Research In Psychotherapy: Outcome Research Versus Process Research

In my Psychology Today blogpost about research in psychotherapy outcomes, and in my last book, I complained about the inflated claims of researchers in psychotherapy - particularly those made by purveyors of cognitive-behavioral therapy (CBT). They grossly overstate both the power and the significance of their results.

Unfortunately, a new report by the Institute of Medicine (IOM) falls for this baloney hook, line and sinker. The report on psychosocial interventions for mental illness and substance abuse has drawn a wide variety of responses from the field - including praise, recommendations for improvement, and some sharp criticism from psychiatrists and mental health professionals who are experts on psychotherapy. I am obviously sympathetic to the critics.

Of particular interest is that the report lauds the so-called "evidence-based psychotherapies" - code for those therapies which are "supported" by the incredibly weak psychotherapy outcome studies. One critic, Peter Roy-Byrne, M.D, summed up the criticisms of the report as follows:" In medicine, there is usually an array of different treatments for the same condition because of individual variability that is still poorly understood. Yet the field of medicine does not spend its time trying to understand what are the common elements between various effective treatments, though it will often explore comparative effectiveness as a way of improving care. It may well be that different kinds of individuals and problems demand different psychotherapeutic approaches rather than that there is one elemental Holy Grail that will be best for everyone.”

Of note is that, at least if you believe in free will as I do, patients always can choose to either respond favorably or unfavorably to any intervention a therapist makes. It is just not all that predictable, because everyone can choose to respond differently. In fact, the very same intervention given to seemingly very similar patients can lead to responses that are completely opposite from each other - in one case the patient improves on some dimension, while in the next the patient may get worse! In psychotherapy, patients are very different from one another in ways that vastly outnumber individual differences that affect treatment outcomes in any other field of medicine.

Holly Swartz, M.D., of the Department of Psychiatry at the University of Pittsburgh School of Medicine, brings up another criticism of the IOM report: “The recommendation to reduce highly complex interventions to their component parts, however, is misguided. A bias toward CBT and CBT-based interventions constitutes an essential flaw in the IOM report, placing affect-focused therapies such as IPT (interpersonal therapy) at risk for unfair negative evaluation and, ultimately, elimination from our therapeutic armamentarium. … [T]he IOM report should advance an inclusive research agenda that reflects and supports the diversity of psychosocial interventions that the IOM purports to represent.”

Yet another problem with the IOM report and similar viewpoints is that they completely ignore the fact that there is a vast literature within psychotherapy research that does not focus on outcomes but on process. Process research looks at the moment to moment interactions of patients and therapists within the context of their particular relationship.

As Les Greenberg, Ph.D, puts it, "Research on change processes is needed to help explain how psychotherapy produces change. To explain processes of change it will be important to measure three types of outcomes—immediate, intermediate, and final—and three levels of process—speech act, episode, and relationship. Emphasis will need to be placed on specifying different types of in-session change episodes and the intermediate outcomes they produce. The assumption that all processes have the same meaning (regardless of context) needs to be dropped, and a context-sensitive process research needs to be developed. Speech acts need to be viewed in the context of the types of episodes in which they occur, and episodes need to be viewed in the context of the type of relationship in which they occur.

Speech acts refers to the fact that speech does not merely convey information to, or exchange propositions with, a listener. Sentences do things that are frequently independent of the meaning of the actual words that are used. Speech causes others to perform acts. If I say, "I hear you're having a party Saturday," I am not describing only my recent experience of having heard about the party. I am probably fishing for an actual invitation. In all likelihood, I have made in advance a determination that this sort of statement is the best way to accomplish my goal of attend­ing the party. I have made a prediction about the future behavior of the listener. If this particular ploy leads to no response or a different response, I will consider alternative strategies.

Those who tout psychotherapy outcome studies, which study psychotherapy interventions as if they occurred in some sort of relationship vacuum devoid of context, seem to want to pretend that the highly significant process research literature does not even exist. In fact, the vast majority of articles published in the journal Psychiatric Research are process studies, not outcome studies.

The Language of Love

At the beginning of J. R. R. Tolkien's The Hobbit, a normally unadventurous fellow named Bilbo is standing in front of his home when a rather mysterious looking old man happens by. Bilbo wishes a good morning to the stranger. To Bilbo's surprise, the outsider does not return the greeting in the expected fashion. Instead, the newcomer questions the meaning of Bilbo's statement.

He inquires whether Bilbo intends to wish him a good morning or to state that it is a good morning whether or not either of them wants it to be. Or does" good morning" mean that it is he, Bilbo, who feels good that morning or that it is a morning on which to be good? Bilbo, a bit perplexed, answers that he means all of those things at once.

