#11 What Therapists Need From Research

Universality and Explanation

The psychotherapy research community has produced many good things, but complaints are common about a mismatch between what research produces and what clinical psychotherapy needs. In my view, the problems revolve around two words: Universality and Explanation. So far, research that is universal is not explanatory and that which is explanatory is not universal. Further along in this post, I’ll describe briefly an approach that can meet both needs.

The Need for Universality

Down in the trenches and as students, what we need are general principles that apply to broad swaths of experience. We need broad rules and concepts that cut across the bewildering variety of problems our patients bring and the equally wide range of techniques we might employ. When a research finding applies only to a narrow range of problems, it is likely not to be helpful with the unique combinations of troubles most patients bring to us. Similarly, research that looks at a specific technique may only be useful to therapists specialized in using that technique.

In one area, that of “common factors,” research has embraced the need for wide applicability. Indeed, well researched common factors have a lot to say about how to optimize any therapeutic context. Wampold (2015) summarizes factors that achieve a “moderate” .5 effect size:

  1. Goal Consensus/collaboration (Working together on agreed upon goals)
  2. Empathy
  3. Positive Alliance
  4. Positive regard / Affirmation
  5. Congruence/Genuineness (Personal and interpersonal appeal and communication skill).

This gives us clinicians some broad guidelines, ones we might have understood instinctively, but it’s good to know that the research supports them. To summarize, we need to pay attention to the quality of the relationship, agree upon goals, help our patients communicate their inner experience so we can achieve accurate empathy, be aware of and repair any breaks, be ourselves and be affirming. Note that empathy naturally leads to positive regard, so that is taken care of. This simple formula covers a lot of ground and forms a basis from which to work, but it doesn’t help us know how to help change the troubling problems that bring patients to therapy. How can we know just how to help patients make specific changes in an infinite variety of maladaptive patterns?

The Need for Explanation

The best way to know what to do as a therapist is to have a clear picture of what is going on and how change works. This requires a framework that explains. The common factors approach doesn’t do this. It addresses primarily the conditions under which effective therapy can best be done but does not look at why people have problems, what holds them in place, or how they can change. In short, while it identifies correlations, it is not explanatory.

Research that is explanatory

A good deal of research does address cause and effect, and is thereby explanatory. Those theories that give an explanation of psychopathology and cure have generally been bound narrowly to the concepts of one or related schools of therapy, which precludes compatibility with other points of view and universality. This is understandable because, in the absence of a broad consensus about how therapy works, each therapy has been left to devise its own explanations, and there has not been a scientific reason to favor one over another. With the exception of common factors, researchers have tended to stay within one theoretical orientation or one diagnostic group and have developed data too limited for easy application to clinical psychotherapy.

A Solution: Universality With Explanation

The key to resolving this problem lies in the educated guess that all successful therapies actually do have a universal explanation. The place to look for that explanation is in the infrastructure, the fundamental mechanisms of change that underlie them all. It is no wonder this common infrastructure has not been identified. It consists of exactly the area of psychotherapy that has only recently begun to be explored, the precise neurophysiological mechanisms of change. Identifying the universal infrastructure of psychotherapy requires more than simply identifying mechanisms of change. It also requires linking from psychological pathology to change mechanisms and from change mechanisms to therapeutic technique. To accomplish this linking, first the pathology addressed by psychotherapy needs to be identified clearly. Second, those pathologies need to be linked with known change mechanisms, and third, the change mechanisms need to be mapped to the techniques of various therapies. Let’s look at how each of those steps might be accomplished.

Pathology Addressed by Psychotherapy

The general acceptance of diagnostic schemes that mix pathologies of mainly biological origin with those that are the result of problems with the mind’s information processing has hampered development of a universal definition of pathology addressable in psychotherapy. To make matters worse, traditional diagnostic labels attempt to identify groups of symptoms that often occur together, rather than basic elements. Working with such a heterogeneous group of problems makes it near impossible to link pathology with specific change mechanisms.

