Br. J. med. Psychol. (197S), 48. 199-206 Printed in Greut Britain


Some implications of psychotherapy research for clinical psychology BY D. A. SHAPIRO* There is some professional unease about psychotherapy amongst British clinical psychologists. Some are committed to its practice, dismissing as irrelevant or unfounded the objection that no scientifically acceptable evidence exists to support this. Others are equally confident in rejecting psychotherapy as a manifest waste of the clinical psychologist’s slender resources. Yet there is a stridency in the expression of both these views which suggests that neither side is really very certain of the correctness of its position. This paper is concerned with ways in which recent research in counselling and psychotherapy might lead us out of this impasse. The first part bears on the evaluation of psychotherapy per se; the second briefly considers the possible contributions of the study of psychotherapy to other areas of clinical work. THE EVALUATION OF PSYCHOTHERAPY The starting point for almost any critical discussion of psychotherapy is the by now familiar assertion that there is no evidence for the effectiveness of this treatment (Eysenck, 1952, 1960, 1%5; Rachman, 1972). This statement, although not altogether at variance with the evidence from published research, does require some elucidation. In particular, it is important to distinguish between two possible meanings of the statement. It could mean ‘Psychotherapy has been shown to be ineffective’. This, however, would not be a justifiable conclusion from present evidence. Not only is the ‘spontaneous remission ’ baseline highly questionable (Kline, 1972), but the available studies including control groups do not adequately spe-

* Department of Sheffield.

Psychology, University of

cify the nature of the patients, therapists and techniques involved (Strupp & Bergin, 1%9). This brings us to the second possible meaning of the above statement. This is ‘Adequate studies of the effects of psychotherapy have yet to be carried out ’. This interpretation, although less obviously suspect than the first, raises the question of what constitutes adequacy in a psychotherapy evaluation study. As has already been implied, this question requires attention to the problems of specification and definition of the disorders in question, of psychologically relevant features of patients and therapists, and of the techniques employed. Much of this paper will be concerned with research which has attempted to tackle these problems. THE ‘ DETERIORATION EFFECT ’ The most simplistic response to the lack of specification of treatment parameters was the attempt by Bergin (1966) to show that psychotherapy, whilst leaving unaffected the average status of treated as compared with control patients, increased the variance in their scores, indicating an admixture of helpful and harmful attempts at therapy. This argument is simplistic, in that it makes no systematic attempt to account for the increased variance, nor does it question the adequacy of the sampling and assessment procedures involved in the conventional ‘outcome’ study. It is therefore not altogether surprising to find (May, 1971; Rachman, 1972) that Bergin’s case is very shaky. It gained plausibility by ignoring the inadequacies of some of the quoted studies, by unjustifiable appeal to the mere fact of apparent deterioration in members of treated groups, and by selection of evidence. As Rachman (1972) makes clear, the ‘deterioration effect’ argument cannot be used



