Research in Psychotherapy

Robin Fox

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351493383
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Research in Psychotherapy is a comprehensive synthesis and assessment of the psychotherapeutic research literature for the use of both researchers and those in clinical practice. It is designed as a general reference work, an instruction guide, and a source of information about specific aspects and problems of research.

The book consists of three parts. Part 1 discusses principles and methods of research as they are applied to psychotherapy. It provides general background material and principles to help non-researchers appreciate some of the important problems that are encountered. In Part 2, existing research on the effects of psychotherapy and the determinants and correlates of outcome are clustered and reviewed. Chapters 4 to 7 are concerned strictly with a review and appraisal of controlled studies that were designed to evaluate the effects of psychotherapy. Chapters 8 to 13 deal with a large body of research on various factors associated with therapeutic outcome--method, style, and technique variables; patient, therapist, and time variables. Part 3 is concerned with research on aspects of the therapeutic process and on the effect of many of these same variables on the therapeutic interchange as distinct from the outcome of therapy. Also discussed is research on various therapeutic phenomena and conditions about which so much has been written and so little really known.

Research in Psychotherapy was written in the conviction that clinical practice should be influenced by research and that rigorous research that meets acceptable experimental standards can be done on the field of psychotherapy.

PART II

RESEARCH ON THE EFFECTS OF PSYCHOTHERAPY

Our little systems have their day.

—tennyson, “In Memoriam”

Most of the change we think we see in life Is due to truths being in and out of favor.

—robert frost, “The Black Cottage”

Healing is a matter of time, but it is sometimes also a matter of opportunity.

—hippocrates, Precepts

3

The Effects of Psychotherapy

The dialogue between the psychotherapist and the researcher has been repeated so often that it has become stereotyped. Any therapist who has talked to a researcher, any researcher who has talked to a therapist, or any therapist-researcher who has talked to himself has probably been through it at one time or another. The therapist claims that therapy is effective because his experience tells him so, and he proceeds to describe a case. The researcher wryly observes that barber-bloodletters were just as convinced of the efficacy of venesection and were, no doubt, as adept at citing successful cases. The therapist lets this go by, or interprets it, and goes on to contend that human personality and psychotherapy are so complex and multidimensional that they cannot be evaluated by experiments. The researcher counters that if therapy can alter the complex interlocking network that constitutes personality, positive changes in some of its components or in some global measure of change should be observable and measurable. The therapist insists that the really important things cannot be measured, that one cannot meaningfully translate warm feelings into cold numbers. The dialogue continues in this vein or descends to a more heated exchange. The researcher calls the therapist resistant because psychotherapy has grown as a craft, with its legend and lore, at a more rapid pace than it has as a science. Its spiritual godfathers were witchcraft, voodoo, and other occult and mysterious processes, and its latter-day saints were writers and philosophers rather than scientists. The therapist refers to the researcher as a nihilistic devil’s advocate whose resistant attitudes obviously stem from his pathological psychodynamics. At the end, neither of the two is much shaken in his faith.

Any practicing psychotherapist who is convinced of the efficacy of his work should welcome its assessment. Systematic appraisal, however, is looked upon with suspicion by many therapists who see it as a process designed to negate and disprove rather than to uncover and establish the facts. The therapeutic literature abounds in testimonials illustrated by carefully selected, wondrous case reports that boggle the eye and captivate the imagination. Every once in a while, an elder statesman recommends caution, expresses reservations, and calls for evaluation. This may be followed by introspection and ritual cleansing by public confession and analysis of a few failures.

New therapeutic approaches typically generate tremendous initial enthusiasm and attract loyal cohorts. Ardor, fervor, and conviction are mighty lieutenants in the missionary cause. Clinicians who are short on tools and long on difficult problem cases make good converts. Case reports that sound terribly convincing are presented and followed by a survey of a successful series of cases. The hard second look is generally not so optimistic. By the time the controlled research is done (if ever), the therapeutic sun may have already set behind the clinical horizon, replaced by the ascendance of a bright new one.

For example, Rosen (1947) stirred great interest by a report of 100 per cent success in a series of thirty-seven psychotic patients treated by his method of direct analysis. Several years later, he averred that thirty-one were still nonpsychotic and progressing well (Rosen, 1953). These cases were subjected to follow-up by other investigators six years after Rosen’s follow-up (Horwitz, Polatin, Kolb, & Hoch, 1958). They were able to locate only nineteen of the original patients for study. They report that the initial diagnosis was schizophrenia in only twelve of the nineteen cases and that six of the remaining seven were psychoneurotic. Following direct analysis, ten of the patients had somatic therapies, four had psychotherapy of other kinds, four continued direct analysis, and one had no therapy. The course of the group of seven nonschizophrenics was what one would “ordinarily expect in a ten-year survey.” It was variable but did not involve repeated hospital admissions. The schizophrenics presented a different picture. The authors maintain that by the time Rosen’s original report was published, five had already been rehospitalized. Nine of the patients had from two to five admissions and two had undergone psychosurgery. More than half were treated with electroshock, insulin coma, psychotherapy, and chemotherapy. They concluded that direct analysis had failed to lead to a sustained therapeutic result and that the outcome was in line with the usual course of untreated schizophrenic patients. Of course, it is possible, though unlikely, that the eighteen missing cases were startling successes. What this does for us is to point up the limited value of presenting case series in any context other than that of controlled research, objective criteria, and adequate follow-up.

