You are on page 1of 9

In Review

Implications of Psychotherapy Research for


Psychotherapy Training
William E Piper, PhD1

This review article considers implications of psychotherapy research for psychotherapy


training. It considers 8 themes that characterize the research literature. The themes involve
outcome findings, common factors, empirically supported therapies, patient treatment
matches, therapy manuals and practice guidelines, brief therapies, combinations of
medication and psychotherapy, and group therapies. Each theme represents a controversial
issue that has implications for the content of contemporary psychotherapy curricula. To
assist trainees in becoming well-informed therapists, themes and implications such as these
should be covered as part of their introduction to learning about the psychotherapies. To
understand the themes and implications, as well as new findings that continually emerge
from the research literature, trainees also need to be familiar with basic research methods
and evaluative criteria, subjects that can also be covered as part of their introduction to the
psychotherapies. As their training proceeds, research findings can be integrated with the
development of their clinical skills in a broad range of psychotherapies.
(Can J Psychiatry 2004;49:221–229)
Information on author affiliations appears at the end of the article.

Highlights
· This review article highlights 8 themes that characterize the psychotherapy research literature.
Each represents a controversial issue.
· Implications of the 8 themes for psychotherapy training in psychiatry are presented.
· It is recommended that trainees be familiar with such themes and their implications for
training, as well as with basic research methods and evaluative criteria, as part of their
introduction to a broad range of psychotherapies.

Key Words: psychotherapy research, psychotherapy training


his article considers the implications of psychotherapy re- mately 3.4% between 1987 and 1997 (3). The demand among
T search for psychotherapy training in psychiatry. Recent psychotherapists with an MD actually increased. According
to current practice as reported in these surveys, the need for
surveys conducted in Canada and the US indicate that psychi-
atrists continue to spend a substantial amount of time provid- training in psychotherapy remains strong.
ing psychotherapy. In a survey of Canadian psychiatrists,
This article is directed to 3 groups of readers. First are admin-
Leszcz and colleagues found that 92% spent almost one-half
istrators responsible for developing and approving psycho-
of their clinical time engaged in psychotherapy (1). A survey therapy training programs. This group includes university or
of the office practices of US psychiatrists conducted by hospital directors of resident training, directors of continuing
Olfson, Marcus, and Pincus indicated that 79% of their pa- medical education (CME), and members of curriculum com-
tients received psychotherapy in 1995 (2). Although the per- mittees. Second are teachers and supervisors who directly
centage had decreased from 89% in 1985, it remained provide psychotherapy training. Third are the consumers; that
substantial. Weissman and Sanderson reported that the US is, those who receive psychotherapy training and provide psy-
Medical Expenditure Panel Survey found the demand for psy- chotherapy to patients. This group includes residents and
chotherapy in the general population unchanged at approxi- licensed clinicians who participate in CME training.

Can J Psychiatry, Vol 49, No 4, April 2004 W 221


The Canadian Journal of Psychiatry—In Review

Scientific journals continually publish a large volume of A simple approach is tempting. Learning to be a skillful psy-
research articles on psychotherapy. Adair and Vohra have chotherapist is a challenging task that takes time, effort, and
described the difficult challenge that all researchers face in hard work, even when trainees feel confident about the useful-
keeping up with the current literature (4). The difficulty for ness of psychotherapy. Highlighting ambiguities, doubts, and
providers and consumers of psychotherapy training is even uncertainties can be problematic, particularly if this is done in
greater: many are primarily clinicians who often do not have a way that leads to expectations of poor outcome, weak moti-
the resources to monitor new publications comprehensively. vation, or diminished morale. Most trainees desire direct reas-
Even when research articles are available, however, they are surance that they are learning both effective techniques and
often not read and thus do not inform psychotherapy training. how to provide them skillfully.
There are several reasons for this. Researchers usually write
Although tempting, a simple approach has several disadvan-
for other researchers, not for administrators, teachers, or train-
tages. The outcome of psychotherapy is multiply determined;
ees. Articles are often difficult to understand because they are
therapist technique is but a single factor. Choosing a promising
laden with jargon. Much research is regarded as artificial and
therapy from a list and attempting to conduct it skillfully will
not applicable to clinical settings (for example, randomized
not guarantee success. Patient, therapist, and relationship fac-
clinical trials [RCTs] of therapy efficacy). Much psychother-
tors are also influential and need to be considered in treating
apy research focuses on brief therapies and neglects long-term
individual patients. To assume otherwise will lead to disap-
therapies that are still provided by many private practitioners.
pointments. Similarly, therapists following a simple model of
In addition, research reports are usually written tentatively,
treatment will be disillusioned when the inevitable limitations
with many qualifications and limitations that do not inspire
of particular techniques become evident. As the field continues
confidence in clinicians, teachers, and trainees.
to develop, a relatively simple approach will not help the thera-
Another problem is the lack of research on training and super- pist evaluate evidence for new or emerging techniques; to do
vision. There is no body of research literature comparing the so, one must be a well-informed consumer. It is the responsibil-
effectiveness of different approaches to training and supervi- ity of training programs to produce such trainees.
sion. Training models are based on tradition, not research. For
example, didactic course work, supervised treatment of cases, In taking a relatively complex approach, this article highlights
and personal psychotherapy is the time-worn model of most 8 themes that characterize the current psychotherapy research
psychodynamic therapy training (5). A more fundamental literature. Each theme represents a controversial issue that has
problem is the lack of training for effective supervision. implications for psychotherapy training and practice. Many of
Because most training programs devote little attention to the the themes are related to each other and represent different
topic of supervision, there is little to study. Most supervisors positions in regard to the controversial issues. Before present-
must rely on their personal experiences as a guide to conduct- ing these themes, which are expressed as conclusions, their
ing supervision. historical context is briefly considered.

