Tag: dodo bird effect

07/7/17

More Equal Therapies than Others, Part 2

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In his introduction to ”The Doctor’s Opinion” in the A.A. Big Book, Bill W. said A.A. favored initial hospitalization for the alcoholic who was “jittery or befogged.” It was imperative that the person’s brain was cleared so he then had a better chance “of understanding and accepting what we had to offer.” The reason to include Dr. Silkworth’s endorsement in Alcoholics Anonymous was to document a “medical estimate” of the A.A. 12-Step plan of recovery.  “Convincing testimony must surely come from medical men who have had experience with the sufferings of our members and have witnessed our return to health.” But that was almost eighty years ago; and there have been some radical changes in the receptiveness of 12-Step recovery.

In modern addiction treatment there are a growing number of voices saying A.A.’s 12-Step approach should either be taken out of the treatment game or sidelined as a “recovery support service” (RSS) instead of being an integral part of the addiction treatment process. However, it would restrict or bench a valuable asset to addiction recovery. The rationales given for this generally follows two lines of argument.

One way is to portray A.A. and other 12-Step groups as religious or cultish in nature. This distortion stems from the secularization of American culture since the late 1930s when A.A. began, as well the failure to make a distinction between spiritual and religious consistent with 12-Step philosophy. See “Spiritual not Religious Experience” for a discussion of this distinction and a response to the accusation that the spiritual nature of A.A. disqualifies it from being used within addiction treatment. The second route is to suggest the 12-Step approach does not fit with the modern medical model of addiction treatment.

In the first ten years of A.A.’s existence the fellowship became convinced that organizationally it had to permanently remain nonprofessional. This was eventually formalized in Tradition Eight. Concurrent with that realization, was the origin of what would be called the Minnesota Model of addiction treatment. The Hazelden Foundation (now the Hazelden Betty Ford Foundation) blended professional and trained nonprofessional staff within a treatment approach based on the 12-Step philosophy of A.A. Throughout the 1950s, Hazelden honed its treatment model on three working principles.

First, alcoholism was seen as a primary condition and not just a symptom of an underlying disorder. Second, alcoholism was a disease and should be treated as such. The American Medical Association (AMA) officially identified alcoholism as a disease in 1956. Third, following the A.A. idea of the alcoholic suffering physically, mentally and spiritually, alcoholism was said to be a multiphasic illness. “Therefore treatment for alcoholism will be more effective when it takes all three aspects into account.” Abstinence was an integral goal of treatment.

These principles set the stage for a model that expanded greatly during the 1960s—one that has been emulated worldwide and has merged the talents of people in many disciplines: addiction counselors, physicians, psychologists, social workers, clergy, and other therapists. These people found themselves working on teams, often for the first time. And what united them was the notion of treating the whole person—body, mind and spirit.

Cracks began to appear in the dominance of the Minnesota Model of addiction treatment even as its hegemony grew in the 1960s. Methadone maintenance as a treatment for heroin addiction arose in the early 1960s. In the 1980s, the biological model of psychiatry began its ascendency and in 1991 the AMA took the further step of endorsing a dual classification of alcoholism as both a psychiatric and a medical disease. In 1992 SMART Recovery began. “SMART Recovery is based on scientific knowledge, and is intended to evolve as scientific knowledge evolve.” In 1994 Moderation Management became a self-help group for individuals who wanted to moderate, not abstain from alcohol.

Addiction professionals developed diverse alternatives to addiction treatment centered on 12-step philosophy. Stanton Peele developed Life Process Program as an alternative to 12-Step treatment, which he now offers as an online program. Marc Lewis wrote The Biology of Desire, refuting the medical view of addiction as a brain disease. He conceived it as an extreme form of learning.

Lance Dodes wrote The Sober Truth, purportedly debunking the bad science behind 12-Step programs and the Rehab industry. It claimed to be an expose of Alcoholics Anonymous, Twelve Step programs and the rehab industry—how “a failed addiction-treatment model” came to dominate America.

David Sinclair developed the Sinclair Method, which conceived of alcoholism as a learned behavior, one that can be removed by the behavior modification principle of extinction. “The solution discovered by Sinclair effectively means you have to drink yourself sober!” And there are others. But the medical model, although it has been modified, remains supreme in addiction treatment.

