If it’s tricky to decide whether pharmacological interventions are effective then it’s very tricky indeed to evaluate whether psychological therapies work. Although techniques from randomised controlled trials can help uncover causal effects, often important components such as double blinding are impossible – how could a practitioner follow a treatment manual without knowing what she or he is doing? Randomisation is not always possible, for example when evaluating routine practice (see Wolpert, Fugard, & Deighton, 2013 for examples). As Jon illustrated in a previous post, a story of mechanism is still necessary even with perfect measurement and methodology.
Perhaps it helps to have a theory of what else other than the therapy itself can cause apparent improvement in symptoms. Lilienfeld et al (2014) develop a taxonomy with 26 causes to begin to address this question. Let’s consider some examples. An intervention might provide palliative benefits; this can be understood by considering the difference between “feeling better” and “getting better”. Someone who wishes to stop excessive drinking might, thanks to a warm and understanding therapist, feel less guilty about drinking and so not change how much they drink. There may be a reduction in cognitive biases as a result of therapy; one’s perception of social skills might improve when in fact they have not changed. Both outcomes would be fine if the therapy were intended only to change perceptions, however, an intervention to reduce alcohol intake or improve social skills might be expected actually to show externally demonstrable changes. Another example given is the therapist’s office error: observed improvement in a safe and friendly therapeutic relationship might not transfer to the harsh world outside.
But what mechanisms are involved here and how should they be described? This is a much bigger question – and perhaps important for understanding therapeutic change. For example, might understanding the therapist office error lead to ideas for effective intervention? Power (2010) provides three broad examples of technique and related mechanisms. Firstly, exposure, whereby emotions are heightened in the therapist’s presence and change mechanisms involve behavioural extinction, relearning, and coping mechanisms. This is often an important component for helping reduce anxiety. Secondly, transference – a psychoanalytic concept (wait, don’t run off!) – whereby interaction with the therapist triggers “pre-existing expectations, templates, scripts, fears, and desires” (nicely explained by Shedler, 2006 p. 22) and, the idea is, they can be reworked in therapy. Thirdly, challenging assumptions, whereby emotions are heightened in relation to a person or situation, and reinterpreting or reconstructing the assumptions causes improvement.
Perhaps a next step in this interesting how-we’re-fooled-by-apparent-change programme might be to link the taxonomy to theories of mechanism like Power’s and others.
About the author
Andy Fugard is lecturer in the Educational Psychology Group at University College London. He is interested in practice-based evidence in mental health, the psychology of reasoning, and the broader autism spectrum.
Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2014). Why Ineffective Psychotherapies Appear to Work: A Taxonomy of Causes of Spurious Therapeutic Effectiveness. Perspectives on Psychological Science, 9, 355–387. doi:10.1177/1745691614535216
Power, M. (2010). Emotion focussed cognitive therapy. Chichester: John Wiley & Sons.
Shedler, J. (2006). That was then this is now: an introduction to contemporary psychodynamic therapy. Retrieved from http://www.jonathanshedler.com/
Wolpert, M., Fugard, A., & Deighton, J. (2013). Issues in evaluation of psychotherapies. In P. Graham & S. Reynolds (Eds.), Cognitive Behaviour Therapy for Children and Families (3rd ed., pp. 34–47). Cambridge University Press.