Te outcome of psychotherapy: Yesterday, today and tomorrow SCOTT D. MILLER, MARK A. HUBBLE, DARYL L. CHOW and JASON A. SEIDEL 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’ confronting the field and the necessity of conducting ‘properly planned and executed 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 substantiating 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. ‘If we want to solve a problem that we have never solved before, we must leave the door to the unknown ajar.’ Richard P. Feynman n 1963, the population of the states granting licenses to practice scientifc basis of Freudian theories United States was approaching 190 psychology was on the rise. In August, and concepts. Hans Eysenck (1952) million.I Te average worker earned just the same month that Reverend Martin published a review of 24 studies under $6000 per annum. A frst class Luther King delivered his, ‘I Have a which concluded that psychotherapy stamp cost 4 cents, a gallon of gas, 29. Dream’ speech from the steps of the was not only inefective, but Te national debt stood at $310 billion. Lincoln Memorial, the inaugural potentially harmful. Te conclusions Around the country, Americans were issue of Psychotherapy was published. provoked considerable public and tuning into Te Beverly Hillbillies, Tree months later, in Dallas, Texas, professional attention, and were the nation’s number one rated TV President John F. Kennedy was immediately disputed by proponents program. ZIP codes were introduced assassinated. In the tumultuous years of psychotherapy (Luborsky, 1954; by the U.S. Postal Service and the that followed, the American experience Rosenzweig, 1954). Beatles released their frst album, Please and identity would be transformed. So, Strupp’s (1963) article in the frst Please Me. A war in Vietnam was on, too, would the feld of psychotherapy. issue of Psychotherapy, and Eysenck’s but few knew where the country was or In the decades preceding the (1964) response, revisited the still what the fghting was all about. appearance of Psychotherapy, practice unsettled debate. Although the efcacy In that year, membership of the was mostly limited to physicians, and of psychotherapy would remain in American Psychological Association psychoanalysis and psychodynamic doubt for some time to come, the stood at 17,000 (Hilgard, 1987). Te approaches predominated (Frank, back and forth between the two sides Diagnostic and Statistical Manual 1992; VandenBos, Cummings, & served to highlight both the ‘staggering (DSM) was 130 pages in length, and DeLeon, 1992). Beginning in the research problems’ (Strupp, 1963, p. listed 106 mental disorders. Treatment 1950s, the prevailing paradigm came 2) confronting investigators and the models numbered fewer than forty under scrutiny. Researchers within ‘necessity of properly planned and executed (Miller, Duncan, & Hubble, 1997; the emerging behavioural school experimental studies into this important Wampold, 2001). Te number of were harshly critical, challenging the field’ (Eysenck, 1964, p. 97). 64 PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 Fifty years later, much has changed. have long argued that psychotherapy 1999; Miller, Duncan, & Hubble, Te U.S. population has increased by is analogous to medicine. From this 2004). Instead of focusing on specifc 40 percent. Owing to the frequent point of view, psychologically informed methods, they insist that mechanisms change in the cost of a frst class stamp, interventions work in much the same common to all approaches, no the printed price has been replaced way as penicillin treats infection. matter the theory or technique, are with the word, ‘Forever’. At the time Te hallmark of their position is that responsible for change. In addition to of writing this article, a gallon of gas efective treatments must contain the instillation of hope, provision of fetches $4.50, and the national debt is specifc ingredients remedial to the a therapeutic rationale and strategies quickly approaching $17 trillion. Only two members of the Fab Four are still alive. Vietnam, once an implacable Despite the consistent fndings substantiating enemy, is now a trading partner of the United States, and the two countries the feld’s worth, a signifcant question remains conduct joint naval training exercises. Today, the American Psychological unanswered: How does psychotherapy work? Association has 137,000 members. Licenses are required to practice condition being treated. For this for achieving change, the therapeutic