Evaluating Various Forms of Psychotherapy and Common Factors

Given that there are so many different types of therapies available today, how does a client decide what type of therapist to approach? One consideration is that some forms of therapy were created by a particular psychologist or psychiatrist and thus may be more restricted by where the psychologist (and others they train) live such as their country or region within a country. For instance, interpersonal psychotherapy (IPT), which focuses on coping with or improving relationships, dealing with grief, life transitions such as retirement or divorce, and resolving conflict with others, has been found to be effective in treating depression and other mood disorders. However, most practitioners of interpersonal psychotherapy (IPT) are on the east coast of the United States since this form of therapy began there and many who have been trained in it live in that part of the country. This limited access may change over time as more clinicians are trained and with increased use of online training programs. Another consideration is the effectiveness of the therapy for the mental disorder the client struggles with. Is one technique more effective than another? According to the American Psychological Association, three factors work together to produce successful treatment. The first is the use of evidence-based treatment that is deemed appropriate for the client’s particular issues. The second important factor is the clinical expertise of the psychologist or therapist in treating the relevant disorder(s) and how well they are trained in the form of therapy. The third factor is the client’s characteristics, values, preferences, and culture and if the client feels comfortable and understood. Many people begin psychotherapy feeling like their problem will never be resolved; however, psychotherapy helps people see that there are steps they can take to make their situation better.

Figure 1. Therapy comes in many different forms and settings, but one critical factor in its success is the relationship between the therapist and client.

Many studies have explored the effectiveness of psychotherapy. For example, one large-scale study that examined 16 meta-analyses (large-scale summary studies of multiple single study results) of CBT reported that it was equally effective or more effective than other therapies in treating PTSD, generalized anxiety disorder, depression, and social anxiety disorder (Butlera, Chapmanb, Formanc, & Becka, 2006). Another study found that CBT was as effective at treating depression (43% success rate) as prescription medication (50% success rate) compared to the placebo rate of 25% (DeRubeis et al., 2005). Another meta-analysis found that psychodynamic therapy was also as effective at treating these types of psychological issues as CBT (Shedler, 2010). However, no studies have consistently found one psychotherapeutic approach more effective than another (Abbass, Kisely, & Kroenke, 2006; Chorpita et al., 2011) across all conditions, nor have they shown any relationship between a client’s treatment outcome and the level of the clinician’s training or experience (Wampold, 2007).

Advocates of this position emphasize a set of common therapeutic factors that produce beneficial outcomes regardless of the model of therapy used. For example, one critical factor that determines the success of treatment is a person’s trusting relationship with the psychologist or therapist (Figure 1). Other key common factors include the following^[1]:

• client factors (making connections with already occurring change patterns in the client’s life, making therapy relevant to the client’s world outside of the therapy session)
• hope and expectancy (enhancing hope and decreasing hopelessness, focusing on realistic interventions, and orienting the client and therapy towards the future)
• novel methods (the therapist provides effective methods that give the client more structure and that offer the client new approaches and new ways to think and behave that address their major concerns)

David Burns (2017), a psychiatrist who popularized and expanded CBT and worked with Aaron Beck, published a recent blog where he points out that when potential bias (or favoritism) from researchers conducting comparative studies is taken into account, most of the different forms of psychotherapy produce approximately similar results. For example, he notes that in studies comparing different treatments for depression, patients who received CBT showed improvement in depression and reduced distortions in their thinking, but so did clients who were treated using other forms of therapy or who received medications. The same was true for other forms of therapy; for example, patients receiving IPT showed improved relationships and decreased conflict with others, but this was also true for other patients who improved even though they had been treated using other interventions. In other words, despite the theory or model of the treatment involved, there were few, if any, specific effects despite the theory’s predictions. Burns (2017) concludes that the etiology of mental disorders is highly complex and there is still much we do not know; the different forms of psychotherapy have substantial evidence that they can help with most mental disorders, mostly likely due to common factors.^[2]

Eclectic and Integrative Therapies

Most clinicians in graduate school are trained in a specific form of psychotherapy that they naturally use over time. As they help more clients and engage in continuing education in their field, they are often exposed to other approaches and other methods. It is fairly common that many of them, while they continue with the core treatment they were trained in, begin to use techniques and methods from other forms of psychotherapy, perhaps to treat specific symptoms or when one of their usual methods may not work well with a given client. This is often done without necessarily accepting or committing to the theory or model of the technique being used. This is usually referred to as “eclectic” psychotherapy (eclectic meaning taking ideas from a broad range of sources). An eclectic psychotherapist may use one mode of treatment for one patient and a different one for another patient. Technical eclecticism is the specific and intentional use of different psychotherapy techniques and methods, seeking to match the client’s unique struggles and background with treatments that have been shown to be effective in that context.^[3] The difficulty with this approach is gaining sufficient training and experience to be effective at using the different methods.

