeon, 1992). Beginning in the 1950s, the pre- acceptance are, however, limited by the habits of thought that pertain vailing paradigm came under scrutiny. Researchers within the to the culture of any region and period. —E. G. Boring emerging behavioral school were harshly critical, challenging the scientific basis of Freudian theories and concepts. Hans J. Eysenck If we want to solve a problem that we have never solved before, we (1952) published a review of 24 studies concluding that psycho- must leave the door to the unknown ajar. therapy was not only ineffective, but potentially harmful. The —Richard P. Feynman conclusions provoked considerable public and professional atten- tion, and were immediately disputed by proponents of psychother- In 1963, the population of the United States was approaching apy (Luborsky, 1954; Rosenzweig, 1954). 190 million. The average worker earned just under $6,000 per Strupp’s (1963) article in the first issue of Psychotherapy, and annum. A first class stamp cost 4 cents, a gallon of gas, 29. The Eysenck’s (1964) response, revisited the still unsettled debate. national debt stood at $310 billion. Around the country, Americans were tuning into The Beverly Hillbillies, the nation’s number one Although the efficacy of psychotherapy would remain in doubt for rated TV program. ZIP codes were introduced by the U.S. Postal some time to come, the back and forth between the two sides Service and the Beatles released their first album, Please Please served to highlight both the “staggering research problems” Me. A war in Vietnam was on, but few knew where the country (Strupp, 1963, p. 2) confronting investigators and the “necessity of was or what the fighting was all about. properly planned and executed experimental studies into this im- In that year, membership of the American Psychological Asso- portant field” (Eysenck, 1964, p. 97). ciation stood at 17,000 (Hilgard, 1987). The Diagnostic and Sta- Fifty years later, much has changed. The U.S. population has tistical Manual (DSM) was 130 pages in length, and listed 106 increased by 40%. Owing to the frequent change in the cost of a mental disorders. Treatment models numbered fewer than 40 first class stamp, the printed price has been replaced with the word, (Miller, Duncan, & Hubble, 1997; Wampold, 2001). The number “Forever.” At the time of writing this article, a gallon of gas of states granting licenses to practice psychology was on the rise. fetches $4.50, and the national debt is quickly approaching $17 In August, the same month that Reverend Martin Luther King trillion. Only two members of the Fab Four are still alive. Viet- delivered his, “I Have a Dream” speech from the steps of the nam, once an implacable enemy, is now a trading partner of the Lincoln Memorial, the inaugural issue of Psychotherapy was pub- United States, and the two countries conduct joint naval training lished. Three months later, in Dallas, Texas, President John F. exercises. Kennedy was assassinated. In the tumultuous years that followed, Today, the American Psychological Association has 137,000 the American experience and identity would be transformed. So, members. Licenses are required to practice independently as a too, would the field of psychotherapy. psychologist in every state. More than 800,000 professionals are able to bill third party payers for mental health services (Brown & Minami, 2010). The Substance Abuse and Mental Health Service Scott D. Miller, Mark A. Hubble, Daryl L. Chow, and Jason A. Seidel, Administration’s (SAMHSA) Web site lists 145 manualized treat- International Center for Clinical Excellence. ments for 51 of the 365 mental disorders now contained in the Correspondence concerning this article should be addressed to Scott D. DSM. This volume, in its fourth edition, has reached an astonishing Miller, P.O. Box 180147, Chicago, IL 60618. E-mail: [email protected] 943 pages. A fifth edition is in the works, and many psychologists, 88 THE OUTCOME OF PSYCHOTHERAPY 89 including the APA president, are calling for the abandonment of & Vermeersch, 2006; Shapiro, Firth-Cozens, & Stiles, 1989; the DSM and transition to the World Health Organization’s Inter- Wampold & Bolt, 2006; Wampold, Mondin, Moody, & Ahn, national Classification of Diseases (Bradshaw, 2012; Clay, 2012). 1997). The principle disagreement between Strupp and Eysenck re- The failure to reach agreement about how psychotherapy works corded in the first volume of Psychotherapy has been resolved. Not is not without consequence. To begin, how will the outcome of only is the efficacy of psychotherapy well established, but so is its psychotherapy ever improve if the two major explanatory para- effectiveness in real world clinical settings (American Psycholog- digms are in continuous dispute and the causal variables defy ical Association, 2012; Duncan, Miller, Wampold, & Hubble, consensus? On that score, meta-analytic evidence shows outcome 2010; Wampold, 2001). Despite the consistent findings substanti- has changed little over the past 40 years despite overwhelming ating the field’s worth, a significant question remains unanswered: support of psychotherapy and a dramatic increase in the number of How does psychotherapy work? In Strupp’s words (1963, p. 2), the diagnoses and treatment approaches (cf., APA, 2012; Smith & field would “not be satisfied with studies of therapeutic outcomes Glass, 1977; Wampold, Mondin, Moody, & Ahn, 1997; Wampold, until (it) succeed(ed) in becoming more explicit about the inde- Mondin, Moody, et al., 1997). pendent variable”—in particular, the contributions made by the The polarization among researchers and inability to answer client, the therapist, the treatment method, and commerce between basic questions about the internal workings of psychotherapy also the participants. Here, debate continues to divide the profession. undermine the standing of the profession within the world of Gathered on one side are those who have long argued that health care, especially among consumers. Nationwide surveys of psychotherapy is analogous to medicine. From this point of view, potential users of psychotherapy find that a clear majority (77%) psychologically informed interventions work in much the same doubt its efficacy (APA, 2004; Therapy in America, 2004). More- way penicillin treats infection. The hallmark of their position is over, although 90% of people report they would prefer to talk that effective treatments must contain specific ingredients remedial about their problems rather than take medication, use of psycho- to the condition being treated. For this group, randomized clinical tropic drugs has continued to rise, whereas visits to psychothera- trials (RCTs) are the principal means of investigation, the findings pists have steadily declined (Duncan, Miller, Wampold, & Hubble, of which are used to generate treatment guidelines, manuals, and 2010). lists of “empirically supported” or “validated” therapies (e.g., Some contend that the threat to the field’s survival is so grave Barlow, 2004; Chambless & Hollon, 1998). They contend that for the profession’s interest would best be served by setting the psychotherapy to advance as a science, psychologists must opera- scientific issues aside and acting as though the medical model tionalize falsifiable hypotheses using specific methods (discrete applies (Nathan, 1997). “Moving aggressively in the direction of independent variables), test those hypotheses, and teach students developing and implementing empirically validated treatment those methods that stand up to rigor and replication (Gambrill, methods,” Wilson (1995) argues, “would seem imperative in se- 1990; Zuriff, 1985). The critical argument supporting this ap- curing the place of psychological therapy in future health care proach is that different therapies are differentially effective,
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