Either a relatively simple or a relatively complex approach Just 50 years ago, there were no controlled or comparative
can be taken in addressing the implications of psychotherapy outcome studies of the psychotherapies. Nevertheless, in
research for training and in making recommendations for cur- 1952, Eysenck published a review claiming that psychother-
ricula. The simple approach would provide lists of therapies apy was not effective (6). He compared the outcome reports of
that have the most evidence of efficacy for particular prob- 24 studies, most of which involved psychodynamic therapies,
lems, provide references from the research literature, and with the outcome reports of 2 control studies involving
emphasize teaching those approaches in training programs. patients who had not received psychotherapy. Eysenck con-
cluded that two-thirds of the patients improved substantially
The more complex approach would also attend to evidence of
within 2 years, whether or not they received psychotherapy.
efficacy. However, instead of focusing on current lists of ther-
Subsequently, there were many criticisms of his review. It was
apies, problems, and references, this approach would direct
argued that patient samples and outcome criteria differed
readers to reviews of the research literature summarizing the
between the treatment studies and the control studies, that
specific evidence of efficacy. The more complex approach
control patients actually received treatment, and that his inter-
would also present limitations and controversies associated
pretation of the treatment studies’ results was biased.
with the evidence. This approach would require familiarity
with basic research methodology and evaluative criteria, Although Eysenck did not appear to win the debate on aca-
which would have to be covered as part of the training. It demic grounds, he scored a victory on psychological grounds.
would emphasize general themes emerging in the field rather People invested in the practice of psychotherapy seemed
than simply listing specific findings. It would convey tenta- embarrassed, off-balance, and demoralized. In time, the
tive rather than definitive observations about the evidence. debate set the stage for a counteroffensive that included

222
W Can J Psychiatry, Vol 49, No 4, April 2004
Implications of Psychotherapy Research for Psychotherapy Training

controlled studies and new reviews. Probably the most influ- research investigator and the theoretical orientation of the treat-
ential review was that of Smith, Glass, and Miller (7). Using a ment that emerges as most effective in comparative outcome
new review method called metaanalysis, which involved cal- studies (12). After statistical adjustments are made for the alle-
culating an effect size for each outcome variable and then giance effect, the outcome differences among therapies usually
averaging the effect sizes across studies, they summarized the disappear. The strongest opponents of this theme are the advo-
results of 485 controlled studies. These authors concluded cates of the empirically supported therapies (EST) movement.
that psychotherapies in general are effective and that there is They claim that the therapies on their lists have evidence of
little difference in effectiveness among the different types of superiority over other therapies for specific diagnoses (13).
psychotherapies. These conclusions were regarded as inaccu- Other opponents are the advocates of aptitude–treatment inter-
rate by a number of people, many of whom were advocates of actions (ATI). This group believes that there are optimal
behaviour therapy (8). They attacked the review methodology matches between patients scoring high on a particular charac-
and the conclusions. Debate about the validity of metaanalysis teristic and specific therapies and patients scoring low on the
and the conclusions one can draw from it has continued to the same characteristic and other specific therapies. They contend
present time. Nevertheless, many metaanalyses continue to be that, when effect sizes are averaged across therapies in
published. In an extensive current review of the outcome liter- metaanalyses, these specific matches (interactions) become
ature, Lambert and Ogles (9) came to the same general conclu- obscured. Opponents also attribute the small number of out-
sions as Smith, Glass, and Miller and acknowledged that the come differences in comparative studies to such factors as
controversy has not subsided. Unfortunately, one of weak methodology; low power owing to small sample size;
Eysenck’s legacies is a polemical climate that has too often led treatment of mildly disturbed, single-diagnosis patients; use of
to attacks and counterattacks between vested-interest groups. brief therapies; and overreliance on symptoms as outcome
The latest example is the debate concerning the value of creat- criteria (14).
ing lists of “empirically supported therapies,” discussed
below as a controversial theme. Implications
Another strong force that has influenced the type of therapies Trainees should be familiar with metaanalysis as a review
studied and practised in North America is health care reform, method, together with its strengths and limitations. They
often referred to as the managed care movement. As should be aware of the findings of major metaanalytic reviews
third-party controller of health care funds, managed care com- that focus on the therapies for which they are being trained.
panies have favoured short-term therapies. Further, decisions
about which therapies to fund have frequently been influ- Theme 2: Common Factors of Therapies are
enced by practice guidelines. These are policy statements More Strongly Related to Outcome Than
from major organizations about the proper treatment of cer- Unique Factors
tain disorders. The preference for short-term therapies has
Common factors are therapeutic factors that are present across
created pressure for researchers to study them and compete in
therapies (for example, a helping relationship, a convincing
determining which therapies meet criteria for empirical sup-
rationale, and feedback concerning progress) (15). In con-
port. It has added fuel to the polemical climate that has charac-
trast, unique factors differ across therapies (for example,
terized psychotherapy research and has resulted in what some
interpretation of transference). Those who believe that there
believe to be extreme positions and simplistic claims that cer-
are few differences in outcome among most therapies, as indi-
tain techniques are superior. Within the context of these
cated by metaanalytic reviews, often attribute this to the pres-
developments, the major themes that characterize the current
ence of common factors. In a series of studies of the actual
psychotherapy literature are considered next. Each is pre-
process of therapies with distinct orientations (that is,
sented as a conclusion. Following this, implications for train-
psychodynamic, cognitive-behavioural, and interpersonal),
ing are considered.
Jones and colleagues found that they had much in common,
particularly in regard to what appeared to be the effective
Theme 1: There Are Few Differences in the ingredients of favourable change (16). Separate research has
Outcomes of Most Psychotherapies found it difficult to demonstrate that the unique theoretical
Metaanalytic reviews have strongly supported this theme, base of different therapies accounts for their effective-
which represents what has been referred to as “the dodo bird ness—additional evidence for the greater importance of com-
effect” (10,11); that is, everybody has won, so all shall have mon factors. For example, a recent review of the literature
prizes. When differences among therapies have emerged, they found little evidence for the unique theoretical underpinnings
have often been attributed to “the allegiance effect.” This refers of cognitive-behavioural therapy (CBT) (17). Similarly, a
to the strong relation between the theoretical orientation of the review of the literature found little evidence that eye