In the 1990s, a movement began in medicine to develop evidence-based practices (EBP). A widely accepted definition of EBP by Dr. David Sackett is that EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”  When applied to addiction treatment, the principle is generally referred to as evidence-based treatment (EBT). The National Institute on Drug Abuse (NIDA) simply referred to EBTs as treatment approaches “that have an evidence base supporting their use.” The website GoodTherapy.org elaborated, saying that EBT was “treatment that is backed by scientific evidence.” This referred to extensive research, which has been documented and demonstrated to be effective on a particular treatment.

Consistent with this understanding, NIDA listed a manualized Twelve Step based treatment model called Twelve Step Facilitation (TSF) as an evidence-based behavioral therapy. TSF actively seeks to engage substance abusers in becoming involved in 12-Step groups, “thereby promoting abstinence.” However, a writer and researcher for Handshake Media, Laurel Sindewald, concluded in her article, “AA Is not Evidence-Based Treatment,” that NIDA wrongly listed TSF as evidence-based.

In Part 1 of this article, “More Equal Therapies than Others,” is a description of TSF and a discussion of how Sindewald’s critique wrongly and inconsistently grouped A.A. and other 12-Step groups with treatment approaches like the Minnesota Model and TSF that use 12-Step philosophy. Her provocative title is the result of mistakenly grouping A.A. and treatment approaches based on 12-Step philosophy together; and then illegitimately transferring her critique of these 12-step treatment approaches to A.A. A.A. sees itself as a fellowship and not a treatment. Here we will briefly look at how Sindewald’s narrowing of the NIDA sense of “evidence-based treatment” allowed her to conclude TSF was not evidence-based.

As was described in Part 1, Sindewald gave a biased description of 12-Step philosophy, stating it viewed addiction as merely “a spiritual disease born of defects of character.” Twelve Step groups supposedly said they were the only cure, “involving faith in a higher power, prayer, confession, and admission of powerlessness.” Contrasted with the NIDA definition of addiction as a disease of the brain, she asked how TSF as a professional medical treatment could be based on an understanding of addiction as a spiritual disease. Note the rhetorical sleight-of-hand in how she conveniently left out the A.A. and 12-Step understanding of addiction as a physical, mental and spiritual illness/disease.

Another place Sindewald used the same tactic was where she defined evidence-based. “In this article, I define ‘evidence-based’ to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples.” Note how her sense of “evidence-based” is more restrictive than NIDA, GoodTherapy.org and even Sackett’s widely acknowledged sense of evidence-based practice for medicine.  Her criteria seem to be even more restrictive than the American Psychological Association’s criteria for well-established “empirically validated treatment” in the “APA Task Force on Promotion and Dissemination of Psychological Procedures” Refer to Table 1 for the criteria.

Gianluca Castelnuovo wrote an article for Frontiers in Psychology on “Empirically Supported Treatments in Psychotherapy.” Consistent with the broader NIDA sense of evidence-based, he said the term evidence does not have one single definition. “evidence-based practice (EBP) includes many forms of evidence other than data from RTCs [randomized control trials].” There are two contradictory visions of what causes change in psychotherapy. One approach emphasizes the primacy of therapist and technique. The second vision focuses of the patient-therapist relationship and what the client brings to the therapeutic relationship.

The first vision sees the specific methods used by the psychotherapist as accounting for, by far, most of the changes in therapy. “Other factors (e.g., therapist relational qualities, patient–therapist relationship) are secondary, at best. This viewpoint is seen most notably in what have been termed the EST and EBP movements.” This approach conducts tightly controlled outcome studies, where specific treatments are pitted against one another or a control group and applied to specific disorders, usually as defined in the DSM. This describes the Project MATCH study, for which TSF was developed. This first sense proceeds from a medical model of “diagnosis plus prescriptive treatment equals symptom amelioration.”

The second view of psychotherapeutic change attributes most positive therapeutic outcomes to client factors (40%) and the therapeutic relationship between client and therapist (30%). The technique used and the skill of the therapist accounts for 30% of positive therapeutic outcomes. This so-called “common factors approach” then discourages attempts to pit one therapy against another or against a placebo group of no treatment (clients placed on a waiting list) as ultimately doomed to failure, since all therapies have the same potential for positive outcomes (the dodo bird effect). And the relationship between the therapist and client is the most important factor for change. Here is where the fellowship sense of A.A. fits because what makes it work is the community of fellow sufferers helping one another.

