What Is New in Psychotherapy and Counseling in the Last 10 Years?

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What Is New in Psychotherapy and Counseling in the Last 10 Years?

Samuel Knapp, Ed. D., ABPP

John Gavazzi, Psy.D., ABPP

October 2016

Preface

This document is the basis for a three-hour home study that can be taken as a stand-alone course or as a pre-course for the live CE program with a similar title. The goal of this course is to help psychologist keep up-to-date on changes in the field of psychotherapy and counseling. It contains 100 statements clustered into seven categories, each of which has implications for the quality of services that psychotherapists deliver. Specifically, psychologists will have better outcomes if they are better consumers of psychological research, know the latest research on patient and psychotherapist factors related to outcome, appreciate how diversity impacts patient outcomes, develop accommodations based on changing patient needs; understand the latest research on psychotherapy outcomes, appreciate the importance of emerging ethical issues and new ways to approach ethical problems. And keep informed of developments related to skill acquisition and continued professional development.

Table of Contents

Introduction

Scientific Basis of Our Profession3

Research on Psychotherapy Process and Outcomes6

Issues Related to Diversity17

Social and Cultural Change21

Changing Evidence Base for Particular Treatments29

Ethics and Risk Management41

Education45

References49

Continuing Education Questions62

Answer Sheet72

Introduction

Neimeyer et al. (2012b) estimated that the half-life for a professional psychologist is nine years and will soon decline to seven years, although the half-life varies across specialty. Professional psychologists need to work assiduously to keep up to date with the changes in the field. This continuing education program strives to do that by having psychologists reflect on the most significant changes in the field of psychotherapy in the last 10 years.

To facilitate this reflection, Samuel Knapp and John Gavazzi present their review of significant developments in the psychotherapy and counseling literature in the last 10 years in the form of 100 statements. This document is neither definitive nor final, but is the basis for more discussion and participant input. Participants will have the opportunity to add their own perceptions on the importance of these developments. This document focuses on changes in psychotherapy alone and does not consider changes in assessment, forensic services, coaching, or other fields of psychology, except as they influence psychotherapy.

Participants should keep several factors in mind:

1. Individual psychologists will select different developments as significant, in part, because they work within specific subfields within the broader fields of psychotherapy or counseling, have different areas of interest, havedifferent theoretical orientations, or are exposed to different sources of information.

1. The 10-year time framefor this review is flexible. What is “new” is a subjective decision. For example, we identify the rise of Motivational Interviewing as new. Although the technique dates back to at least 1991, we opine that its use and the evidence supporting its efficacy has increased in the last 10 years.Because we include the increased validation of older concepts, there may be times that we include something as new that the reader had “known all along” or thought was common knowledge.

Also, some concepts get recycled. They go “out of fashion” and then new research invigorates them again. Some of the new information involves further validation of concepts or controversies that have been around for many years.

1. Although the focus is on psychotherapy and counseling, it is sometimes difficult to separate an advancement in psychotherapy/counselingfrom an advancement in another related field of psychology (or another discipline).

4. Remember the old adage, “the map is not the territory.” This document is not the territory; nor does it even purport to be the map. It is only a fragment of the map that needs your help to complete.

In conclusion: we:(1) do not have a list that is universal for all participants; we expect participants to vary in what is useful for them;(2) do not get too hung up looking for something exactly within the last 10 years or exactly within the field of psychotherapy and counseling; and (3) have generated this list to help stimulate discussion among workshop participants (although we learned something ourselves compiling this document). This is an evolving document that can be revised and updated as new perspectives and information come to light.

We have divided this document into seven different categories: the scientific basis of our profession, research on psychotherapy outcomes, research on diversity, social and cultural changes, evidence concerning the effectiveness of specific treatments, ethics and risk management, and education. We developed this document without expecting any specific number of statements. However, as we completed this version we found that the number of statements approached 100. Of course we realize that other readers may want to split up some of the statements into two or three separate statements, or that other readers may wish to combine certain statements.

One Hundred Statements on What Is New in Psychotherapy and Counseling

in the Last Ten Years

1. Scientific Basis of Our Profession

Statement One: Much of what we “know” to be true in mental health treatment (including outcomes for pharmacology or psychotherapy) may not be true or has been inadequately qualified.

Many reported treatment effects in health care, including psychotherapy and pharmacology, are based on small sample sizes or have other methodological features that allow a high risk of false positives. Much of what we assume to be research based and accurate may not be so, or may be so under conditions more limited than what we currently believe.

Concerns about the accuracy of published data are not unique to psychology. All fields of research have the same issues. In the field of psychiatric research, the methodological problems associated with drug studies are so substantial that some researchers have questioned the efficacy of many commonly used psychotropic medications.Ioannides et al. (2013) estimated that perhaps one half of the purported significant effects of drugs may be inaccurate. For example, a closer look at the research methodology suggest that antidepressant medications may have a greater placebo effect than once believed (Kirsch, 2014).