Can J Psychiatry, Vol 49, No 4, April 2004 W 223


The Canadian Journal of Psychiatry—In Review

movements were a necessary component of eye-movement Alternative methods include naturalistic, correlational,
desensitization and reprocessing therapy (18). process–outcome, structural modelling, and qualitative
approaches, each of which can provide valid data about ther-
Implications apy outcomes.
Trainees should be familiar with the common factors and
learn how to facilitate them skillfully in their clinical work. Implications
Trainees should be familiar with the criteria and lists of thera-
Theme 3: The Criteria for Empirically pies associated with the EST movement. They should also be
Supported Therapies Should be Used to Select aware of its limitations. Important patient, therapist, and rela-
Which Therapies Are Taught in Training tionship factors should be covered, as well as the many differ-
Programs ent approaches to studying the effectiveness of the
Criteria for empirically supported therapies and lists of thera- psychotherapies.
pies that meet those criteria were originally championed by an
American Psychological Association task force (19). Subse- Theme 4: There Are Some Good Matches
quent lists have been prepared (20,21). The criteria have Between Specific Patient Characteristics and
emphasized RCT designs, treatment manuals, homogeneous Specific Therapies
diagnostic groups, and independent replications. Many Evidence for good matches has come from the EST movement
advocates have been from the behavioural and cognitive- and ATI research. The former has focused on patient diagno-
behavioural orientations, with associated treatments dominat- ses and the latter on patient personality dimensions. Perhaps
ing the lists. To their credit, they have advocated an account- the strongest evidence for matches, as identified by the EST
able, evidence-based approach to choosing treatment for movement (21), involves the anxiety disorders and forms of
specific problems. However, their approach has been viewed CBT. Examples include CBT for panic disorder and general-
by many as premature and restrictive. Opponents of the EST ized anxiety disorder, exposure for phobias, and exposure and
movement, which have included both clinicians and research- response prevention for obsessive–compulsive disorders.
ers, have criticized the use of RCT methodology. While
Evidence from ATI studies has most often demonstrated a
accepting the strong internal validity of RCTs (that is, having
match between a personality dimension and 2 or more distinct
confidence that the treatment was responsible for the outcome
therapies. Researchers have emphasized the importance of
differences), they have emphasized the weak external validity
making a priori, theoretically based predictions in ATI stud-
(that is, generalization to clinical practice) of RCTs. They
ies; this enhances the chances of finding a match as well as the
have argued that clinicians usually do not accept patients ran-
credibility of the findings. Two examples that are frequently
domly, treat patients restricted for age and sex, treat patients
cited come from the work of Beutler and colleagues (27) con-
with minimal comorbidity, or use manualized, time-limited
cerning the personality dimensions of externalization and
therapies (22). They have described RCT studies as tests of
reactance. Externalizing patients responded better to skills-
efficacy, not tests of effectiveness (that is, studies conducted
oriented, symptom-focused therapies, whereas internalizing
in natural clinical settings). In the UK, difficulties have been
patients responded better to insight-oriented therapies.
reported in teaching general practitioners basic CBT skills
Reactance refers to resistance to directives. High-reactant
(23) and in bringing about superior improvement with CBT,
patients responded better to self-directive therapies, whereas
compared with nondirective counselling (24). These findings
low-reactant patients responded better to directive therapies
highlight the difficulty of transferring the practices of
(28). Another example concerns quality of interpersonal rela-
research clinics that conduct RCTs to primary care settings.
tionships. Patients with a history of relatively gratifying inter-
Opponents of the EST movement have also emphasized the personal relationships do better in confrontive, insight-
importance of nondiagnostic patient characteristics, therapist oriented therapies, while patients with a history of relatively
characteristics, and patient–therapist relationship characteris- problematic relationships do better in supportive psycho-
tics in affecting outcomes. To counter the EST movement, therapies. This match has been found in both individual and
some opponents have created their own task force and com- group therapies (29,30). The ATI approach may have particu-
piled lists of empirically supported relationships (25,26). lar promise with group therapies. A review of the
These lists highlight such relationship characteristics as the group-therapy literature found that 83% of the ATI studies
therapeutic alliance, goal consensus, self-disclosure, and had significant findings (31).
group cohesion in group therapies. Opponents have also
argued that RCTs suffer from dropouts, which undermines Implications
random assignment, and that they are but one of many meth- Trainees should be aware of the specific matches identified by
ods to investigate the effectiveness of the psychotherapies. the EST movement. They should also be familiar with