When discussing the significance of common factors in “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” Barry Duncan noted how experienced therapists know psychotherapy requires the unique tailoring of a therapeutic approach to a particular client and circumstance. And if a therapist attempts to do therapy by the book, it often doesn’t go very well. There are limitations to manualized therapies, even TSF.

The structure minimizes the factors brought to therapy by the client. It restricts or eliminates the therapeutic relationship or fellowship between client and therapist. And it emphasizes the factors (therapist and technique), which typically have the least positive outcome effects. If you want to determine whether a therapeutic approach is “evidence-based” or “more equal” than other therapies when treating a designated DSM disorder, you will likely use a structured, manual-based treatment. And you will have a wrong-footed, biased sense of relationship-based models of change like the Twelve Steps of A.A.

For more information of the therapeutic power of common factors and the dodo bird effect, see the above-linked article by Barry Duncan. Also read the Wampold et al. article, “A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’”; or “The Dodo Bird Effect” and “Another Brick in the Wall” on this website. If you are interested in exploring “the science behind 12 Step recovery,” try If You Work It, It Works! by Joseph Nowinski.

05/19/17

Another Brick in the Wall

© Igor Goncharenko | 123rf.com

A Task Force for the American Psychological Association said that if clinical psychology was to survive in the heyday of biological psychiatry, it had to emphasize the strength of what it had to offer, namely “a variety of psychotherapies of proven efficacy.” So it proceeded to develop criteria to identify empirically validated treatments. Yet outcome research has regularly shown over the past forty years that “when treatments intended to be therapeutic are compared, the true difference between all such treatments is zero.” This has been referred to as the “dodo bird effect,” reflecting the observation made in 1936 by Saul Rosenzweig that common factors were responsible for the efficacy of various psychotherapies. Barry Duncan remarked: “the task force not unlike the pigs in George Orwell’s Animal Farm, continues to assert that some therapies are more equal than others.”

The APA Task Force on Promotion and Dissemination of Psychological Procedures noted that treatment manuals have become a required element of psychosocial treatment research. The standardization in treatment manuals reduces the methodological problems caused by “variable therapist outcomes.” Since no treatment will work for all problems, “it is essential to verify which treatments work for which types of problems.” Following this rationale, the Task Force suggested criteria for Empirically Validated Treatments (EVT) for two categories: Well-Established Treatments and Probably Efficacious Treatments.” You can see the criteria for each in Tables 1 and 2 in the above link.

In “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” Duncan commented that although the APA had good intentions in trying to preserve a section of the therapy market for the psychology profession, “declaring an approach to be an EVT and suggesting that it should therefore be the prescribed treatment of choice is empirical bankruptcy.” The EVT approach equates the client with the problem and describes the treatment as if it is isolated from what has been shown to be the most powerful factors that contribute to therapeutic change—the client’s resources and the therapeutic relationship of client and therapist.

The EVT position virtually ignores 40 years of outcome data about common factors and the veracity of the dodo bird verdict. Model factors are pale in comparison with client and relationship factors; efficacy over placebo is not differential efficacy over other approaches.

Duncan said the EVT “house of cards” was built on the medical model of “diagnosis plus prescriptive treatment equals symptom amelioration.” He pointed back to a 1949 conference in Boulder when psychology’s training guidelines was framed with medical language and concept of mental disease. Later, when the National Institute of Mental Health (NIMH) decided to apply the same methodology it used in drug research to evaluate psychotherapy—randomized clinical trials (RCT)—it had profound effects. This methodology meant a study had to include manualized therapies (to approximate drug protocols) and DSM defined disorders to be eligible for an NIMH-sponsored research grant.

The result was that funding for studies not related to specific disorders dropped nearly 200% from the late 1980s to 1990. “Force fitting the RCT on psychotherapy research is empirical tyranny and bereft of scientific reasoning.” It takes what is a human relational method of change and tries to cram it into a series of operationally defined behavior modifications.

The RCT compares the effects of a drug (an active compound) with a placebo (a therapeutically inert or inactive substance) for a specific illness. The basic assumption of the RCT is that the active (unique) ingredients of different drugs (or psychotherapies) will produce different effects with different disorders. The field has already been there and done that—the dodo bird verdict is a reality, and the active ingredients model (or drug metaphor) borrowed from medicine does not fit.

