Beyond Integration: the Triumph of Outcome Over Process in Clinical Practice SCOTT D. MILLER, BARRY L. DUNCAN AND MARK A. HUBBLE The empirically validated, integrative and evidence-based practice movements share in the belief that specific therapeutic ingredients, once isolated and delivered in reliable and consistent fashion, will work to improve outcome. Yet research and clinical experience indicates otherwise. How best to proceed in the light of such findings? Miller, Duncan and Hubble argue that the best hope for integration of the field is a focus on the common goal of change and the use of outcome to inform the clinical process. Significant improvements in client retention and outcome have been shown where therapists have feedback on the client’s experience of the alliance and progress in treatment. Rather than evidence-based practice, therapists tailor their work through practice-based evidence. ‘The proof of the pudding is in the eating’. Cervantes, Don Quixote (IV. 10, p. 322) Three basic approaches characterize the psychotherapy integration movement (Saltzman & Norcross, 1990). The first,technical eclecticism, refers to the use of a variety of techniques ‘without necessarily subscribing to the theories that spawned them’ (Norcross & Newman, 1992, p.11). Emphasis is placed on selecting the most useful procedures for a given individual on the basis of demonstrated efficacy (Norcross, 1997). In contrast, the second, theoretical two decades ago, one finds little reason ‘eclectic’ therapist uses only 4 of the integration, as the name implies, to be sanguine. As Norcross (1997) existing 250-1000 (depending on how refers to efforts aimed at synthesizing noted with open distress, ‘psychotherapy one counts) different treatment models the underlying theories of different integration has stalled…the meaning… and techniques. Those used frequently approaches (Saltzman & Norcross, remains diffuse, its commitment typically have a strong family resemblance 1990). Here, the focus is more theoretical philosophical rather than empirical, and (i.e. the combination of techniques than pragmatic. The best aspects of its training idiosyncratic and unreliable’ from solution-focused and narrative different approaches are combined into (p. 86). More troubling, available approaches) or are applied in accidental, a superordinate theory that hopefully, evidence calls the validity of the entire hit or miss combinations. This practice ‘leads to new directions for practice and project into question. hardly qualifies as eclecticism! research’ (p. 12, Norcross & Newman, In 1990, Jensen, Bergin, & Greaves Though not for lack of trying, no 1992). The third and final approach to concluded that the integration movement evidence of differential effectiveness integration is called the common factors. ‘will have been wasted unless it can be exists for the perspective. For instance, Dating back to 1936 and the work of shown that specific combinations of significant attempts have been made Saul Rozenzweig, this perspective techniques produces superior outcomes to identify, ‘what kind of therapy, or might rightly be considered the earliest with given disorders’ (p.129). On this elements thereof, benefits what kind attempt at psychotherapy integration. score, consider the data on technical of client’ (p.219, Shoham-Salomon & Emphasis is placed on identifying the eclecticism. The pragmatic blending of Hannah, 1991). Beyond complaints that core ingredients ‘shared by all effective various approaches remains the most the resulting ‘matching matrices’ are therapies’ (p. 7, Hubble, Duncan, & popular clinical orientation among either too simplistic or too complex to Miller, 1999a). practicing therapists despite the fact that be of much value in modern clinical While definitions of the the research clearly shows no therapist work, comparative, component (e.g. three dominant approaches are is truly eclectic (Jensen, Bergin, & dismantling), and person by treatment straightforward, since the formation Greaves, 1990; Norcross, 1997; Smith, interaction studies have failed to provide of the Society for the Exploration of 1982; Watkins, Lopez, Campbell, & any consistent or compelling empirical Psychotherapy Integration (SEPI) nearly Himmel, 1986). As it is, the modal support (Ahn & Wampold, 2002; Baker 2 PSYCHOTHERAPY IN AUSTRALIA . VOL 10 NO 2 FEBRUARY 2004 PSYCHOTHERAPY IN AUSTRALIA . VOL 10 NO 2 FEBRUARY 2004 3 & Neimeyer, 2003; Dance & Neufeld, are combined. However, rather than description suggests that the model is less 1988; Smith & Sechrest, 1991). Such improving outcomes or offering new about amalgamating theories of therapy might be expected given that technical avenues for research and treatment, the than understanding how change occurs eclecticism