224
W Can J Psychiatry, Vol 49, No 4, April 2004
Implications of Psychotherapy Research for Psychotherapy Training

examples of effective matching of patient characteristics and Implications


therapies from the ATI literature. Manuals and practice guidelines are useful tools for teaching
trainees the basic theoretical and technical orientations asso-
ciated with different therapies; therefore, they should be a part
Theme 5: Therapy Manuals and Practice of psychotherapy training. However, teachers should empha-
Guidelines Should Be Used for Training and size the potential problems associated with rigid adherence to
Clinical Practice manuals and practice guidelines and provide other important
components of training, such as didactic seminars, observa-
Psychotherapy researchers developed manuals to standardize tion opportunities (involving trainees and faculty), and close
the therapist’s theoretical and technical orientation. Reducing supervision of cases.
therapist variability can strengthen the internal validity of tri-
als. The use of manuals spawned adherence measures, which
Theme 6: Brief Therapies Should Be Provided
are used to quantify the degree to which therapists follow
manuals. For advocates of empirically supported therapies,
to Patients Before Long-term Therapies and
the use of manuals is an essential criterion. Teachers and clini-
Should Be Emphasized in Training Programs
cians have had mixed reactions. Manuals vary considerably in The vast majority of psychotherapy research conducted in
length (for example, from 20 pages to book length) and in the North America over the last 50 years has focused on relatively
degree to which they instruct therapists to comply or be flexi- brief therapies; that is, of 20 sessions or less. For example, in
ble in providing the technique. There has been concern that Smith, Glass, and Miller’s review of 485 studies (7), the
manuals may contribute to therapist rigidity and less satisfac- included therapies averaged 11 weeks’ duration. Surveys of
tory outcome. This concern has spawned competence mea- therapies provided in outpatient clinics also indicate a pre-
sures, which indicate how skillfully the therapist provides dominance of brief therapies. There are several reasons for the
treatment. Evidence from a large-scale psychotherapy train- high prevalence of brief therapies in clinics and research stud-
ing study indicates that therapists trained with manuals ies. First, there are strong economic pressures from third-
became more adherent but less competent in providing ther- party payers to cover brief treatments. Second, many patients
apy (32). Concern about the possible negative effects of using expect and desire brief treatments. Third, therapists from
manuals has been greater among therapists from some orien- some orientations (for example, psychodynamic) have been
tations (for example, psychodynamic) than others (for exam- interested in applying their techniques innovatively in brief
ple, cognitive-behavioural). Psychodynamic therapists therapies (for example, early-transference interpretation).
follow a more patient-driven model, where uncertainty about Fourth, considerable research evidence from dose–response
how the session begins and what follows is part of the studies indicates that many patients can accomplish important
intended unpredictable process. If the therapist greatly deter- changes in brief periods of time. Studies by Howard and col-
mines the content or provides standard responses, the process leagues (38) and Kopta and colleagues (39) suggest that over
is not considered to be psychodynamic. Thus, some manuals 50% of patients experience significant improvement after 8
for psychodynamic therapy (33) have been designed to pro- sessions and 75% after 26 sessions.
vide general guidelines and to encourage therapists to use Others have been more skeptical about what brief therapies
their judgement regarding interventions (for example, the can achieve. They have been more interested in evidence of
number and timing of interpretations). Adherence measures clinically significant, rather than merely statistically signifi-
for such therapies must assess the degree to which general cant, change. Clinical significance is based on normative
guidelines are followed. They should monitor not only what information and requires that, after treatment, the patient’s
the therapist should be doing but also what the therapist problems are more characteristic of normal than of pathologi-
should not be doing (34). Both psychodynamic therapy teach- cal scores of disturbance. In a large survey using the more
ers and cognitive therapy teachers agree that training compe- stringent criterion of clinical significance, Lambert, Hansen,
tent therapists takes considerable time and goes well beyond and Finch found that only 50% of patients achieved improve-
teaching therapists to adhere to manuals (35,36). ment after 21 sessions and 75% after more than 40 sessions
(40). In a follow-up to the well-known National Institute of
Many of the same issues affect the use of practice guidelines Mental Health (NIMH) collaborative study of depression,
(37). Advocates believe that they usefully present Shea and colleagues found that 16 weeks of CBT or interper-
state-of-the-art procedures for treating patients with specific sonal therapy or antidepressant medication were insufficient
disorders. Opponents argue that they prematurely bring about to achieve full remission and lasting recovery for most of the
closure in areas of treatment that need development and that patients (41). In our research team’s recent clinical trial of 20
they soon become obsolete. sessions of dynamically oriented interpretive or supportive