This is where the Special Interest Group on Convergence of SEPI, the Society for the Exploration of Psychotherapy Integration, has developed an approach not tied to any one orientation or therapy. With colleagues, Gregg Henriques, Andre Marquis, Ben Johnson, and Richard Lane, we have approached diagnosis by limiting ourselves to those problems resulting from less than satisfactory information processing. We have called these units of pathology Entrenched Maladaptive Patterns (EMPs). While psychotherapy can lead to biological changes such as modification of gene expression and changes in bodily regulation, psychotherapeutic efforts are primarily focused on patterns of information processing. By further narrowing from syndromes and collections of problems to simple units of pathology, we have been able to identify features common to all. Without going into detail here (see further, Smith & Johnson, 2018), essentially all these problems represent the mind’s attempts at coping with threats based on processing new and stored information which was acquired through evolution, prior personal learning, or the lack thereof, such that the response pattern is not well suited to the present.

Linking Change Mechanisms to Pathology

Having a universal description of the pathology addressable by psychotherapy makes it possible to identify the well studied learned fear paradigm as a subset of the overall group of EMPs. Memory science has elucidated how learning is encoded and stored. Neurophysiologists, especially Nader et al (2004), studying various mammals and humans, have clearly identified two and only two mechanisms through which learned fear responses can be modified. Furthermore, they have identified the specific neurophysiological requirements for change and have extended this research to addictive cravings and other areas as well.

While it is theoretically possible that some other change mechanism will be identified, new learning and the two mechanisms known to be capable of modifying existing patterns of response appear to be sufficient to explain therapeutic action. At least for now, it appears fair (as well as universal and explanatory) to base a working hypothesis on the idea that the mechanisms relevant to the learned fear paradigm and new learning can be generalized to all pathology addressable by psychotherapy.

Clinical Requirements for Change:

  1. Activation of old maladaptive response patterns with affect, required for both Extinction and Memory Reconsolidation, the two known mechanisms for change in established patterns (for example through exploration and empathy). 
  2. Exposure (in temporal juxtaposition) to new information that contradicts the old pattern and generates prediction error as required for both Extinction and Memory Reconsolidation. (accomplished, for example, through interpretation, cognitive and experiential exercises, and within relationship).
  3. New learning, cognitive or experiential, offering healthier response patterns and narratives, where not previously acquired (multiple sources).

Mapping Neurophysiology to Clinical Psychotherapy

 The reader is invited to make further connections between the above three requirements and psychotherapeutic technique. For example, Alexander and French’s 1946 Corrective Emotional Experience embodies #1 and #2 above. Similarly Fonagy’s metallization also embodies an old, instinctive response modified by the encounter with a larger perspective. In the same vein, Prolonged Exposure bases its power on the juxtaposition of old fear-filled memories with a new, safe context.

Nonspecific Facilitative Factors:

In order to build a more complete and universal explanation of all the activities of psychotherapy, we also need to add four nonspecific factors which each map to multiple psychotherapeutic actions and techniques.

  1. Arousal regulation to maintain arousal within a window optimal for change.
  2. Support for motivation to do the hard work of therapy. 
  3. Safety and informed consent.
  4. Maintenance of a positive therapeutic relationship (supports all 6 factors above).

Conclusion

Meeting the clinician’s need for universality and explanation, we hope the research community will increasingly focus on the common infrastructure of psychotherapy as a way to bind diverse therapies into a larger whole with common characteristics and processes. Identifying units of pathology and relevant change processes can lead to research on what techniques work best under what conditions and for whom. This kind of data would be highly useful to clinicians in matching technique to a particular patient and circumstance as well as a specific Entrenched Maladaptive Pattern.

Jeffery Smith MD

References:

Bruce E. Wampold. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015 Oct; 14(3): 270–277.

Jeffery Steven Smith & Benjamin Johnson. The Affect Avoidance Model: An Integrative Paradigm for Psychotherapy (Major Revision, Final). ResearchGate.org, June 2018

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