by Michael D. Anestis, M.S.
This morning, I came across an interesting article published in the most recent issue of the Journal of Clinical Psychology. The article was written by Joshua Swift of the University of Alaska Anchorage and Jennifer Callahan of the University of North Texas and it's central purpose was to determine the extent to which a client coming in for therapy values common factors (e.g., therapeutic alliance) more or less than the scientific evidence supporting the effectiveness and efficacy of a particular form of therapy (e.g., what percentage of clients with a particular diagnosis tend to recover as a result of this specific form of therapy?).
A total of 57 clients from a university-based psychology clinic filled out a series of questionnaires prior to the onset of treatment indicating the degree to which they value particular aspects of therapy. Specifically, they were asked to indicate whether they would prefer a form of treatment with scientific evidence supporting it's efficacy (70% recovery rate) that lacks a particular common factor (e.g., strong therapeutic alliance) or a treatment with varying levels of support (ranging form 10% to 70% recovery rate) that promises high levels of that same common factor. As an example, a client may have been asked to indicate their preference for each of the following options:
****
70% recovery rate/weak therapeutic alliance vs 10% recovery rate/strong therapeutic alliance
70% recovery rate/weak therapeutic alliance vs 20% recovery rate/strong therapeutic alliance
70% recovery rate/weak therapeutic alliance vs 30% recovery rate/strong therapeutic alliance
70% recovery rate/weak therapeutic alliance vs 40% recovery rate/strong therapeutic alliance
70% recovery rate/weak therapeutic alliance vs 50% recovery rate/strong therapeutic alliance
70% recovery rate/weak therapeutic alliance vs 60% recovery rate/strong therapeutic alliance
70% recovery rate/weak therapeutic alliance vs 70% recovery rate/strong therapeutic alliance
****
The idea here is to determine to what extent evidence is valued by a client prior to treatment relative to other factors that they might believe are more important. In this particular study, the authors examined the importance of four common factors:
- Therapeutic alliance
- Interpersonal responses of the therapist
- Therapist level of experience
- The degree to which the client determined the direction of therapy sessions
What they found was that the client would accept a treatment with a 38.14% lower recovery rate in order to have a stronger therapeutic alliance; a treatment with a 48.54% lower recovery rate to ensure that the therapist is warm, empathic, and accepting; a treatment with a 25.77% lower recovery rate to ensure a therapist with greater amounts of education and professional experience; and a treatment with a 34.71% lower recovery rate in order to ensure that they would do more of the talking during therapy sessions. In other words, clients were willing to accept a treatment that does not work nearly as often in order to attain other things that are important to them.
The authors looked at these numbers and concluded that it might not make sense to always start with the treatment with the greatest level of empirical support, as clients appear not to weigh effectiveness very highly and, as such, might drop out of treatment prematurely given the absence of other factors. That is certainly one way to look at these numbers, but I, perhaps not surprisingly given the focus on this site, have a very different view:
First of all, implicit in the question asked in this study is the idea that scientifically supported treatments are lacking with respect to common factors. In other words, it makes it sound as though choosing the evidence-based treatment means choosing a less experienced, less empathic therapist you won't enjoy working with and who will talk at you the entire time you are there. Who would want that? Actually...I might if that therpist is the one most likely to solve the issue that is causing me such distress and impairment, but I suspect I might be in the minority on that one. The problem with all of this is that there is absolutely no evidence whatsoever that evidence-based treatments maintain lower levels of any of these variables. In other words, the choice presented to the clients is one that there is no reason they should ever have to make.
My second issue with this is the weight given to client preference over outcome. The assumption in this paper is that, if a client ends up in a treatment they prefer less, they are more likely to drop out and less likely to have a strong outcome. This makes intuitive sense. The thing is, the evidence does not back that up either, at least not with any degree of consistency. A little over a year ago, I wrote about results on a study that examined this very question (click here to read that article) and which found that clients who received their treatment of choice were no less likely to drop out of treatment and no more likely to exhibit greater improvement post-treatment.
My third issue with this is that clients first presenting for treatment are often lacking experience with respect to the notion of empirical evidence. In other words, most folks out there are not a nerd like myself. They do not read scientific journals in their free time. They have not taken a boat load of graduate level stats classes and developed a strange affinity for numbers. They do not think about things like regression to the mean, mechanisms of change, and actuarial data when considering the value of therapy. As such, when they are given the opportunity to express their preference for numbers or common sense ideas that we know from day-to-day life (e.g., talking to somebody who seems to understand you), the question in inherently weighted in favor of the second option because the client has not been given any opportunity to fully understand the first one and they're in a hurry to get some help for something troubling enough to prompt them to come to a clinic in the first place. Afterall, common factors are what most people think about when they think about psychotherapy. What makes the work of folks like Paul Meehl, who so clearly and repeatedly demonstrated the superiority of actuarial methods to clinical intuition, so remarkable is that it runs in direct contrast to our natural expectations. Sometimes the facts are not obvious. Sometimes things do not work as we expect that they will, even though we make a compelling case for why we intuitively believe that they will. That's why we need to rely on numbers. That's why sometimes, when we are upset and we have a preferred path, it is important for an imformed health care provider to encourage us to consider an alternative.
My point here is not that clients should be forced to take part in a particular form of treatment (although I do think that only once evidence-based treatments have been attempted should non-evidence-based treatments be covered by insurance...this as a means to motivate clinicians to provide treatments that work rather than simply treatments they can sell). Instead, I think that, when a client expresses an interest in non-evidence-based treatments due to a preference for common factors that, for one reason or another, they fear the evidence-based approach will lack, the therapist should engage in motivational interviewing and psychoeducation, thereby allowing the client the opportunity to arrive at their own conclusion from a more educated stance.
Swift and Callahan (2010) put together an interesting study here and raised an extremely important topic of conversation, but I ultimately disagree with the general conclusions of their paper. That being said, I do agree with their conclusions that therapists and clients should make decisions collaboratively and that therapists should not assume that they know their clients' preferences. I simply think that client preferences could, at times (based on these data), be due to a lack of information and, regardless, be unlikely to steer the client towards a better outcome. What do you think about all of this?
************
If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store of scientifically-based psychological resources.
Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University
Subscribe in a reader