independently as a psychologist group, randomised clinical trials relationship is most often cited as one, in every state. Over 800,000 (RCTs) are the principal means of if not the most potent transtheoretical professionals are able to bill third investigation, the fndings of which are ingredient of psychotherapy (Bachelor party payers for mental health used to generate treatment guidelines, & Horvath, 1999; Grencavage & services (Brown & Minami, 2010). manuals, and lists of ‘empirically Norcross, 1990; Norcross, 2010). Tree Te Substance Abuse and Mental supported’ or ‘validated’ therapies converging lines of research are cited Health Service Administration’s (e.g., Barlow, 2004; Chambless & in support of these nonspecifc factors (SAMHSA) website lists 145 Hollon, 1998). Tey contend that for as the most signifcant independent manualised treatments for 51 of the psychotherapy to advance as a science, variables responsible for client 365 mental disorders now contained psychologists must operationalise change: (1) the absence of diferential in the DSM. Tis volume, in its ffth falsifable hypotheses using specifc efectiveness when specifc approaches edition, has reached an astonishing methods (discrete independent are directly compared and when 947 pages. Many psychologists, variables), test those hypotheses, and researcher allegiance and other biasing including the APA president, are teach students those methods that variables are controlled (Wampold, calling for the abandonment of the stand up to rigour and replication 2001); (2) dismantling studies which DSM and transition to the World (Gambrill, 1990; Zurif, 1985). Te show that the contribution of specifc Health Organization’s International critical argument supporting this techniques to treatment outcome is Classifcation of Diseases (Bradshaw, approach is that diferent therapies are negligible (Duncan et al., 2010); and 2012; Clay, 2012). diferentially efective, and specifc (3) research showing consistently Te principle disagreement between therapies are more efective than greater variance in outcomes between Strupp and Eysenck recorded in the nonspecifc treatment-as-usual (TAU). psychotherapists in a given study frst volume of Psychotherapy has been Exponents for the other side insist than between the types of therapy resolved. Not only is the efcacy of that any suggestion psychotherapy is they are practicing (Bemish, Imel, psychotherapy well established, but so comparable to a medical intervention & Wampold, 2008; Beutler et al., is its efectiveness in real world clinical is grossly inaccurate (Frank & Frank, 2004; Crits-Christoph & Mintz, settings (American Psychological Association, 2012; Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001). Despite the consistent fndings substantiating the feld’s worth, a signifcant question remains unanswered: How does psychotherapy work? In Strupp’s words (1963, p. 2), the feld would ‘not be satisfied with studies of therapeutic outcomes until [it] succeed[ed] in becoming more explicit about the independent variable’ — in particular, the contributions made by the client, the therapist, the treatment method, and commerce between the participants. Here, debate continues to divide the profession. Gathered on one side are those who Illustration: © IStock, Getty Images, 2014. PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 65 1991; Crits-Christoph et al., 1991; understandable. Economic pressures that 90% of states were implementing Imel, Wampold, Miller, & Fleming, on practitioners are powerful and real. strategies to support the use of 2008; Kim, Wampold, & Bolt, 2006; Without a doubt, debate does not put ‘evidence-based practices’ (EBPs). Luborksy et al., 1986; Lutz, Leon, food on the table. With few exceptions, such eforts have Martinovich, Lyons, & Stiles, 2007; For all that, an equally passionate equated EBP with lists of specifc Okiishi, Lambert, Eggett, Nielsen, & call comes from the other side. treatments for specifc disorders (e.g., Dayton, 2006; Shapiro, Firth-Cozens, ‘Te medicalisation of psychotherapy’, Addiction and Mental Health Services, & Stiles, 1989; Wampold & Bolt, Wampold (2001, p. 2) protests, ‘might 2011). In turn, reimbursement has 2006; Wampold, Mondin, Moody, & well destroy talk therapy as a beneficial been made contingent on an adherence Ahn, 1997). treatment of psychological and social to ofcially sanctioned therapies. At Te failure to reach agreement problems’. On the face of it, the premise present, one looks in vain