Perhaps the old man had reason to suspect that the hobbit was not feeling so friendly as the cheery" good morning" might indicate. The old man was Gandalf the wizard. Unbeknownst to Bilbo, he was familiar with Bilbo and was also well acquainted with the tribe of hobbits to which Bilbo belonged. He knew about their mistrust of strangers and their dislike of the new and the unknown. He also knew that hobbits tended to be polite at times when they did not really wish to be.

Knowing all of this, it would be difficult indeed for anyone to take Bilbo's friendly salutation at face value. As a matter of fact, the wizard was right on target when he questioned the meaning behind the statement. Bilbo was uncomfortable with the presence of a stranger and did not trust him at all. He was probably concerned that the old man's presence might indicate that the morning was not going to be good at all.

In my second book, Deciphering Motivation in Psychotherapy, I look at hidden aspects of language, and in particular its inherent ambiguity. Any sentence in any language can have at least two different meanings. Even a simple "I love you" can be interpreted on multiple levels, as I will soon illustrate. But first, some background information about how any sentence always has a dual reference.

The first of the two meanings is the literal meaning of the words used, while the second is the what the sentence means in the context of the relationship of the two people having the conversation. In order to understand this second level, one also has to understand that words can also be actions that do things that go well beyond talk. Linguists refer to this phenomenon as "speech acts."

For instance, if I go up to someone and say, "I hear you are having a party Saturday night," I am not only relaying information about what I heard someone say, I may also be actively fishing for an invitation. If I fish for an invitation in this manner, I am also indirectly acknowledging the fact that within this particular relationship, I do not have the right to simply ask the person directly to invite me to the party. I am most likely also not entitled to ask why I had not been invited in the first place. The way I fish for an invitation says a lot about the relationship I have with the person I am speaking with. Linguists refer to this level of communication as the pragmatics of language.

When it comes to language among members of a family system, sometimes family members must keep their intentions ambiguous. Language seems especially well constructed to allow individuals to keep their private thoughts and plans ambiguous. Ambiguity is especially handy if a person's intentions may or may not be at odds with the rules by which the family operates. In dysfunctional families, family members are often conflicted or confused about certain family rules. They may feel, for example, that they are in a "damned if you do - damned if you don't" situation. If so, they can make use of the inherent ambiguity of language to keep their intentions unclear.

Now back to "I love you." A man in couple's therapy loudly complained about his wife's jealously and insecurity whenever he so much as spoke to another woman. "Why do you raise such a big fuss?" he asked his wife, with obvious frustration. She replied, "I do it because I love you."

As much of language does, "I love you" can have two completely opposite or antithetical meanings. It can mean something selfish or something altruistic. Of course, it can also mean both simultaneously.

Most people who hear the wife's "explanation" in the example above will assume, because of her apparent insecurity, that the selfish version applies. In other words, they roughly translate the statement into, "Because I am insecure and dependent and need you so badly, I cannot stand the thought of anyone else having you even innocently, so I make a fuss even if it drives you nuts."

The meaning people often do not pick up on is the altruistic meaning. Roughly translated, the sentence might mean, "You're the one who is insecure. It really gives your ego a boost when I act so hopelessly dependent on you. If I did not act that way, you would be crushed! I'm willing to make myself look like the insecure one because I love you so much; I am willing to do that for you."

Do wives ever do this? My opinion: they do it all the time. And so do husbands, parents, siblings, and children.

Why would the wife need to be ambiguous about what she means by "I love you"? If the husband really knew that she was only acting insecurely for his benefit and did not really feel that way, her behavior would no longer boost his ego when she threw a fit. It might even deflate it even more. Therefore, she has to be deceptive in order to have her intended effect on him.

Unfortunately, this issue may make the pragmatics of the simple "I love you" even more complex. Suppose the couple is psychologically sophisticated and the husband starts to wonder if maybe the wife is laying the insecurity on too thick and that it might be put on only for his benefit. If his wife is correct about his being the insecure one, his ego would start to deflate.

If this were to happen, the wife might then start to act in ways that lead the husband to yet a different, third interpretation of the wife's original explanation: "She is rationalizing her behavior as being for my benefit to cover up the fact that she is really selfish."

If the wife succesfully made him think that, she would then be able to continue to provide the altruistic service. Linguistically, she would be acting out yet a fourth interpretation: "My behavior really is for your benefit. However, since you suspect it and I am trying to keep it a secret, I will let you think that interpretation #3 is correct. That way, you will not know that I am in fact acting this way for your benefit."

Are people really clever enough to come up with crazy and complicated schemes like this? As they used to say on the old TV show, Laugh In, you bet your sweet bippy they are. I see it all the time from patients in therapy. These motives are not, however, something people readily admit to. As therapists, however, we have ways of getting it out of them!