fostering, broad involvement in the client’s problems, focusing on practical and psychological assistance with problems which could prevent the establishment of a rewarding but law-abiding life-style. The treated subjects had better records over two years than the controls (fewer as well as less severe offences), although the numbers were too small for statistical evaluation. Reading, vocabulary and arithmetic were better in the counselled group, this being attributed to the fact that more of them were successfully returned to school. Truax et al. (1966) obtained a significant difference in subsequent institutionalization rates over a year between female juvenile delinquents seen in group counselling by therapists shown in previous studies to offer high levels of the interpersonal SOME PROMISING ‘OUTCOME ’ STUDIES ‘facilitative conditions’ and a control group. There are in the literature several instances These three studies also found psychologicaltest of promising results in ‘relationship’ therapy changes consistent with the behavioural criteria associated with attempts to specify (relatively already mentioned. These included reductions modest) goals, techniques and therapist and in manifest anxiety and aggression. Each of the three above studies showed client characteristics. The first example is in the field of delinquency. Three independent studies positive results, in terms of a relatively unamhave shown evidence that counselling or psy- biguous behavioural criterion of success, of a chotherapy reduces the incidence of further treatment procedure which was offering more trouble with the law as compared with un- than just undefined ‘relationship therapy ’. The treated controls. Persons (1966) conducted group Persons study involved a pre-planned, structherapy aimed at providing a sequence of (i) tured approach to the development and utilizaestablishment of supportive relationship, (ii) tion of therapeutic relationships; the Massimo interpretation and differential reinforcement, in- & Shore project was oriented to vocational and cluding role-playing, ( 5 ) induction of stress con- other real-life problems; and the Truax et al. cerning antisocial behaviour, and (iv) discussion study provided relationships of a quality which of difficulties in returning to the community. This was, according to a reasonably well-validated sequence seems to involve establishing a rela- criterion (Shapiro, 1%9; Truax & Carkhuff, tionship in which the therapist acquires influ- 1%7), well above average. Thus the success of ence over the patients, and then systematically these projects is plausibly attributable to defined exercises this influence via modelling, shaping, features of the helping procedures involved. and persuasion techniques. Disciplinary records A second area in which positive results are to during institutionalization favoured the treated be found is in the counselling of under-achieving group, who also showed a lower recidivism rate students. A review by Bednar & Weinberg (1970) over a one-year follow-up period than both the suggests that about half (13 out of 23) of a series untreated group and the base-rate. Massimo & of studies yielded significant grade point average Shore (1%3; Shore & Massirno, 1966) report a superiority in counselled as compared with nonvocationally oriented programme, with involve- counselled students. Furthermore, Bednar & ment by the therapist in all aspects of the Weinberg indicate that certain features of the adolescent delinquent clients’ life. The principle counselling procedures of the various studies are here was of job-oriented, independence- associated with effectiveness in terms of this to account for the ‘average ineffectiveness ’ finding. Paradoxically enough, Bergin’s argument was the basis for a successful prediction in a study by Hobson & Shapiro (1970). In this experimental investigation of short-term changes in patients’ self-reported state during psychotherapy sessions, greater short-term variability was found during these sessions than during comparison periods. The precise meaning of this finding is not clear. Its further investigation involves considering the role of short-term ’ worsenings ’ in psychotherapy (Shapiro & Hobson, 1972; Shapiro et al., 1975; Shapiro & Shapiro, 1974).

Psychotherapy research 20 1 relatively objective criterion.* These include (i) selled in the studies reviewed by Bednar & length of counselling (over 10 hours), (ii) struc- Weinberg were relatively high in dependency, turedness (i.e. directive, authoritarian, aca- and thus were more likely to be helped by demic and prescriptive, rather than non-directive, structured counselling. A similarly designed client-centred, non-prescriptive or aff ectively study by Brown (1%9) indicated that students oriented), and (iii) group procedures (rather than admitting to high anxiety on a manifest anxiety individual). These findings are at variance with scale were helped by unstructured counselling, traditional counselling and psychotherapy as indicated by anxiety scale changes as well as theory, which emphasizes intensive focus on a GPA, whereas those low in manifest anxiety therapeutic relationship in an unstructured set- scores were helped by structured counselling. ting. However, academic studies programmes Students who express anxiety in a self-report alone tend to be ineffective, although effective measure may be more inclined to express it in combination with counselling. And the evi- verbally than those who do not express anxiety dence on the durability of the counselling effect, in the test. Students placed in groups inapproalthough on the whole discouraging, favours priate to their anxiety level showed increased programmes combining directive, academic re- anxiety over treatment, whilst those in appromedial help and counselling aimed at the social, priate groups showed a decrease. A fourth study motivational and emotional ' dynamics' of under- comparing different treatment approaches with achievement. This evidence on student counsell- students differing in personality was conducted ing thus suggests that a well-defined criterion by Di Loreto (1971). His subjects were students may be attained at an overall level better than admitting to, and responding to an offer of chance. Although one might suspect a bias treatment for, interpersonal anxiety. Di Loreto towards publication of positive as opposed to found that rational-emotive therapy was effecnegative findings, the tentative identification of tive with introverts, client-centred therapy with factors associated with success provides some extraverts, and systematic desensitization with basis for predicting successful outcomes of both groups. His measures included self-reports, programmes combining the didactic and the behaviour ratings and therapist ratings. With dynamic. their respective ' appropriate ' groups, rationalAU the above work is, of course, based on emotive and client-centred therapy were as the crude assumption that the single criterion, effective as systematic desensitization;with their academic under-achievement, requires a single 'inappropriate ' groups, they were no more effectreatment package for all cases. Perhaps the most tive than a placebo control condition. important work to emerge from the student The studies of delinquentsandunder-achievers counselling literature is that suggesting that reviewed here suggest that specific goals, such different programmes are differentially effective as better academic grades or fewer brushes with with students differing in personality. Two stu- the law, may be more attainable than the less dies by Gilbreath (1%7, 1968) have shown that easily defined personality changes sought by ' structured ' group counselling is effective in traditional psychotherapy. In a similar vein, the raising the GPA of students showing evidence value to patients recently admitted to an organiof high dependency needs, whereas 'unstruc- cally oriented psychiatric unit of brief-contact tured ' counselling is effective with students with therapy has been demonstrated by Dreiblatt & low dependency needs. Given counselling ' inap- Weatherley (1%5). In particular, the second of propriate' to their personality, students do no their two studies, in which different types of brief better than untreated controls. These findings contact (all limited to 12 contacts of up to 10 would imply that the majority of students coun- minutes) were compared, showed that contacts * W.Yule has pointed out (personal communica- not involving discussion of the patient's symption) that GPA is not always a fully objective or toms led to speedier discharge than control conditions of no contact and attention control contamination-free measure.