Can J Psychiatry, Vol 49, No 4, April 2004 W 225


The Canadian Journal of Psychiatry—In Review

therapy (29,42), less than one-half of the patients achieved Implications


both clinically significant and reliable change by the end of In addition to learning how to provide brief therapies, trainees
treatment. Although these levels were maintained through should be made aware of the considerable research literature
1 year of follow-up, they did not increase. In regard to specific that supports their effectiveness; they should also be made
outcome criteria, change in brief therapies more often aware of their limitations in regard to the types of change that
involves symptoms than interpersonal or personality change. are possible and the number of patients who do not achieve
High comorbidity of disorders (for example, major depres- clinically significant change. Similarly, training in long-term
sion and personality disorder), which is seen in community therapies should emphasize indications for this form of treat-
clinics more often than in university-based research clinics, is ment as well as the unproven nature of its effectiveness.
also associated with less impressive improvements (43). In
general, all these findings suggest that the effects of brief ther- Theme 7: The Combination of Psychotherapy
apies are both encouraging and disappointing—the glass is and Medication Results in Better Outcomes for
both half full and half empty. Most Problems Than Either Treatment Alone
In a recent literature review, Thase and Jindal (46) conclude
Although the modal form of long-term psychotherapy has that there is growing evidence of the superiority of combined
been psychodynamic therapy with a planned duration of treatments for recurrent and severe major depression, schizo-
1 year or more, Crits-Christoph and Barber (44) have noted phrenia, obsessive–compulsive disorder, and bipolar affec-
that it may also represent recurrent brief therapies, mainte- tive disorder, as exemplified by the Keller and others study
nance therapies, or brief therapies that required more time (47). They argue persuasively that previous reviewers who
than initially expected. Very few outcome studies of found little evidence that the combination added benefits did
long-term psychotherapies exist. Those that have been con- not sufficiently take into account study design and statistical
ducted tend to be retrospective or prospective but lack com- limitations. Thase and Jindal do not believe that there is at
parison conditions and random assignment. Thus, the present sufficient evidence to support the routine use of com-
scientific evidence for their effectiveness is less extensive and bined treatments for milder depressive and anxiety disorders,
strong, compared with the brief therapies. This indicates that particularly in light of the cost of providing both.
their effectiveness is unproven, not that they have been shown
Implications
to be ineffective. In fact, dose–response studies have demon-
Trainees should be aware that combined treatment is widely
strated that some patients do not improve unless they receive
accepted and that there is evidence of benefit for several disor-
long-term therapy. Several factors have discouraged research
ders. They should also be aware that current evidence does not
on long-term therapies. Economic conditions have high-
appear to support the routine use of combined treatment for
lighted the importance of learning about brief therapies, ethi-
the most prevalent, less severe disorders.
cal concerns have precluded the use of certain long-term
control conditions, and research studies of long-term therapy
are considerably more expensive, time-consuming, and diffi-
Theme 8: Group Therapies Have Outcomes
cult to complete. Nevertheless, conducting studies of Similar to Individual Therapies
long-term psychotherapy is a much-needed research objective Reviews of comparisons between the effectiveness of individ-
that granting bodies and researchers will, one hopes, pursue. ual and group therapies have provided consistent evidence of
virtually equivalent outcomes (48,49). Because multiple
patients can be treated in groups, a strong argument can be
Many clinicians believe that patients with long-term made for their greater cost-effectiveness. Despite such find-
characterological problems that have not responded well to ings and conclusions, group therapies have been underused.
brief therapies or patients who require improvements in func- Resistance appears to come from both patients and therapists,
tioning that extend beyond improvements in symptoms are who typically experience greater loss of control, individual-
appropriate for long-term therapy. Many teachers of psycho- ity, understanding, privacy, and safety in the group situation.
therapy also believe that long-term cases are excellent learn- Given the current economic strain in the health care field, it
ing opportunities for trainees. Nevertheless, skeptics can be expected that pressure to use group therapies will
emphasize the unproven nature of long-term therapies and increase.
maintain that it is unethical for therapists to provide long-term
therapy to patients with problems that respond well to brief Implications
therapies. They argue that choice of therapy should be a prod- Trainees should be aware of the similarity of outcomes for
uct of the patient’s informed consent regarding the cost- individual and group therapies, and educators should increase
effectiveness of different therapies (45). training in group therapies.

