O ABCTA S S O C I A T I O N F O R B E H A V I O R A I .

A N D C O G N I T I V E T H E R A P I E S

r s s N 0 2 7 8 - 8 4 0 1

V O L U M E ] 2 , N O . 4 . A P R I L 2 O O 9

Contents

Researcb Forunt

The Dodo Birr l ,Tl 'eal-rnen I TFc Irn irlu e.antl DisseminatingEmpir ical ly Supporter lTreatments

J crIirI j rrh Sir :v, [/ri.r rrcr.s i t,t' o f' ]\: n n s.t' It,u r t i, t .

Jrrrral lrarr l) . IJrrpplt . 7'1rc l lel tren

[,]niu: r.si4' of J e nuu.Le rn, aurI f)iarrnc L.

C hirnrl rl ess, [ ] nit: e rs i,t1' o f' Pe nt us y I tn nio

IF n a rcacnr prcsir lcnt irr l !r) lunl l i r th, Bebat r, ' t

I l / t tra1,isr, Ritymr)n(l DiGitrst 'p1te ubscncJI t l ra t e l f t r r ts to . l i sser t t rnu tc cnrp i r i t i r l l y s t rp -porte(l trcatments (EST;), and cspecial ly cogni-t ive-bchavioral treatments, have bcen l imited bypcrccptions "that all psychotherapies are equal.lycffeccivc [the Dodo l]ird verclictl, and . . . thatcommon faccors, therapisr, and relarionship vari-ables account f i rr thc majori ty oi rhe variancc int l-rerapy olrtcomc studies" (2007, p. t t8). Hecalled for dialogue with proponents of thoseviev"'s, in an effort to trnclcrstand their persl>ectivcand convey the alternative. Ultimately, "either

rve rebut these conclusions, concluct neq' researchto shorv they are wrong, or tr'e accepr them andchange our rnessage " (p. I t9). The airn of t l -r is ar-t icle is to provide some historical conrexr in rermsof prcvit.rus attempts to respond to these con-tentions and to present an update on recent re-search bearing directly on the Dodo Bird verdictand the :rssertions regarding variance accountedfor by active ingredients (e.g., rechnique).

the Behavior Therapist

Reseorch Forum

Jedidiah Siea, lonathan Huppert, and Dianne L. ChamblessThe Dodo Bird, Treatmc.nt Techniclue, ancl Disseminating

Empirical ly Supported Treatments o 69

Student Forum

Sarah E. Et,nns, Atrdrea R. Penq, Anranda Kras,Emily B. Gale, and Christopher Canrybell

Su pervisirrg antl Me.ntoring Undergraduates:

A (lradu;rte Sfllc-lcnt Pcrspec-tive . 77

Or ig insDcrek D. Rat,d nnd lanres K. Luisalli

Antccedents to a Paradigrn: Ogden l , i rrdsley

arrcl B. F. Skirurer's Founding of "Behavior Therapy" . 52

Clossi f ied . as

At ABCTWelcome., Ncrv Mcmbers . 86

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Letters of intent MUST BE RECEIVED BY August 3, 2009.' Vision letters u. i l l be required b,v September 1,2009.

Apfil . 2009

rontinred on p. 7 1

6'

Dodo Bird Verdict

Aggregation

Evidence for the claim that all psy-

chotherapies are equally efficacious derives

from meta-analyses that combine various

treatmenrs for various disorders (e.g.,

Luborsky et al., 2002; \X/ampold et al.,

1997). At most, these meta-analyses yield

smail effect sizes for average between-con-

dit ion comparisons (e.g., / = 0.2I;

\Tampold et al.), and the authors infer that,

overall, no two psychotherapies are differ-

enrially cf{icacious for treating a disorder.

Suc l r a t , ,n t lus ion , howcver , i s hasc . l on t l rc

fullu.ig-q-r .."to"ins thut b.

riients for all disorders do not differ on aver-

ag_-e, _n_o particular treatment is superior to

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2diD ;()ramblcss, 2002; Crits-Christopl i ,

1997; Hunsley & Di Giul io, 2002; andmany othcrs who have arguecl this point).