(guessing task). The authors speculate that the contacts enhanced the patients’ self-esteem, citing self-ideal correlations from worts in support of this. Whatever the precise mechanisms, it seems that brief contacts were able to supply something not available in the normal ward routine. Whilst traditional counselling and psychotherapy may over-emphasize the importance of personal contact in therapy, this study supports the view that it should not, on the other hand, be discounted altogether. The studies reviewed so far are significant because they imply that the move to specification of relatively modest, behaviourally definable treatment objectives, and to the identification of individual differences associated with differential response to treatments, may be associated with less ambiguous outcomes than customary with relationship therapies. On this view, the paucity of favourable results on the ‘outcome’ of psychotherapy may be attributable to the fact that relationship therapies are traditionally embedded in theoretical frameworks which have not fostered studies such as those reviewed above. Psychoanalytic and client-centred theories have shared the tendency to view their respective procedures as universally applicable. Whilst diagnostic categories are a highly imperfect way of expressing the differences between patients, to discount them as completely as the Rogerians have done is to lose sight of important limitations on the functioning, for example, of chronic schizophrenics. (Rogerian theory assumes that personal growth, conceived in terms of what one might term a ‘horticultural model’, will occur in anyone exposed to social conditions deemed favourable by the theory.) The disappointing results of the massive Wisconsin Schizophrenic Project (Rogers, 1%7) may well be attributable to this misconception. In contrast, the demonstration by Mainord et af.(1%5) of the effects of ‘confrontation ’ in group therapy on the number of behavioural ‘positive incidents ’ recorded by ward staff shows how a simplified, directive technique may be of value with chronic patients with whom it is unrealistic to hope to establish a conventional therapeutic relationship. Psycho-

analytic techniques are similarly offered to all in a remarkably uniform way. Although psychoanalysts are often very selective in offering treatment, if they do so at all there is little attempt to systematically tailor the technique to the patient. If personality and treatment techniques interact in their effects upon outcome, then it is hardly surprising that therapies based on these uniformity assumptions (Kiesler, 1%6) show no consistent evidence of effectiveness.




