An evaluation of anything can only be made in reference to something else. Water has no intrinsic value itself, but it is very valuable to someone thirsty. So with this in mind, what are we evaluating the importance of theory and the centrality of the therapeutic relationship against? The spirit of the question is this: how effective is theory, and therapeutic relationship, in bringing about the goals of psychotherapy. We are evaluating their efficacy.

 

Importantly this essay will evaluate them independently. The absolute majority of existing efficacy research has sought to prove the efficacy of x theory for y disorder without attempting to separate the contribution of the theory to the result from the therapeutic relationships contribution. We cannot measure the weight of water, without knowing the weight of the water’s container.

 

With this and some other fundamental issues in mind, which will be explored, some newer research has attempted to separate theory from the therapeutic relationship making it possible to evaluate their efficacy independently. This essay will focus on that, evaluating theory and the relationship independently. It will examine a notable piece of research and it’s paradigm shifting conclusions.

The therapeutic relationship is important. It seems theory may not be. While this is controversial, it will be examined from a number of angles, some caution advised, and a claim made that despite the finding, until more research is conducted, there is still value in using existing theories.

Background

To understand the context for this evaluation it is important to be clear on what psychotherapy is:

Psychotherapy is the comprehensive and intentional engagement between therapist and client for the healing, growth or transformation of emotional, physical, relationship, existential and behavioural issues…through well-founded relational processes. ("Definition of Psychotherapy," n.d., para. 1)

 

Healing, growth, or transformation is a key part of this definition by the Psychotherapy and Counselling Foundation of Australia. Evaluating the importance of theory or the therapeutic relationship must be measured in terms of their ability to bring about change. We are not evaluating how comprehensive they are, or how intentional, but how well they bring about change. Fortunately, the psychotherapy’s efficacy has long been researched and determined. According to Wampold (2000), the argument is settled, “clearly, the global efficacy issue has been decided…yes” (p. 714) and Lambert (2013) notes that over fifty years of research psychotherapy has proven  “substantial benefit” (p. 204) for clients.

 

This essay instead evaluates the efficacy of two components of psychotherapy independently: theory and therapeutic relationship. We immediately however encounter a significant problem. Psychotherapy efficacy research is the subject of numerous controversies. Cuijpers, Karyotaki, Reijnders, et al. (2018) describe many issues such as low-quality research and negative findings not being published amongst other problems, and they go on to say that many psychotherapy researchers “are not aware of the fundamental problems” (p. 356).

 

However the existing research, while controversial, is the best indictor we currently have for efficacy so it will be considered along with placebo studies. Due to the risk of bias, researcher error and sample size, there is danger in highlighting and drawing conclusions from individual pieces of research. Where possible, meta-analytic studies will be examined which Westen, Novotny & Thompson-Brenner (2004) said “support a more nuanced view of treatment efficacy” (p. 631).

Is theory important?

Freud’s medical background and the lack of scientific rigor at the time psychoanalysis was created help to explain why his theories came to prominence. When Freud’s colleagues split away from him to develop their own theories, a number of schools of theory emerged. (Wampold & Imel, 2015, pp. 7-19). There was a great deal of rivalry amongst these schools, “like battling siblings, [they] competed for attention and affection in a “dogma eat dogma” environment” (Norcross and Goldfried, 2005, p. 3). The ascendency of theory had started.

Theories about theory

There are many theories in psychotherapy. There are also many theories about why theory is important. However there appears to be little research examining if theory is actually important. Before examining that research, it is necessary to review some of the ideas about why theory might be important.

 

Bruce Wampold (2019) claims theory is a like a road map. He says “theory provides the framework for therapeutic action: which questions to ask, what to attend to, how to respond to client verbal and nonverbal behavior, when and how to intervene, and how to assess progress.” (p. 4). Blow, Sprenkle, & Davis (2007) claim theory orients the therapist, help a therapist guide the client, and can establish hope (p. 310). Neukrug (2015) writes that theory offers us a “comprehensive system of doing counseling, and assists us in conceptualizing our client’s problems, knowing what techniques to apply and predicting client change. (p. 101).