Evcn oper r t ing w i t l r t l r i s r (as( )n inA, musr

meta-analyses havc fbund diff-erences bc-twecn rrcatment orientat ions (Luborsky etal. ; Shapiro & Shapiro, i982; Smith t

Glass, 1977; l)Tampold et al.) , cvcn whentaking into account allegiance. Further-

morc, in responsc to Vampold et al. 'smcta-anir lysrs, Crits-(.hristoph suggcstcdtl-rat aggregating various populations, dis-

orders, and treirtments would likely ob-

scure rcal differrnccs in I re:rt n)ent

outcomes. Moreover, half of the studies ex-amincd by rVampolcl and colleagues evalu-ated the trcatment of anxiety, and ncarly

70Vo compared cognitive to behavioraltherapics, characteristics of the studies that

may minimizc the l ikel ihood of f inding

substantial trearment differences. Crits-Christoph demonstrated that 14 o€ rhe 2L)studies that \J/ampold and colleagues in-cluded that compared two treatments for

specific disorders grounded in different ori-

entations yielded large effect sizes.Similarly, Beutler, Chambless, ancl others(Chambless a Ollendick, 2001; Htrnsley &Di Giul io, 2002) have cited mult iple stucl-ies and reviews that question the Dodo Bird

verdict.As a further challenge to the Dodo Bird

verdict, Siev and Chambless (2007) re-cently condLrcted meta-analyses comparing

CBT and relaxation (two bona fide treat-ments for anxiety disorders) for panic disor-der (PD) and generalized arLxiety disorder(GAD) In so doing, we compared two spe-

th cific cognitive-behavioral interventions in- the treatment of two anxiety disorders. The

results revealed that for PD, CBT outper-

formed relaxation ac postcreatment on al l

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panic-rc latcd measures anr l indices of c l in i -

cal ly s igni f icant change. In contrast , for

GAL), tlic t\\'o treatmcnts wcre equivalcnt

on al l rneasures. Furthcrmorc, t l - rerapists in

al l s t t rd ies s 'erc crossecl rv i th t rcatnrent con-

dir ion, and most authors asscsscd c l ienr ex-

pr t t , r t iuns . rnJ rer i r tgs r i l ' t rcei lncnr

credibilitl ', rvhich wcre high ancl never dif-

ferecl by t reatment group. These method-

ological st rengths bolster the l ikel ihocrd

that t reatment techniqucs rr f fected t reat-

ment ei-fects.

In addit ion ro combining various rrcat-ments ancl disorclcrs, many mcta-analysesin u'hich tl-re Dodo Bircl verdict is aclvarrceddo not distinguish betr.veen prin-rarv andsecondary outcon)e measLrres (Wamlrold etal., 1997). Rarl.rer, they derivc a single effcctsize i i rr each berween-concl i tron comparisonby averaging al.l outcome measurcs. Theirlogic fcrr doing so is:

Given tl.re assumprion rhat reserrrclrers( l t ( ! ) \c uur(() t I ( met5ures r l tat . t r . 2:err t r . rn, 'ro the psychok-rgical funcrioning oi the pa-

tients involved in tlre stucly', it is the effi'cr oft h ( t r eJ lmrn t On t hc S . r r r t uu tLun rL m( r -

7 l

sures that is importanr. . . . Focusing on afew of many outcome measules to establishsuperiority causes fishing and error rateproblems (Cook g Campbell, 1919) anddistracts the researcher from examining tl.reset of outcome measures, which might haveproduced a negligible effect size. ($Tampolder al. , [)97 , p.210)