226
W Can J Psychiatry, Vol 49, No 4, April 2004
Implications of Psychotherapy Research for Psychotherapy Training

Other controversial themes that characterize the field of psy- treating problems that are severe and recurrent, and the fact
chotherapy research also have implications for training. Three that many teachers find them to be a useful means of learning
additional examples follow. First is the theme that supportive about patients and psychotherapy, long-term therapies should
therapy is a distinct form of psychotherapy that is effective for be included in the curriculum. A similar argument can be
many types of problems (50,51). Second is the theme that inte- made for including couple and family therapies.
gration of different techniques has become a recommended
The combination of psychotherapies and medications is a nat-
approach to the practice of psychotherapy; examples include
ural and important topic for the curriculum of psychiatrists in
cognitive behavioral analysis system of psychotherapy
psychotherapy training because they have general training in
(CBASP) for chronic depression (52) and coping strategies
medicine and, therefore, a unique area of expertise among
therapy (CST) for bulimia nervosa (53). Third is the theme
mental health professionals. Further, given their expected
that transference and countertransference are important
leadership role in many mental health teams, it is important
events to be recognized and dealt with in all types of psycho-
that psychiatrists receive training in supervising, consulting,
therapy, not just in dynamically oriented psychotherapies
and making referrals.
(54). Space limitations do not permit elaboration and consid-
eration of the implications of these and other themes. It is important that the curriculum not be restricted to the
acquisition of specific clinical skills. As indicated previously,
the field of psychotherapy research is continually evolving in
Discussion terms of both methodology and content. Teachers should be
The implications of the themes that have emerged from the encouraged to integrate research evidence of effectiveness,
research literature suggest specific content for a curriculum in reviews of the literature, and the latest studies that contribute
psychotherapy training. To be informed consumers, trainees new information about the psychotherapies with the teaching
require training in basic research methodology. This includes of clinical skills. Obviously, research does not address many
becoming familiar with the different methods of reviewing areas of training. Hopefully, considerably more areas will be
research literature, such as metaanalysis; an appreciation of covered. In the meantime, there are some excellent resources
different approaches to studying the effectiveness of the based on considerable teaching and clinical experience that
psychotherapies; and knowledge of basic methodological and can help fill the gaps with reasonable suggestions. These
statistical weaknesses that affect the conclusions one can include publications by Cameron and colleagues (55–57).
make about studies. The objective is not to transform trainees Last but not least, trainees should be familiar with the contro-
into researchers but to provide trainees with a basic set of versial themes and implications highlighted in this article.
skills for understanding research literature that can be confus- Although they may heighten some uncertainties about the
ing. Trainees should be familiar with the EST movement, broad range of psychotherapies being taught, they will pro-
including its lists of treatments and disorders and its limita- vide a more realistic and enlightened perspective of the field,
tions. Similarly, trainees should be aware of good patient– commensurate with the goal of creating well-informed, com-
treatment matches from the aptitude-treatment literature. petent psychiatrists.
They should also be familiar with the empirically supported
relationships movement, including its lists and limitations.
References
Rather than taking sides, trainees should be encouraged to
develop a constructively critical perspective to both 1. Leszcz M, MacKenzie KR, el-Guebaly N, Atkinson MJ, Wiesenthal S. The CPA
practice research network findings from the third project, 2001. Part V: Canadian
movements. psychiatrists’ use of psychotherapy. CPA Bulletin 2002;34(5):28 –31.
2. Olfson M, Marcus SC, Pincus HA. Trends in office-based psychiatric practice.
The extensive presence of brief therapies in the research liter- Am J Psychiatry 1999;156:451–7.
ature and in clinics across North America indicates that they 3. Weissman MM, Sanderson WC. Promises and problems in modern
psychotherapy: the need for increased training in evidence-based treatments. In:
should definitely be prominent in the curriculum. They Hager M, editor. Modern psychiatry: Challenges in educating health
professionals to meet new needs. New York: Josiah Macy Jr Foundation; 2002.
include brief dynamic therapy, CBT, and interpersonal ther- p 132–65.
apy. Both individual and group forms of these therapies 4. Adair JG, Vohra N. The explosion of knowledge, references, and citations.
Psychology’s unique response to a crisis. Am Psychol 2003;58(1):15–23.
deserve attention. Accompanying these therapies are treat- 5. Binder JL. Issues in teaching and learning time-limited psychodynamic
ment manuals that can be constructively used in training. psychotherapy. Clin Psychol Rev 1999;19:705–19.
6. Eysenck HJ. The effects of psychotherapy and evaluation. J Consult Psychol
Limitations associated with the use of the brief therapies and 1952;16:319–24.
their manuals need to be considered. Evidence for the 7. Smith ML, Glass GV, Miller TI. The benefits of psychotherapy. Baltimore (MD):
The Johns Hopkins University Press; 1980.
effectiveness of long-term therapies, both individual and
8. Rachman SJ, Wilson GT. The effects of psychological theory. New York:
group, is not of the same type or as strong as the evidence for Pergamon Press; 1980.
the brief therapies. Nevertheless, given the other types of evi- 9. Lambert MJ, Ogles BM. The efficacy and effectiveness of psychotherapy. In:
Lambert MJ, editor. Bergin and Garfield’s handbook of psychotherapy and
dence of their effectiveness, their potential usefulness in behavior change. 5th ed. New York: John Wiley and Sons Inc; 2004. p 139–93.