 

In the most systematic explanation, Boy and Pine (1999) claim theory has six functions:

1)    It helps counselors find unity and relatedness within the diversity of existence.

2)    It compels counselors to examine relationships they would otherwise overlook.

3)    It gives counselors operational guidelines by which to work and helps them evaluate
their development as professionals.

4)    It helps counselors focus on relevant information and tells them what to look for.

5)    It helps counselors assist clients in the effective modification of their behaviour,
cognitions, emotional functioning, and interpersonal relationships.

6)    It helps counselors evaluate both old and new approaches to the process of counseling.” (p. 12)

 

These are all fine theories. But they are theories. An evaluation of the importance of theory should not seek a theory for why theory is important. Instead it should seek evidence that theory is actually important.

 

Since existing theories cannot be administered without a therapist administering them and since this runs the risk of the therapist or some other factor influencing the outcome, there is only one place to seek the evidence we need: placebo studies.

 

Placebo studies: evidence for the importance of theory

Placebo studies are “deeply imbedded in several controversies in medicine and in psychotherapy” (Wampold & Imel, 2015, p. 5). However they allow us to break psychotherapy down into components and test each independently.

 

Multiple meta-analyses (Bowers and Clum, 1988; Barker, Funk & Houston, 1988; Lambert & Bergin, 1994; Stevens, Hynan & Allan, 2000) have determined a similar pattern when examining psychotherapy versus no treatment, psychotherapy versus placebo, and placebo versus no-treatment. Though their methods and final numbers differ, they had consistent findings: psychotherapy is more effective than a placebo-treatment, and a placebo-treatment is more effective than no treatment at all (Wampold, 2015, pp. 226-227).

 

However, of special note is a meta-analysis study by Baskin, Tierney, Minami & Wampold (2003) who examined when the placebo-treatment was “structurally equivalent” (p. 974) to the active-psychotherapy also tested. This means where the placebo and actual treatment did not differ in number of treatments, length of treatment, form, training of the therapist, whether interventions were individualized and whether clients could discuss actual issues or neutral topics.

 

Baskin et al’s (2003) conclusion was remarkable: the difference in efficacy between well-designed, structurally equivalent pseudo-placebos and active treatments, was statistically negligible (p. 976).

 

This is a significant finding. Placebos that are similar to established theories in structure, are indistinguishable from established theories at bringing about change in a client. In other words, this evidence shows, theory might not be important at all.

 

It would be wise to be cautious about this however. This was one meta-analysis and it seems little follow on or exploratory research has been done in the nearly twenty years since. However this is a ground breaking finding. The absence of further investigation of such a significant finding is considered later in this essay. However first a more pressing question arises. If theory is not important, or at least nowhere near as important as once thought, how do we explain the proven efficacy of psychotherapy versus no treatment?

Common Factors

A much simpler way of thinking about this is beautifully illustrated by this quote from Kottler, Carlson, & Wallace (2014):

 [it] is one of the true mysteries of the therapy universe that historical figures as diverse as Carl Rogers, Albert Ellis, Virginia Satir, Fritz Perls, and Sigmund Freud could have all been effective in their work given their apparent extreme differences in values, style, and approach.” (p. 16)

 

So if not theory, what else could be bringing about change for clients? Lambert (2013) posited three possible explanations:

 

1) different therapies can achieve similar goals through different processes;

2) different outcomes do occur but are not detected by past research strategies; and

3) different therapies embody common factors that are curative, though not emphasized by the theory of change central to a particular school. (p. 199)

 

Most research has focused on this last option of common factors, the term itself coming from Rosenzweig’s 1936 work Some Implicit common factors in diverse methods in psychotherapy. According to Norcross (1999) common factors are the variables of the treatment setting that include: client, therapist, techniques not specific to a particular methodology, expectancy, and therapeutic relationship (p. 4).