However, the average of all outcomemeasures does not accurately capture the ef-ficacy of the treatment for individuals suf-fering from a specific disorder, and is likelyart i f ic ial ly to attenuare thc magnitudc ofthc cllcct size. I'hc cxtent to which ir trcat-rncnt for a r l isort lcr (c.g., PD) alfccts do-rnir ins of comnron comorbicl i ty (. .g.,

r leprcssion) is cr i t ical infbrmrrt ion, but is notof equal irnport in cvaluatins thc trcat-ment's efficacy as is thc exrent to u'hich itrrllecrs core sympt()ms r>f the disorclcr: (c.g.,panic syrnptoms anrl cl iagnosric strrtus).Althorrgh i t is tr trc that rcsearchcrs shoulclirrtir:r:latc a priori the prin-rary dcpenclcntnlcasurcs, rcas()nxblc conccms trbour 1r()sthoc report ing biascs (e.g., sclect ively eln-phasrzing significiint tinclings fitrn-r a l:rrgcset ol rnostly nonsigni l icrrnt f int l ings) olrr lrrno t p rc t l r rd t ' r ( \ r i l rL l l c rs f r t l rn rnvcs t iga t i r r tsccondary ( lutcorncs. Combining mersl lrcsof prim:rr l , an.l sccon,lrtry oLltcorncs f i)rccscirn t>lrscurc or rn:rsk cntircl]' mc:rningfirldi f i i rences in trcatmcrrt cff lcts (scc (-r i ts-

Chrisroph, 1997).Mcta-analyt ic data comparing CBT anrl

rclaxation firr PD ancl GAD that \verc norpublishcd in Sicv rurcl Cl iambless (2(X)7) i l -Iustratc thc importarrcc of consit ler ing notonly disordcrs scparatc-ly, but prinrary irndsccr>ndary outconrc mcasurcs scparately, xsrvell. Three graphs zlrc l)rcsentcd in Figure 1t lrat prtrgressivcl l i l l rrstrate u' l t1' mct.r-analyses that aggrcgatc effcct sizes rcrossclomains ancl outcrrtnc mcasurcs nliry bcmisleacling. As clepictecl in the first graph,the combined effect size comparing CIITand relaxation fbr PD and GAD across alldomains was/ : O. l9 ,p = .07 , the n . ragn i -tude of n'hich is consistent u, i th the uppcrlimit of betrvecn-treatncnt dilferences rc-ported l.>y \X/ampold ct al. ( 1997), anrl equalto tl.re eFfecr lound by Luborsky et al. (2002)

in their revieu' of meta-arralyses. The secondgraph dcnronstrates thi l t , wlren ct>nsidereclscparrately by disorcler (:Llbeit aggrcgateclacross domains), CBT outperformed relax-a t ion f t ) r PD,d :0 .11 ,1 < .01 . In cont rasr ,the becrveen-treatment ellect size in the do-

main of GAD was small and nonsignificanr,d : 0.08, ! = .19, rhereby supporring rhenotion that treatments may differ depend-ing on the disorder studied. Finally, as evi-dent from the third graph, v"'hen effect sizeswere derived separately [or primary and sec-ondary domains of treatment outcome,CBT outperformed relaxation for primaryoutcomes of PD with a moderate effect size,d: 0.49,! < .002, whereas the treatmentsdid not differ on secondary outcomes (i.e.,

depression and generalized anxiety), / :

0.02,1t : .89. There were no dif f-erences inprin-rary vcrsus sccondary' or.rtconrcs firrGAD t,/s < 0.{)9,ps > .55). Hcncc, rhe cl i f-fcrcnce betwecn CBT and rclaxation fbr PDin thc prirnary donr;r in of outconre ls morcthan two-and-a-half t i rnes as large as oncwould conclude on the basis of the original,allSrcgated cflect sizc, rvhercls there wcrcno dif fcrcnccs bctrvcen rhe trcatrnents forGAI ) .