Can J Psychiatry, Vol 49, No 4, April 2004 W 227


The Canadian Journal of Psychiatry—In Review

10. Luborsky L, Rosenthal R, Diguer L, Andrusyna TP, Berman JS, Levitt JT, and 36. Dobson KS, Shaw BF. The training of cognitive therapists: what have we
others. The dodo bird verdict is alive and well—mostly. Clin Psychol Sci Prac learned from treatment manuals? Psychotherapy 1993;30:573–7.
2002;9:2–12. 37. Sanderson WC. From the literature. The case for evidence-based psychotherapy
11. Rosenzweig S. Some implicit common factors in diverse methods of treatment guidelines. Am J Psychother 1998;52:382–7.
psychotherapy. Am J Orthopsychiatry 1936;6:412–5. 38. Howard KI, Kopta SM, Krause MS, Orlinsky DE. The dose–effect relationship
12. Luborsky L, Diguer L, Seligman DA, Rosenthal R, Johnson S, Halperin G, and in psychotherapy. Am Psychol 1986;41:159–64.
others. The researcher’s own therapeutic allegiances: A “wild card” in 39. Kopta SM, Howard KI, Lowry JL, Beutler LE. Patterns of symptomatic recovery
comparisons of treatment efficacy. Clin Psychol Sci Prac 1999;6:95–132. in psychotherapy. J Consult Clin Psychol 1994;62:1009–16.
13. Chambless DL. Beware of the dodo bird: the dangers of overgeneralization. Clin 40. Lambert MJ, Hansen NB, Finch AE. Patient-focused research: using patient
Psychol Sci Prac 2002;6:13–6. outcome data to enhance treatment effects. J Consult Clin Psychol
14. Rounsaville BJ, Carroll KM. Commentary on dodo bird revisited: why aren’t we 2001;69:159–72.
dodos yet? Clin Psychol Sci Prac 2002;6:17–20. 41. Shea MT, Elkin I, Imber SD, Sotsky SM, Watkins JT, Collins JF, and others.
15. Messer SB, Wampold BE. Common factors are more potent than specific therapy Course of depressive symptoms over follow-up. Findings from the National
ingredients. Clin Psychol Sci Prac 2002;6:21–5. Institute of Mental Health Treatment of Depression Collaborative Research
16. Ablon JS, Jones EE. Validity of controlled clinical trials of psychotherapy: Program. Arch Gen Psychiatry 1992;49:782–7.
findings from the NIMH Treatment of Depression Collaborative Research 42. Piper WE, McCallum M, Joyce AS, Azim HF, Ogrodniczuk JS. Follow-up
Program. Am J Psychiatry 2002;159:775–83. findings for interpretive and supportive forms of psychotherapy and patient
17. Parker G, Roy K, Eyers K. Cognitive behavior therapy for depression? Choose personality variables. J Consult Clin Psychol 1999;67:267–73.
horses for courses. Am J Psychiatry 2003;160:825–34. 43. Reich JH, Vasile RG. Effect of personality disorders on treatment of Axis I
18. Davidson PR, Parker KCH. Eye movement desensitization and reprocessing conditions: an update. J Nerv Ment Dis 1993;181:475–84.
(EMDR): a meta-analysis. J Consult Clin Psychol 2001;69:305–16. 44. Crits-Christoph P, Barber JP. Long-term psychotherapy. In: Snyder CR, Ingram
19. Task Force on Promotion and Dissemination of Psychological Procedures. RE, editors. Handbook of psychological change. New York: John Wiley and
Training in and dissemination of empirically validated psychologist treatments: Sons Inc; 2000. p 455–73.
report and recommendations. Clin Psychol 1995;48:3–23. 45. Beahrs JO, Gutheil TG. Informed consent in psychotherapy. Am J Psychiatry
20. Chambless DL, Sanderson WC, Shoham V, Bennett Johnson S, Pope KS, 2001;158:4–10.
Crits-Christoph P, and others. An update on empirically validated therapies. Clin 46. Thase ME, Jindal RD. Combining psychotherapy and psychopharmacology for
Psychol 1996;49:5–18. treatment of mental disorders. In: Lambert MJ, editor. Bergin and Garfield’s
21. Chambless DL, Baker MJ, Baucom DH, Beutler LE, Calhoun KS, handbook of psychotherapy and behavior change. 5th ed. New York: John Wiley
Crits-Christoph P, and others. Update on empirically validated therapies, II. Clin and Sons Inc; 2004. p 743–66.
Psychol 1998;51:3–16. 47. Keller MB, McCullough JP, Klein DN, Arnow B, Dunner DL, Gelenberg AJ,
22. Krause MS, Howard KI. “Between-group psychotherapy research and basic and others. A comparison of nefazodone, the cognitive behavioral analysis
science” revisited. J Clin Psychol 1999;55:159–70. system of psychotherapy, and their combination for the treatment of chronic
23. King M, Davidson O, Taylor F, Haines A, Sharp D, Turner R. Effectiveness of depression. N Engl J Med 2000;342:1462–70.
teaching general practitioners skills in brief cognitive behaviour therapy to treat 48. McRoberts C, Burlingame GM, Hoag MJ. Comparative efficacy of individual
patients with depression: randomised controlled trial. BMJ 2002;324:947–52. and group psychotherapy: a meta-analytic perspective. Group Dynamics: Theory,
24. Ward E, King M, Lloyd M, Bower P, Sibbald B, Farrelly S, and others. Research, and Practice 1998;2:101–17.
Randomised controlled trial of non-directive counselling, cognitive-behaviour 49. Burlingame GM, MacKenzie KR, Strauss B. Small group treatment: evidence for
therapy, and usual general practitioner care for patients with depression. I: effectiveness and mechanisms of change. In: Lambert M, editor. Bergin and
clinical effectiveness. BMJ 2000;321:1383–8. Garfield’s handbook of psychotherapy and behavior change. 5th ed. New York:
25. Norcross JC. Purposes, processes, and products of the task force on empirically John Wiley and Sons Inc; 2004. p 647–96.
supported therapy relationships. Psychotherapy 2001;38:345–56. 50. Pinsker H. A primer of supportive psychotherapy. Hillsdale (NJ): Analytic Press;
26. Steering Committee. Empirically supported therapy relationships: conclusions 1997.
and recommendations of the division 29 task force. Psychotherapy
51. Rockland LH. Supportive therapy: a psychodynamic approach. New York: Basic
2001;38:495–7.
Books; 1989.
27. Beutler LE, Engle D, Mohr D, Daldrup RJ, Bergan J, Meredith K, and others.
52. McCullough JP. Treatment for chronic depression. New York: Guilford; 2000.
Predictors of differential response to cognitive, experiential and self-directed
53. Tobin DL. Coping strategies therapy for bulimia nervosa. Washington (DC):
psychotherapeutic procedures. J Consult Clin Psychol 1991;59:333–40.
American Psychological Association; 2000.
28. Shoham-Salomon V, Hannah MT. Client-treatment interaction in the study of
54. Gabbard GO. Psychodynamic psychiatry in clinical practice. 3rd ed. Washington
differential change processes. J Consult Clin Psychol 1991;59:217–25.
(DC): American Psychiatric Press; 2000.
29. Piper WE, Joyce AS, McCallum M, Azim HFA. Interpretive and supportive
55. Cameron P, Ennis J, Deadman J, editors. Standards and guidelines for the
forms of psychotherapy and patient personality variables. J Consult Clin Psychol
psychotherapies. Toronto: University of Toronto Press; 1998.
1998;66:558–67.
30. Piper WE, McCallum M, Joyce AS, Rosie JS, Ogrodniczuk JS. Patient 56. Cameron PM, Leszcz M, Bebchuk W, Swinson RP, Antony MM, Azim HF, and
personality and time-limited group psychotherapy for complicated grief. Int J others. The practice and roles of the psychotherapies: a discussion paper. Can J
Group Psychother 2001;51:525–52. Psychiatry 1999;44(Suppl 1):18S–31S.
31. Piper WE. Client variables. In: Fuhriman A, Burlingame GM, editors. Handbook 57. MacKenzie KR, Leszcz M, Abbass A, Hollander Y, Kleinman I, Livesley J, and
of group psychotherapy. New York: John Wiley and Sons Inc; 1994. p 83–113. others. Guidelines for the psychotherapies in comprehensive psychiatric care: a
32. Henry WP, Schacht TE, Strupp HH, Butler SF, Binder JL. Effects of training in discussion paper. Can J Psychiatry 1999;44(Suppl 1):4S–17S.
time-limited dynamic psychotherapy: mediators of therapists’ response to
training. J Consult Clin Psychol 1993;61:441–7.
33. Piper WE, Ogrodniczuk JS. Therapy manuals and the dilemma of dynamically
Manuscript received and accepted December 2003.
oriented therapists and researchers. Am J Psychother 1999;53:467–82. 1
34. Ogrodniczuk JS, Piper WE. Measuring therapist technique in psychodynamic
Professor, Department of Psychiatry, University of British Columbia,
psychotherapies. Development and use of a new scale. J Psychother Pract Res Vancouver, British Columbia.
1999;8:142–54. Address for correspondence: Dr WE Piper, University of British
35. Binder JL. Observations on the training of therapists in time-limited dynamic Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1
psychotherapy. Psychotherapy 1993;30:592–8. e-mail: piper@interchange.ubc.ca