Essential to the evaluation of psychotherapy is the appraisal of the theories upon which it is based. Although it is obviously impossible to discuss these fully in a single paper such as this, three issues for which recent research has implications will be considered. First, even if universal principles of therapy are necessary, it is possible that traditional therapy has chosen bad principles. Bierman (1%9) reviews evidence suggesting that active, warm therapist behaviour leads to greater and more productive participation by the client. This is in contrast with the passive role enjoined by Freudian and early Rogerian theory. Taken at face value, such a conclusion might help to account for the equivocal results of therapies based on these traditional theories. Secondly, the unconditionality of regard and concern by the therapist required by Rogerian theory is at variance with the actual conduct of client-centred therapy by Rogers and others. Several studies have shown sequential dependencies between client and therapist statements (e.g. Murray, 1956; Murray & Jacobson, 1971; Truax, 1966,1%8), and the evidence from Truax (1968) relating the degree of this interdependence to outcome suggests that it is the theory which should be changed to fit the practice, rather than the other way round. The effectiveness of client-centred therapy might be enhanced if therapists were less inhibited by the ideal of unconditionality. Perhaps they should be encouraged to reinforce or elicit self-exploration by systematic intensification of the condition-

Psychotherapy research 203 ality which appears to be a therapeutic element FURTHER IMPLICATIONS FOR CLINICAL WORK in their approach as currently practised. Thirdly, there is the general problem of the In this second part of the paper, some implicascientific status of the elaboratetheoretical struc- tions of psychotherapy research for other areas tures erected around traditional relationship of clinical psychology will be outlined. For therapies. Although it would be rash to dismiss convenience, the field will be divided into assessthem all as in principle unscientific, these the- ment and treatment procedures. ories do appear inadequate bases for research In the field of assessment it is apparent that and practice. In particular, their notorious resis- psychological tests of personality are of very tance to falsification militates against a sound doubtful clinical utility (Mischel, 1968). One progression from theory, to experiment, to con- implication of this view is that psychological firmed clinical utility. This does not mean that, formulations of patients’ problems are likely to for example, none of Freud’s ideas can be tested depend, to some degree at least, upon interviewscientifically. Although Farrell (1964) suggests ing procedures. Research on the interactive that psychoanalytic theory is a premature em- processes of psychotherapy offers some suggespirical synthesis, offered in advance of the evi- tions as to how we might proceed with this, as dence, Kline (1972) shows that some of this well as warning against some of the likely evidence is emerging. Kline’s review suggests pitfalls of the interviewas aninformation-seeking that Freudian theory accounts for some objec- method. One example of each of these will be tive data not predictable from any other psy- given. chological theory. However, it remains true that Research carried out within the client-centred much of the theory espoused by psychoanalysts framework offers some basis for suggesting that is beyond the scope of his review or has yet to a patient’s exploration of his problems, as he find empirical verification. In the former cate- experiencesthem, can be enhanced by provision gory are most of the psychoanalytic beliefs of the so-called ‘therapeutic conditions’ of emconcerning the conduct and mechanism of ther- pathy, warmth and genuineness (Shapiro, 1%9; apy; and in the latter are the postulated pre- Truax & Carkhuff, 1%7). Both correlational and genital psychosexual origins of the personality experimental studies have shown this relationsyndromes and of many of the disturbances ship. If, therefore, self-exploration as defined in treated by analysis. Psychotherapy generally Truax’s scale is one’s goal, then one should places enormous reliance on theorizing of the attempt to offer the ‘therapeutic conditions’ as psychoanalytic sort. The important question, in defined by the relevant scales. There is evidence the present context, is whether the characteris- from these researches that the conditions are tically ‘pre-scientific ’ manner of psychoanaly- teachable. Although the status of the Truax tically based therapies is a necessary feature of scales of warmth and genuineness in Britain is treatments making use of interpersonal proces- in doubt (Shapiro, 1973), the value of this ses, ‘insight’, selfexploration, etc. If not, then approach in eliciting patient self-exploration a more rigorous approach to theory construction warrants investigation. This does not imply, of and evaluation might be expected to yield better course, that the treatment ensuing upon a for‘outcomes’. Important ingredients of this ap- mulation gained as a result of such selfproach would include not only the specification exploration need be relationship-oriented. It of treatment procedures, their objectives and might very well be behaviourally defined and individual patients’ suitability for the treat- executed. The pitfalls of assessment by interview are ments, but also safeguards against alternative explanations of results such as placebo effects illustrated by studies indicating how an inter(A. K. Shapiro, 1971) and demand characteris- viewer’s behaviour can influence the client’s responses. Studies of sequential dependencies tics ( h e , 1%2). in early therapy sessions (e.g. Caracena, 1%5)