More often than not, surveys have been retrospective in nature. They consist of tabulations of judgments of success and failure, either dichotomized or scaled to reflect the degree of improvement, and are summarized in a percentage of improvement. In most surveys, there is no way of knowing what such terms as “recovered,” “much improved,” and “slightly improved” mean. There is little constancy in the meaning of these terms from survey to survey. The original data is poor because it usually relies exclusively on the subjective judgment of the therapist or that of the researcher, who depends on case records written by the therapist. The errors are then compounded by a reviewer (see Eysenck, 1952, 1960, 1965; Levitt, 1957a) who takes the improvement percentages (which may be grossly inaccurate to start with) from diverse sources and averages them to arrive at a total estimate of outcome regarded as authoritative because it is based upon so many thousands of cases. The size of the N in such an amalgamation is bound to be impressive but contributes not at all to the validity of the information.

Examination of a large number of surveys convinces us that this kind of study is a blind alley. We could present an exhaustive list of the hundreds of surveys that have been published, but we feel that it would only serve to obfuscate the issues. There is no proof at all that whatever change took place was attributable to psychotherapy. These surveys, in the aggregate, form a vast swamp in which a reviewer could get lost forever. These studies cannot be compared with one another, they cannot be reproduced, they cannot be interpreted, and above all they cannot be averaged. The wisest course is to bypass them entirely.

In derogating the utility of surveys and surveys of surveys for the purpose of evaluating the effects of psychotherapy, we do not mean to imply that they serve no other purpose. The natural progression of appraisal is the selected case presentation, the case survey with gross subjective criteria, the uncontrolled but more objective outcome survey, and finally the controlled experiment. A phenomenon is observed and reported. A series of similar observations is systematically recorded. This is repeated with more careful measurements and the introduction of procedures to reduce error and bias, finally leading up to a rigorous study with appropriate controls. The earlier efforts are, in a sense, pilot studies and necessary preliminary steps before the complex task of designing and conducting controlled research.

There have been many basically adequate researches, designed systematically to measure the effects of psychotherapy on a treated group without bias, with careful before and after measures. However, they have lacked a control group. These studies leave us in limbo, not knowing whether or not the patients would have gotten as much better or worse, as the case may be, without treatment. They leave each reader to form his private opiriion in accordance with his own predilections. The authors of these studies are usually well aware of the limitations of their studies and tell us that, for whatever reason, it was not possible to obtain a control group. Having acknowledged the need for controls and their inability to obtain them, many proceed to interpret their results as if they had them. Cappon (1964), for example, in about as honest a self-appraisal of one’s therapeutic work as is possible, stated that he was not trying to prove that the results were due to therapy. The title of his paper, however, was “Results of Psychotherapy.” Once having gone on record that the results of psychotherapy were not necessarily the results of psychotherapy, he stated that he had no “obsessive preoccupation” with controls as the “sine qua non dictate of science.” Having thus excused himself from meeting minimal requirements, he proceeded to express the opinion that the favorable results were indeed due to psychotherapy. The use of controls is simply a method for reducing reasonable doubts to a minimum. They are one of a researcher’s occupational tools, not a preoccupational obsession.

Dittman (1966) observed, “To this reviewer the controlled study certainly yields results that can be counted on, but is not the only road to the ‘truth.’ The large studies which came out of the Veterans Administration during the year, with data collected in such a way that internal comparisons by length of treatment, diagnosis, and the like, can be made, cannot be dismissed simply because there was no control group for comparison” (p. 58). To date, we have not come across any other road to truth that can be counted on. The excellent studies referred to are not to be dismissed since they did answer the questions that they were designed to answer. They were not meant to be evaluations of the effectiveness of therapy, however, and cannot be used as such.

The control problem has led to a search for a baseline of exp...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• PREFACE AND ACKNOWLEDGMENTS,
• INTRODUCTION,
• I. PRINCIPLES AND METHODS OF RESEARCH IN PSYCHOTHERAPY
• II. RESEARCH ON THE EFFECTS OF PSYCHOTHERAPY