Among the problems when the RCT methodology is used for psychotherapeutic research is that the findings are profoundly limited because they do not generalize to the way psychotherapy is conducted in the real world. “Efficacy in RCTs does not equate to effectiveness in clinical settings; internal validity does not ensure external validity. . . . Experienced therapists know psychotherapy requires the unique tailoring of any approach to a particular client and circumstance.” When therapists do psychotherapy by the book, it doesn’t go very well. Duncan said doing therapy by manual was like having sex by a manual.

The EVT position is not only selective science at its worst, it is another brick in the wall of medical model privilege in psychotherapy. The end result of our Faustian deal with the medical model: Psychotherapy is now almost exclusively described, researched, taught, and practiced in terms of pathology and prescriptive treatments and is firmly entrenched in our professional associations, licensing boards, and academic institutions. It is so taken for granted that it is like the old story about a fish in water. You ask a fish, “How’s the water?” and the fish replies, “What water?”

Then the more structured a therapeutic relationship is (as with manualized therapy), the less room there is for a real relationship to develop between the client and the clinician. This structure inevitably leads to the client being viewed as the problem, rather than part of the solution. And it implicitly applies a medical model to psychotherapy: “diagnosis plus prescriptive treatment equals symptom amelioration.” It ignores a 40-year body of empirical evidence that indicates how common factors of various therapies, centered on the client and the therapeutic relationship, are far more indicative of therapeutic efficacy than whether or not a particular psychotherapy is an empirically validated treatment.

For more information on therapeutic power of common factors and the dodo bird effect, see “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” by Barry Duncan, which is linked above. Also read the Wampold et al. article, “A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’”, or “The Dodo Bird Effect” on this website.

05/9/17

The Dodo Bird Effect

The original art work and the reproduction here are in the public domain

In order to get dry after a swim, the Dodo in Alice in Wonderland proposed that everyone run a race. He said the participants could run anyway they want. They could even start and stop whenever they wanted. When the race was completed and the Dodo bird was asked who won, and he said: “Everybody has won, and all must have prizes.” Intriguingly, the Dodo’s announcement has been used as a metaphor when discussing the outcome research of psychotherapeutic approaches.

The metaphoric application of the dodo bird effect to describe the equivalence of effectiveness when comparing psychotherapies first occurred in a classic paper written by Saul Rosenzweig in 1936: “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” The article was republished in the July 2010 issue of the American Journal of Orthopsychiatry, which you can read if you pay APA PsycNET $11.95. An alternative approach would be to read an article by Barry Duncan, “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird” available for free under the link.

Duncan saw Rosenweig’s article as having a clairvoyant ability to predict the intervening years of research that underlies the argument for the common factors perspective of psychotherapeutic approaches. Essentially Rosenweig (and the common factors approach) attributed the positive outcomes of these approaches to factors common to the various therapies and not necessarily to the particular therapeutic approach itself. Michael Lambert made a significant contribution to the modern sense of the common factors perspective, according to Duncan, when he identified four therapeutic factors as the principle elements accounting for improvement in psychotherapy. Based upon Lambert’s work, Scott Miller and a team of researchers expanded the use of the term “common factors” from its traditional sense of nonspecific relational factors to include four specific factors: client, relationship, expectancy and placebo, and technique.

Clients have been typically portrayed as passive targets or recipients for the all-important technical intervention of a therapy. However, research by Tallman and Bohart demonstrated “that the client is actually the single, most potent contributor to outcome in psychotherapy—the resources clients bring into the therapy room and what influences their lives outside it.” Client attributes like persistence, openness, faith, optimism, supportive family members, or membership in a religious community might be important factors operative in the individual’s life before they enter therapy. “Assay and Lambert ascribed 40% of improvement during psychotherapy to client factors.” This is a departure from the conventional emphasis on the contribution of the therapist, the therapeutic model or technique.

Clients are the main characters, the heroes and heroines of therapeutic stage, and they are the most potent contributor to psychotherapeutic change. This common factor suggests that therapists eschew the five Ds of client desecration (diagnosis, deficits, disorders, diseases, and dysfunction) and instead find ways to enlist the client in service of client goals. Whatever path the psychotherapist takes, it is important to remember that the purpose is to identify not what clients need but what they already have that can be put to use in reaching their goals.