228
W Can J Psychiatry, Vol 49, No 4, April 2004
Implications of Psychotherapy Research for Psychotherapy Training

Résumé : Implications de la recherche sur la psychothérapie sur la formation en


psychothérapie
Ce rapport de synthèse examine les implications de la recherche sur la psychothérapie sur la
formation en psychothérapie. Il étudie 8 thèmes qui caractérisent la documentation sur la recherche et
qui sont : les résultats, les facteurs communs, les thérapies soutenues empiriquement, la
correspondance des traitements aux patients, les manuels de thérapie et les lignes directrices sur la
pratique, les thérapies à court terme, les combinaisons de médicaments et de psychothérapie, et les
thérapies de groupe. Chaque thème représente une question controversée qui a des implications sur le
contenu des programmes d’études contemporains en psychothérapie. Pour aider les stagiaires à
devenir des thérapeutes bien informés, les thèmes et implications de la sorte devraient être abordés
dans le cadre de l’introduction à la formation en matière de psychothérapies. Pour comprendre les
thèmes et implications, de même que les nouveaux résultats qui sont constamment issus de la
documentation sur la recherche, les stagiaires doivent aussi être familiers avec les méthodes de la
recherche fondamentale et les critères d’évaluation, sujets qui peuvent aussi être abordés dans le cadre
de leur introduction aux psychothérapies. À mesure que se déroule leur formation, les résultats de la
recherche peuvent être intégrés au perfectionnement de leurs compétences cliniques dans une vaste
gamme de psychothérapies.

Can J Psychiatry, Vol 49, No 4, April 2004 W 229