focuses on what is arguably many offerings have exacerbated the very (Prochaska, 1999). More will be said the weakest contributor to outcome - confusion the integrative movement was later about why this approach lies beyond technique - which data indicate accounts designed to stem. traditional integrative frameworks. for between 8-15% of the variance One notable exception to this bleak Last, but not least, is the common (Duncan & Miller, 2000; Wampold, 2001). state of affairs may be found in the work factors approach. Of the three, this Turning to theoretical integration, of Prochaska and colleagues on the perspective has the strongest empirical both the field and practitioners appear, in theory, to be committed Outside of the laboratory and halls of higher education, to blending ideas from different therapeutic modalities. As Norcross it remains so very true that techniques and models (1997) notes, ‘every third or fourth volume on psychotherapy now touts itself are accumulated rather than integrated, employed as integrative’ (p. 86). The same may be said of continuing education events idiosyncratically rather than systematically. and journal articles where everything from cognitive-behavioral and transtheoretical approach (Prochaska, support (Hubble, Duncan, & Miller, strategic (Yapko, 2001), depth-oriented 1999; Prochaska & Norcross, 2002). 1999b). As Beutler & Consoli (1992) noted and brief therapies (Ecker & Hulley, While often cited as an example of in the first edition of the Handbook of 1996), to string theory and energy theoretical integration (Norcross & Psychotherapy Integration, ‘most of the meridians (Callahan & Mindell, 2000) Newman, 1992), Prochaska’s own effectiveness of psychotherapy can be attributed to factors that are common’ (p. 264). Nothing has changed in the interim. The evidence that specific ingredients account for treatment effectiveness remains weak to non- existent. Indeed, Wampold (2001) concludes in his meticulous review of the literature, ‘Decades of psychotherapy research have failed to find a scintilla of evidence that any specific ingredient is necessary for therapeutic change’ (p.204). While a core group of common factors has been identified and defined (Frank and Frank, 1991; Miller, Duncan, & Hubble, 1997; Hubble, Duncan, & Miller, 1999b; Rosenzweig, 1936; Wampold, 2001), their utility in day-to-day clinical work is questionable. To begin, a paradox is created the moment any attempt is made at operationalization. Logically, there is and can never be a ‘common factors’ model of therapy because all models by definition already include the factors. Even the usefulness of the factors as general organizing principles for clinical practice is uncertain. A case in point is the therapeutic alliance - widely thought of as a fundamental ingredient of all approaches (Hubble, Duncan, & Miller, 1999b). And yet, research to date shows that training therapists to focus on the alliance has not been productive (Horvath, 2001). 2 PSYCHOTHERAPY IN AUSTRALIA . VOL 10 NO 2 FEBRUARY 2004 PSYCHOTHERAPY IN AUSTRALIA . VOL 10 NO 2 FEBRUARY 2004 3 Whither Integration? of an organized and systematic approach health care policy and planning’ (p. 5). ‘This is it! You can’t get there from here, to treatment - the idea that specific Still, the facts are difficult to ignore: and besides there’s no place else to go.’ factors, once identified and then reliably psychotherapy does not work in the same ‘Sheldon Kopp (1975) delivered, will enhance outcome. At way as medicine. The improvements this juncture, the data clearly show that in outcome hoped for and promised by Though it is tempting to blame the training therapists to deliver ‘manualized the identification, organization, and current problems in the integrative care’ (R. Klekar, 2003, personal systematization of therapeutic process movement on a lack of information, communication) increases adherence to have not materialized. The question proper education, or inadequate the manual. Not withstanding, the same that remains unanswered, of course, is training, a simpler, more parsimonious, research shows no resulting improvement how best to proceed in the light of such explanation exists. As worthy as the aims in outcome and the strong possibility findings? What are the alternatives for may be, the movement fails to capture of untoward negative consequences guiding clinical practice? To find the the essence or reflect the exigencies of (Beutler, Malik, Alimohammed, answers, an analysis from a classic work psychotherapy as it is practiced in the Harwood, Talebi, Noble, & Wong, 2004; in the field of business is now examined. real world. Outside of the laboratory and Lambert & Ogles, 2004). With regard to halls of higher education, it remains so the former, researchers