Regardless of the therapist’s theoretical approach, relationship variables account for 30% of successful outcome variance in therapy. “Next to what the client brings to therapy, the therapeutic relationship is responsible for most of the gains resulting from therapy.” Related to this, the client’s perception of the relationship is the most consistent predictor of therapeutic improvement.

The core conditions identified by Carl Rogers as “necessary and sufficient” conditions for personal change in therapy are accepted as important factors by most schools of therapy. These core conditions, accurate empathy, positive regard, nonpossessive warmth and genuineness, have been empirically supported. They are also consistently reported in client reports of successful therapy.

“Placebo, hope and expectancy” is estimated to contribute 15% to the outcome of psychotherapy. In part, the client’s assessment of the credibility of the healing rituals of the therapy’s rationale and related techniques play a role here. These curative effects come from the positive and hopeful expectations that accompany the use and the implementation of the therapeutic method. “Rituals are a shared characteristic of healing procedures in most cultures.” The procedures are not the causal agents of change. “What does matter is that the participants have a structure, concrete method for mobilizing the placebo factors. From this perspective, any technique from any model may be viewed as a healing ritual.”

In Persuasion and Healing, Jerome Frank said the therapeutic enterprise has a strong expectation that the client will be helped. He suggested that an underlying factor to all the different approaches to psychotherapy, like the placebo in medicine, is that people are offered hope that something can be done to help them. Sometime merely the name of a therapeutic procedure mobilizes a person’s hope of relief. “For therapy to be effective, patients must link hope for improvement to specific processes of therapy as well as to outcome.” Frank said:

Despite differences in specific content, all therapeutic myths and rituals have functions in common. They combat demoralization by strengthening the therapeutic relationship, inspiring expectations of help, providing new learning experiences, arousing the patient emotionally, enhancing a sense mastery or self-efficacy, and affording opportunities for rehearsal and practice.

Therapeutic models and techniques account for 15% of improvement in therapy. Conceived broadly, model/technique factors can be understood as therapeutic or healing rituals. From this perspective, even therapies like EMDR, eye-movement desensitization response, offer nothing new. When a therapist tells a client “to lie on a couch, talk to an empty chair, or chart negative self-talk,” they are engaging in healing rituals.

Because comparisons of therapy techniques have found little differential efficacy, they may all be understood as healing rituals—technically inert, but nonetheless powerful, organized methods for enhancing the effects of placebo factors.

Rosenzweig said it mattered little whether the therapist talked in terms of psychoanalysis or Christian Science. What counted was “the formal consistency with which the doctrine used is adhered to, thereby offering a systematic basis for change and an alternative formulation to the client.”

And yet, the therapy field continues to be “model maniacal,” according to Duncan. He quoted Arthur Bohart as saying the dodo bird effect is ignored because it is so threatening to special theories. “The data call for a change in how we view therapy, but the field continues to stick to the old technique-focused paradigm.” Another reason is the ongoing search for the GUT—the Grand Unified Theory—of therapy that cures all or most suffering individuals. But the cure always seems just around the corner or just out of reach.

Self-proclaimed experts present mysterious scans of brains showing incontrovertible truth that “mental illness” exists and medical science is on the verge of conquering it. But when reality sets in, therapists know that they can never produce the epic transformations witnessed on videos or reported in edited transcripts. Psychotherapists painfully recognize that colorized brain images will not help when they are alone in their offices facing the pain of people in dire circumstances.

The final reason the dodo bird effect is ignored is because clinicians are too invested in the privilege model perpetuated by graduate schools, professional organizations and managed care companies. Psychiatrists are one example, particularly with their hegemony of targeting particular drugs as treatments for specific disorders. Drawing from the medical example of evidence-based practice, there are a growing number of evidence-based or evidence-verified treatments. But the EVT position essentially ignores the 40 years of outcome data about common factors and the truth of the dodo bird effect.

The dodo bird effect means that the client and what they bring to the therapeutic encounter is the most important factor for its effectiveness, rather than the therapist or the therapy. The next most important factor is the therapeutic relationship of client and clinician. Consequently, relationship skills such as acceptance, warmth and empathy are fundamental for establishing a good therapist-client relationship. A therapist with these skills will ensure their practice doesn’t go the way of the dodo bird, which went extinct in the 1600s.