The Centrality of the Therapeutic Relationship

The concept of therapeutic relationship, though not the exact term, dates back to Freud and his reconsideration of the role of transference. Bordin was responsible for the term working alliance (interchangeable with therapeutic relationship) and pushed the concept beyond its psychoanalytic origins, he claimed the alliance had three elements, agreements on the therapeutic goals; consensus on the tasks that make up therapy; and a bond between the client and the therapist (Horvath, Del Re, Flückiger, & Symonds, 2011, p. 10).

 

Is the therapeutic relationship important?

Efficacy research

Research into the efficacy of therapeutic relationship has been substantial and returned similar findings. According to Crits-Christoph, Connolly-Gibbons, & Mukherjee (2006) “there is substantial evidence for a link between the alliance and treatment outcome (Horvath, 2001; Horvath, Del Re, Fluckiger, & Symonds, 2001; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000)” (p. 302).

 

By far the largest finding was in Horvath et al’s meta-analysis (2011) which examined 201 studies and found the therapeutic relationship to account for 7.5% of the variance. According to Kottler, Carlson & Wallace (2014) this means “the amount of change attributable to the alliance is about seven and a half times that of a specific treatment method” (p. xviii).

 

Lambert (1992) found that specific techniques or theories accounted for no more than 15% of the variance in therapy outcomes, with the therapeutic relationship accounting for 30% of the variance outcomes. (Kottler, Carlson, & Wallace, 2014, p. 3).

 

Placebo conclusions

The earlier discussion on placebo testing illustrates that the therapeutic relationship is critical. When a relationship plus a placebo-structure-treatment is tested, the result is the same as psychotherapy. When a relationship plus placebo-unstructured-treatment is tested, the result is half as good. Combined these tell us two things: the relationship is important; the theory much less so.

 

It is however possible to see a significant weakness in this. While a treatment (theory) can be substituted and tested independently, it is not possible to placebo the relationship component of the test. The placebo tests are not telling us that the theory isn’t right, just that it isn’t necessary to bring about the change it hopes to bring about.

The difficulty of paradigm shifts

Given the remarkable conclusion of Baskin et al’s 2003 study, it seems surprising there has been little specific follow up research to confirm or explore these findings. There are however a number of reasons why this may be understandable. Wampold and Imel (2015) believe that if theory is rejected and common factors are determined to be the principal cause of benefit in psychotherapy, it “would collapse the entire scaffolding of the theoretical bases of modern psychotherapy” (p. 33). Lambert (2013) claims some in the field of psychotherapy may resist acknowledging common factors as the principal cause of benefit citing Frank (1976) that “little glory derives from showing that the particular method one has mastered with so much effort may be indistinguishable from other methods in its effects” (p. 74)” (p. 202).

Conclusion

Efficacy research and placebo studies, particularly Baskin et al (2003), indicate that theory may be nowhere near as important as once presumed. However, there is still work to be done and clinicians should not yet throw theories away.

 

It is possible that existing research is flawed for a number of fundamental reasons. Allegiance, or preference for a school of theory, has been shown to have a significant positive impact on client outcomes in research. Though therapist allegiance is difficult to study (Wampold & Imel, 2015, p. 128), it could be unethical to knowingly risk these positive outcomes by undermining all therapists’ allegiances to their theory of choice.

 

Whether theory is important for old reasons, or new reasons, or whether in time the common factors will come to completely trump theory is unknown. Simply, more research is needed. But it is needed. Researchers need to push the field forward by fearlessly and without bias or attachment to the past exploring this topic. We have to be comfortable letting go of what Hauser and Hays (2010) described as our “beautiful hypothesis” and move towards the unknown. We really need to understand how psychotherapy works. Doing that will raise the field and give our clients the best chance at change.

References

 

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Baskin, T., Callen Tierney, S., Minami, T., & Wampold, B. (2003). Establishing Specificity in Psychotherapy: A Meta-Analysis of Structural Equivalence of Placebo Controls. Journal of Consulting and Clinical Psychology, 71(6), 973–979. https://doi.org/10.1037/0022-006X.71.6.973

 

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Top of Form

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