Prochaska and Norcross (2018) describe another approach called theoretical integration. In contrast to technical eclecticism, clinicians using this approach actually blend two or more models of therapy, both theory and techniques, in an attempt to find a more effective approach to helping clients. Among other elements, Prochaska and Norcross (2018) describe eclecticism as “technical . . . choosing from many . . . and applying the parts” while theoretical integration is “theoretical . . . combining many . . . and unifying the parts.”^[4] Prochaska and Norcross (2018) also describe their own approach called transtheoretical therapy, which is grounded in the transtheoretical model, a theory about how people change over time and adopt new behaviors; their model of therapy promotes the use of change techniques from most major forms of therapy at specific points, depending upon the person’s stage of readiness to change.

In one sense, CBT is a broad-scale example of theoretical integration because the underlying model of cognitive therapy includes the relationship between dysfunctional thoughts and behaviors and accepts the role of classical, operant, and observational learning in psychopathology.  Here are a couple of other examples:

• Psychodynamic-behavior therapy, created by Paul Wachtel, while still emphasizing the important role of early childhood experiences, argues that these early personality patterns are not fixated, are visible in interpersonal relationships in the present, and can be changed by both helping people recognize these underlying dynamics and modifying how they live in the present using behavioral methods. Prochaska and Norcross (2018) quote Wachtel:  “fundamental personality change requires fundamental change in how we handle the events of our daily lives.”^[5]
• David Burns (2017), mentioned above, created an integrated form of therapy called TEAM CBT. TEAM stands for Testing (regular, ongoing assessment of both client symptoms and the strength of the therapeutic relationship), Empathy (a heavy emphasis on humanistic acceptance of the client and acceptance of client free will and choice), Agenda Setting (accepting and looking for client resistance to change, addressing it, and building an agenda for change priorities with the client), and Methods (which include a wide range of techniques from CBT, motivational interviewing, Gestalt therapy, interpersonal aspects, relapse prevention and more, selected in collaboration with the client). This therapy is almost a blend of technical eclecticism with theoretical integration built on the foundation of common factors found to be effective across different therapies.^[6]

While medical treatments for mental disorders are often seen as incompatible or opposed to psychotherapy, there are various situations where medications and therapy are used simultaneously, often referred to as combination therapy; this term is also used to describe situations where physicians or psychiatrists prescribe several different medications in a patient’s treatment. In a study of data from 3100 physicians, Cascade, Kalali, and Blier (2007)^[7] found that in treating depression, physicians tended to use only one antidepressant in treating depression, but used combination therapy with other drugs if they believed the patient’s symptoms were more severe. Psychiatrists were four times more likely to use antidepressant combinations than primary care physicians. These authors also noted that in real-world practice, only one-third of patients with depression achieved remission after sufficient treatment with a single antidepressant and that in other fields of medicine, use of multiple treatment medications is common. A drawback of combined medical treatments for mental disorders is the cost of multiple treatments, but if these treatments prevent hospitalization or suicide attempts, it would be considered cost-effective. Sammons and McGuinness (2015),^[8] two prescribing psychologists, note that most patients with mental health problems receive only medications, although they prefer psychotherapy alone or in combination with medications. They also note that there are patients who do not respond to medication alone and also patients who do not respond to psychotherapy alone; for these patients, combined treatment that involves both psychotherapy and medication tends to result in improved outcomes and reduced costs, mostly due to decreased need for healthcare utilization in the future versus those who only achieve partial remission.

For patients with certain disorders, especially those with a greater biological contribution to the etiology such as bipolar disorder or schizophrenia, combination therapy has been a common aspect of practice for some time. The medications are used to address significant symptoms that do not respond well to therapy such as mania or hallucinations or delusions, but psychotherapy is often very helpful in addressing psychosocial needs (such as improving relationships with others, developing self-care or communication skills, etc.), reducing stress to improve treatment outcomes, increasing self-acceptance and the need for treatment, and learning skills to help them prepare for release or living on their own. Most inpatient units and usually residential treatment units serving patients like this often involve them in a psychotherapeutic environment called psychosocial rehabilitation where they learn practical skills in communication, assertiveness, self-care, managing finances, and more, often using forms of CBT.