The Center for Open Science sought to determine how much of the science of psychology could withstand replication. They coordinated replication studies of100 published findings and found that less than one half of the replication studies confirmed the positive results found in the original study (for p values it was 36% of the replicated studies; for effect size, 47% of the replicated studies; Open Science Collaboration, 2015). The rate of successful replications was lower in social psychology journals and higher in cognitive psychology journals. None of these studies subject to replication dealt with the treatment of mental illness. Nonetheless, the methodological issues raised could apply there as well.

In spite of these problems with replication, psychologists need to continue to review, evaluate, and utilize current research in psychotherapy and other fields (e.g., behavioral economics) because it enhances their ability to provide high quality psychological services. We need to remain cognizant that no study is perfect; but simultaneously, we need to remain current as to what the preponderance of the research supports.

Statement Two: Efforts to reduce inaccurate or misleading findings include changing the statistics used in studies, replicating previous studies, publishing studies that did not find significance, encouraging the sharing of data sets, and interpreting results with cultural factors in mind.

How to Reduce the rate of false-positive findings?

1. Pre-register studies so that file drawer problem is minimized and researchers cannot go data mining (“p-hacking”) or expand the sample size with the goal of getting results simply to get their research published. Psychologists need to look critically at articles which conduct multiple statistical tests to investigate an issue. Unless these tests are chosen to evaluate a predesignated hypothesis, they increase the likelihood of false positives.

2. Have editors give more priority to good studies that do not find significance. Driessen et al. (2015) found that the effect size for anti-depressant medication and psychological treatments decreased by 25% when they have added unpublished studies to their meta-analyses.

3. Encourage or require researchers to share their data. Ebrahim et al. (2014) found that the re-analyses of data from medical studies sometimes led to changes in the direction of the findings and the interpretation of the data.

4. Use different statistics and report effect sizes. Gaasedelen (2016) notes that “a significant treatment effect found for the sample as a whole does not mean the observed effect can generalize across each individual member of the sample or population” (p. 192). He noted that the “improper use of statistics can have deleterious consequences” (p. 196).

5. Consider Cultural Factors. What was learned in studies with WEIRD research participants (Western, educated, industrialized, rich, and democratic) may not generalize to other non-Western cultures (or even to subcultures within Western democracies; Henrich, Heine, & Norenzayan, 2010). Researchers need to consider cultural values and norms in conducting and evaluating research findings.

For example, recent attention has focused on tiger parenting (Chinese parenting style emphasizing parental criticism and demanding strict obedience). American children are more likely to thrive when their parents adopt an authoritative parenting approach and do poorly under authoritarian parenting. Some data suggest that Chinese or Chinese-Americans do the same (Kim et al. 2013). That is to say, tiger parenting is not very effective for raising healthy children in Chinese or Chinese-American families. But the elements of Chinese or Chinese-American parenting includes some elements nuances of parenting that are not captured by traditional Western notions of authoritative parenting.

6. Asymmetric Attention: This bias occurs when a researcher gives a free pass to expected results of a study while rigorously checking unexpected results. In order to decrease bias, researchers need to rigorously check both positive and negative results.

1. Explicitly consider alternative hypotheses. In most research, investigators will test to see if their data matches the proposed hypotheses of the study. However, rather than just gathering data to prove or disprove a hypothesis, it may be more helpful to test one hypothesis against a competing hypothesis directly.

8. Team of rivals. As a rule of thumb, research completed by authors from different theoretical camps may be more valid and reliable because it reduces the likelihood of groupthink. A team from different theoretical orientations or different fields will likely generate hypotheses, results, and conclusions that better reflect reality.

Statement Three: Although the amount of research fraud (at least in psychology) probably has not increased, there are new procedures for detecting it; the amount of detected fraud in scientific research has increased in recent years.

The ability of researchers to identify fraud (statistical techniques can determine which outcomes are high unlikely to occur by chance) has improved in recent years, although there is no evidence that the frequency of fraud is increasing (Steen, 2011). Retractions are important, but once a study gets published, it tends to take on a life of its own and gets cited and referenced in future work. Retractionwatch.com is a web site dedicated to monitoring and publishing scientific retractions.

What Are Practical Implications for Professional Psychologists?

As informed consumers of psychotherapy and medical research, psychologistsneed to show appropriate sophistication when reading articles by looking at sample size, effect size, and practical significance (as well as statistical significance). Reading the research sometimes entails more than reading the abstract, the introduction, and the discussion sections of a scientific paper.

II. Research on Psychotherapy Process and Outcomes

Statement Four: Many researchers recognize the limits of research studies that only pit a treatment from one theoretical orientation against another.

Dissatisfaction with the culture wars (“my theoretical orientation is better than your theoretical orientation”) in psychotherapy is growing because: outcomes of different orientations are often similar or highly similar; common factors account for a large portion of patient variance; and the actual behavior of individuals in therapy is often highly similar, despite self-reported differences in theoretical orientation. Furthermore, controlled outcomes studies, once considered the gold standard for research, need to be supplemented with process studies (looking at what works), and well controlled N=1 or case studies (Wampold, 2015).

