Burying the Dodo: Why the Common Factors Debate is Not Over Yet Robert J. DeRubeis Department of Psychology University of Pennsylvania Australian Regional Group Meeting Society for Psychotherapy Research Brisbane, 1 December, 2009 Key Collaborators • Dan Strunk (Assistant Professor, the Ohio State University) • Jay Fournier (on clinical internship at the Western Psychiatric Institute and Clinics) The Dodo Verdict • A meme that thrives in the psychotherapy research community • What does it convey? • Why does it convey “it” so effectively? • If we could agree on a clear assertion related to the Dodo, or the Verdict, or its use in psychotherapy rhetoric, what could available findings tell us about the assertion? Meet the Dodo From the Oxford University Museum of Natural History From Wikipedia’s “Dodo” entry • Raphus cucullatus, a flightless bird endemic to the island of Mauritius. • Has been extinct since the mid-to-late 17th century. Commonly used as the archetype of an extinct species because its extinction occurred during recorded human history, and was directly attributable to human activity. • The word is probably related to the Dutch word “dodaars” ("knot-arse"), referring to the knot of feathers on the Dodo’s hind end. Why the Dodo? • Because it’s extinct? • No. Because of what the Dodo famously said in Lewis Carroll’s “Alice in Wonderland,” and how that saying has been applied to psychotherapy research findings. The Dodo, presenting Alice with a thimble to honor his proclamation that, after the Caucus race, “Everyone has won, and all must have prizes.” The connection between psychotherapy and the Dodo • Saul Rosenzweig (1936) – Invoked the Dodo in reference to psychotherapy – First to conjecture that there are/were implicit common factors in diverse methods of psychotherapy – Made the conjecture absent empirical data • In 1975, Lester Luborsky revived the Dodo/psychotherapy connection, in his influential paper in the Archives of General Psychiatry , “Comparative studies of psychotherapies: Is it true that "Everybody has won and all must have prizes"? • Is now a common meme used to express (or deny) the view that “all psychotherapies are equally effective” A bit of irony • Carroll used the scene to mock the futility of UK’s political caucuses. • The “Caucus Race” was run helter-skelter, with no rules and no finish line (and Alice’s own thimble was returned to her by the Dodo as her “prize”). • The saying might apply better, then, to reflect a belief that there have been few if any comparative psychotherapy studies with agreed-upon rules – not that we have identified any winners. Two contrasting views The Dodo is a wise old bird The Dodo is an anachronism • Psychotherapy works (thus, • The effectiveness of a psycho- there cannot only be losers), therapy must be established and by research findings • There are enough comparative • For many problems, some (and other) data to tell us that treatment(s) have been shown the type of therapy does not to be superior to other matter, so all are winners treatments • Insofar as traditional therapies • In the absence of comparative have less evidence behind evidence, prefer the therapy them, absence of evidence does that has been shown to work not equal evidence of absence What is at stake? • Curricula in training programs • Funding of treatment by insurance companies and governments • The direction of psychotherapy research What kind of evidence might (or should) strengthen or bury the Dodo? Strengthen Bury • Strong evidence that • Strong evidence that variation in factors common variation in amount/quality to all treatments account of technique accounts for for a whole bunch of the outcome, over and above variance in outcome common factors • Repeated demonstrations • Some replicable, trust- in comparative studies that worthy evidence that the differences are differences in important negligible outcomes result from two different treatments We haven’t all agreed on the ground rules for the race(s) • What do we make of the correlations between outcome and measures of common factors (e.g., the alliance)? • What size of effect (differences between treatments) is large enough for us to care about? • What kinds of studies need to be done before researchers will agree about whether Treatment A > Treatment B (under certain or all circumstances)? • How do we take into account the wisdom of the therapist? We haven’t all agreed on the ground rules for the race(s) • What do we make of the correlations between outcome and measures of common factors (e.g., the alliance)? Model of Change Process Treatment Manipulation Patient Processes Application of Acute Long-term Components Outcome Outcome Active Extra- Components Competencies therapy Factors Prognostic Indices Proposed contributors