D. A. SHAPIRO suggest that therapist verbalizations categorized the Mickelson & Stevic studies. Indeed, Morris as ‘approach’ responses elicit or reinforce ex- & Suckerman (1974a, b) have demonstrated the pressions of hostility or dependency. The impli- effect of therapist warmth on the effectiveness cation of this is that, in attempting to determine of systematic desensitization, whether this is the extent of (say) a patient’s hostility, the carried out ‘live’ (Morris & Suckerman, 1974u), psychologist must guard against unwitting ten- or by an automatedprocedurewith a pre-recorded dencies to ‘approach’ or ‘avoid’, and thus therapist (Moms & Suckerman, 1974b). influence, the expression of this feeling. Similar mechanisms are probable with other affects. It CONCLUSIONS is very instructive to listen to a tape recording of oneself conducting a supposedly ‘ objective ’ This review suggests that the literature does interview with the ‘approach-avoidance ’ cri- not justify, and may indeed make untenable, the teria (Bandura et al., 1W)in mind. view that social relationships have no place in In treatment, students learning behaviour ther- the modification of psychological disturbances. apy frequently complain that the patient pre- It implies that, with greater specificationof goals, sents them with problems not readily dealt with techniques and client and therapist characterisby the behavioural techniques in use. Perhaps tics, the nature and extent of the contribution the client-centred ‘therapeutic conditions’ could of social relationships to treatment outcomes will serve as a useful adjunct to behaviour therapy. become increasingly clear. Similarly, the operaTwo studies have found the level of the Truax tion of interpersonal processes between the conditions offered by interviewersto affect their clinical psychologist and his patients in other efficacy as behaviour modifiers. Vitalo (1970) contexts is a valuable object of concern. In found that Taf€el-typeverbal conditioningfollow- contrast, it would appear that to argue about ing a 10-15 minute interview was effective only ‘whether psychotherapy works or not ’ is futile when the interviewer was one who had shown (Bergin, 1971; Kiesler, 1966). Much of the high therapeutic conditions in a separate assess- dissatisfaction with the conventional psychoment of his work with patients. Mickelson & therapy outcome literature stems from the fact Stevic (1971) found that high-conditions coun- that the word ‘psychotherapy’ is uselessly sellors were more effective than low-conditions vague. If this is so for research, how or why is counsellors in inducing information-seeking be- the word admissible in clinical work? A conhaviour by high-school students in ‘behavioural venient label, whose currency derives from counselling’ concerned with vocational and over-use of a medical model in ways which are educational goals. both imprecise and incorrect, has become a prop It might seem that the efficacy of automated for conceptual confusion. Perhaps the way out desensitization (Krapfl & Nawas, 1%9) would of the impasse with which this paper began is to argue against the possibility I have been discuss- advise clinical psychologists against the routine, ing, namely that the quality of the therapist- unquestioning practice of ‘psychotherapy ’, but patient relationship may affect the outcome of not against the exploration and evaluation of the behaviour therapy. However, this conclusion contribution of various interpersonal techniques would not be justified. Although the absence of to their work. a therapist rules out therapist effects, once he is present, he may well affect (for either good or ill) even a process which could have been set ACKNOWLEDGEMENTS up to run without him. Similarly, the absence of This work was supported by a Bethlem-Maudsley sex-pairing effects in desensitization (Nawas & Research Fund grant to Dr R. F. Hobson. The idea Pucel, 1971) is poor evidence against the sort of of writing this paper arose in conversations with Dr relationship factors implied by the Vitalo and M. B. Shapiro.


Psychotherapy research



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Some implications of psychotherapy research for clinical psychology.

Br. J. med. Psychol. (197S), 48. 199-206 Printed in Greut Britain 199 Some implications of psychotherapy research for clinical psychology BY D. A. S...
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