The old debate was between relationships versus techniques. “Contrary to this artificial dichotomy between the treatment and the relationship, research suggests that the client, therapist, relationship, and treatment method all contribute to treatment success and failure” (Markin, 2014, p. 328)

Although many psychotherapists claim to be integrative, there is danger in haphazard integration if it involves using techniques that are incompatible with the philosophy or style that the therapist has already established (Boswell, 2015).

It is not always clear that what is being delivered in the real world is actually the evidence based therapy developed in research studies. The self-identified theoretical orientation of the psychotherapist might not accurately predict what the patient actually receives (Waltman & Williston, 2015).

Statement Five: An emphasis on transdiagnostic symptoms is growing.

Various researchers are promoting transdiagnostic symptoms and treatment protocols. There has been a proliferation of treatment techniques that are often highly similar. A goal has been to look for change principles “that cut across theoretical orientation and diagnostic categories” (Boswell, 2013, p. 381).

One of the elements of the Unified Protocol is to “reduce emotion avoidance, improve emotion tolerance, and promote more adaptive responses to strong emotions” (Boswell, 2015, p. 40). Some patients have introceptivesensitivity(awareness of internal physical states) that is too easily triggered or misinterpreted. Self-criticism is another such transdiagnostic problem (Schanche, 2013). One of the transdiagnostic treatments is mindfulness (Dunn et al., 2013) which can improve awareness, reduce self-criticism, and reduce rumination.

Beutleret al. (2013) looked at specific principles of change as opposed to theoretical modalities per se. Some of the important principles of change include facilitating a treatment relationship (such as through acknowledgement, reflection or reassurance), developing a treatment contract, or modifying treatment to the unique characteristics of each patient (see

Statement Six: Therapist effectiveness is unrelated to experience, gender, age, or education level (among licensed professionals).

Therapist effects appear unrelated to years of experience, gender, age, profession, or higher qualifications (Chow et al., 2015). Psychologists need to be able to more accurately assess their effectiveness to provide high quality services. Among other factors this requires controlling for biases that impede our ability to assess outcomes accurately.

Statement Seven: Some therapists are better than others, but even the best therapist vary in their areas of strength.

Some therapists are better than others (the very good ones are called supershrinks). Even so, therapist effectiveness may vary greatly across specific domains and not be a general quality that cuts across all patients and diagnoses (Kraus et al., 2011). No therapist was considered highly competent in all 16 domains measured, although some therapists consistently had better outcomes than others.

Supershrinks tend to be good at developing collaborative treatment relationships, have a repertoire of strategies that they can use effectively,monitor patient progress (Wampold, 2009), work hard, and are hypervigilant to threats to good outcomes (Robinson, 2009).

Therapist effectiveness is likely to improve when the therapists (a) establish a baseline of performance; (b) get feedback on how they are doing; and (c) engage in deliberate practice (Chow et al., 2015). The factors related to outcome include “the amount of time spent targeted at improving therapeutic skills” (Chow et al., 2015, p. 337).

StatementEight: Psychotherapists are vulnerable to the “better-than-average” effect.

Walfish et al. (2012) found a “better-than-average” effect for mental health professionals. They found 25% of those surveyed rated themselves in the top 10% of competence. None rated themselves in the bottom 50%. They gave themselves a mean ranking at the 80th percentile and their modal ranking was 75th percentile. Those survey estimated, on the average, that 3.6% of their patients deteriorated during treatment. However, this rate was well below the 5 to 10% rate of expected rate of deterioration found in a more objective review (Castonguay, Boswell et al., 2010).

Davis et al. (2006) found similar better-than-average effects for physicians. Some physicians, especially at the lower levels of competence, had greatly overestimated their abilities.

StatementNine: Overconfidence can reduce receptiveness to feedback; a certain amount of humility appears helpful.

Younggren (2007) warned against professional narcissism or the tendency to over-value one’s expertise and knowledge. This trait can impair the quality of service that a psychologist offers. Alexander et al. (2010) found that physicians who rated higher in narcissism were less receptive to productive feedback.

In contrast, to professional narcissism, Nissen-Lie and Ronnestad (2016) claim that humility is an essential ingredient of highly effective psychotherapists. Humility refers to recognition of one’s limitations and healthy self-doubt. Their study showed that psychotherapists who showed humility (combined with self-love and self-tolerance) tended to have better patient outcomes. Perhaps one important ingredient is the willingness to accept feedback. They quote Kierkegaard, “to help is not to dominate, but to serve.”

Miller (2015) cited research by Chow (2014) who reported that the most effective therapists are sometimes “surprised” by patient feedback, indicating a willingness to be open to new ideas; and Hans Strupp’s Vanderbilt study, which found that the more effective psychotherapists acknowledged making more mistakes than other psychotherapists.

StatementsTen: Psychotherapists and other health care professionals may be vulnerable to thinking errors that limit their effectiveness.

Psychologists are vulnerable to the same types of cognitive thinking errors as laypersons (and physicians), thus risking a compromise to their quality of care (Groopman, 2007; Rogerson et al., 2011). These cognitive biases include the availability heuristic, confirmation bias, trait negativity bias, the actor-observer bias, and the fundamental attribution error among other processes. Sanders (2009) found that a most common source of error by physicians in a hospital was confirmation bias.