to the process of change • Therapeutic Alliance – Meta-analysis, r = .22 (Martin et al. 2000) – Temporal confound in most studies • Adherence to Methods of Cognitive Therapy – Two published studies from our research group – “Concrete” methods of CT predict subsequent change Strunk et al. (2009) – Participants: 60 moderately to severely depressed adults – Symptom Measures • Beck Depression Inventory (BDI-II) • Hamilton Rating Scale for Depression Observer Rated Measures of Process – Concrete and Abstract Adherence – Working Alliance Inventory (WAI) Intraclass correlations coefficients: .59 - .77 Sample Concrete Adherence Item Examine Available Evidence : Did the therapist help the client to use currently available evidence or information (including the client’s prior experiences) to test the validity of the client’s beliefs? 1 2 3 4 5 6 7 Not at all some considerably extensively Session-to-Session Change Session 1 Session 2 Session 3 Session 4 Session 5 Process Measure Symptoms ()()()() r p Cognitive Therapy -- .41 .001 Concrete Cognitive Therapy -- .27 .04 Abstract Working Alliance .15 .96 Summary • Adherence, especially concrete adherence, predicted session-to-session symptom change • Therapeutic Alliance did not predict symptom change • Is the null alliance finding an anomaly? Previous Studies with Forward Predictions Correlation of Alliance and Statistically Study n Outcome Significant? DeRubeis & Feeley, 1990 25 r = .10 No Feeley, DeRubeis & 25 r = -.27 No Gelfand, 1999 Barber et al.,1999 252 r = .01 * No Barber et al., 2000 86 r = .30 * Yes Klein et al., 2003 367 r = .14 Yes Strunk et al., 2009 60 r = .15 No * Indicates an average correlation when multiple outcome measures used We haven’t all agreed on the ground rules for the race(s) • What size of effect is big enough for us to care about? How large was the observed drug vs. placebo advantage, in ES terms? • For patients in the mild-to-moderate range, d = .11 • For patients in the severe range, d = .17 • For patients in the very-severe group, d = .47 Why we can’t expect big effects in psychotherapy research Potentially measurable aspects of the therapeutic process: • Fit – the correspondence between what the client most needs in order to thrive and change, and the therapeutic plan, based on the therapist’s judgment of the client’s needs. – It could – but need not – refer to the fit between a brand name therapy and a client’s needs. – Could refer to the aggregation of judgments and plans made by the therapist, in relation to the client’s needs at each moment. Potentially measurable aspects of the therapeutic process: • Fit – the correspondence between what the client most needs in order to thrive and change, and the therapeutic plan, based on the therapist’s judgment of the client’s needs. • Implementation – the degree to which the therapist delivers on his or her plan. Skill is another word for this. • Relationship – the connection between the therapist and the client, such that the client engages the process of therapy. (Controversial point #1: Strategic uses of the relationship fall best under “fit” and “implementation” in this nosology.) Potentially measurable aspects of the therapeutic process: • Fit – the correspondence between what the client most needs in order to thrive and change, and the therapeutic plan, based on the therapist’s judgment of the client’s needs. • Implementation – the degree to which the therapist delivers on his or her plan. Skill is another word for this. • Relationship – the connection between the therapist and the client, such that the client engages the process of therapy. (Note: Strategic uses of the relationship fall best under “fit” and “implementation” in this nosology.) 100 80 60 40 20 % Improvement% Post-treatment by 0 Absent Minimal Creditable Very Good Exquisite Quality of Therapy ( aFit + bSkill + cRelationship) 100 80 60 40 20 % Improvement% Post-treatment by 0 Absent Minimal Creditable Very Good Exquisite Quality of Therapy ( aFit + bSkill + cRelationship) 100 80 60 Responsive 40 20 % Improvement% Post-treatment by 0 Absent Minimal Creditable Very Good Exquisite Quality of Therapy ( aFit + bSkill + cRelationship) 100 Spontaneous remitter 80 60 Responsive 40 20 % Improvement% Post-treatment by Not amenable to change 0 Absent Minimal Creditable Very Good Exquisite Quality of Therapy ( aFit + bSkill + cRelationship) 100 Spontaneous remitter 80 60 Needs very little Responsive Demanding 40 20 % Improvement% Post-treatment by Not amenable to change 0 Absent Minimal Creditable Very Good Exquisite Quality of Therapy ( aFit + bSkill + cRelationship) 100 80 60 40 20 % Improvement% Post-treatment by 0 Absent Minimal Creditable Very Good Exquisite Quality of Therapy ( aFit + bSkill + cRelationship) 100 Spontaneous remitter