1'hc cl ivcrgcnt inrpl icir t ions of- thcsc rc-sults ancl thosc <rf Wrrn"rpokl ct al. ( 199') rc-l lect basic cl i f lcrcnccs in nrethoclologicalirpproachcs to treatr)1cnt olltconrL' clata, irntln,: i thcr slrtrulcl l .c pcrccivcd as stat isr icalsl ight of hanci. Rathcr, in conducting or in-tcrpret l lu] r lrese datlr , one nrust ct>nsrcler af irnclanrent:t l isstrc: tWlrat is thc qr.rcst ion? Itis our contcntion that rarcl l ' clocs thc rc-searchcr, cl inician, or consunler carcrvhcthcr, on averalle, trcatmcnts fbr all dis-orrlers ircross all clomains do not difitr.Rathcr, tlic consunrcr (to take one, for ex-amplc) wishes to know what trc:rtment wil lbest alleviatc the distrcss causccl by l-ris orher s1'nrptonrs (cL thc fundamcntal psy-chotherapy ( luestion of Paul, who art icu-latccl the importance of asking not onlys'hethcr psvchorheral)y rvorks, but "\What

tfelrtmcnt, by whom. is mosc cffc'ctivc forthis incl iviclr.ral rvi th that spccif ic problem,and under * 'hich sct of circumstances?"

{1967, p. I I l ; ernphasis in the original l) .rVhcn the presenting problern is PD, thebest answcr to that question (if the oprionsare CBT and relaxation) is that CBT is l ikelyto reduce prin-rary panic-relatcd syml)tomsby approxinr'ately half a standard deviationmore than is relaxation. Cast as a binomialc l l i ' t r s izc J isp l ry . l t l r i s repruscnts xn i r ) -crclrse in thr- rarc of success frorn l[J9Z to62c,/c, . Tlte r,,'isc consr-rrner srrf fering from PDu'ill choose CBT.

Bona Fide Tieatments

Even advocates of a common factors ap-

proach ro psychorherapy acknowledge that

not all conceivable interventions are efflca-

c ious. Instead, the Dodo Bird verdict ex-

tends only to bona fide treatmcnts,

meaning those "intended to be theraperrtic"

( \Wampold et a1. . , 1.91)7, p. 2Or) .This d is-

tinction between bona fide and sham treat-

ments in evaluating the relativc efficacy of

dift'erent treatments, while having appeal,

also introduces a number of tl-reorctical ancl

conceptual c l i f f i cu l t ies.

$Tarnpold and col leagLres (c.g. . Ahn &

V/anrpolc l , 2(X) l ; I ' lcssrr & \ r \ ' : rnrPolc l ,

2002) concludc rh i l ( t rc i r tmcnt ( )Lt tc()nte

studics are l i r t i lc bccutrsc comlrar isons bc-

twccn Lrona f ide t rcatments y ie lc l c l in ical ly

insi rn i f icant c l i f ferenccs and t l rosc bctween

bona f ic lc t rc l tmcr) ts ant l contro ls y ic ld un-

intcrcst ing r l i f f i rcncrs. This contcnt iotr is

sontct ' l r i r t c i rcr . r l lLr , h<ts 'cvcr , bccatrsc c iLrc-

gor izat ion as a l . lona l lc l t r rcatnrcnt is bt>th a

r r i t c r i o r r f o r i nch rs i ou i n , an t l l i r t i n rp l i ca r i o r t

of , rhc rcsrr l ts o1- c l in ical exl .cr i (ncc i tn( l

rrcilrmcnt or-rtcon)c rescar<-h (antl mcrlL-

analyscs rhat synthcsizc nrLr l t ip lc sLlc l l s tu( l -

ics) . T i r i l lusrratc, considcr the histon' o{-

brhavi t>ral t rcat l r lents for obscssivc-corn-

; ru ls ivc r l isorder ( ( )Cl) t . Forry ycars : rgr>, bc-

hi rv ioral r l rcrapists t rcatc<l OC[) u i th

rc. lax:r t ion. As cxposurc and rcsl ronse 1.rc-vcr)rion (ERP) rl,as clcvciqrcd, clinicians ,lis-

covcrccl rhat it q'as f:rr more elflcacious than

rclaxation, rvhich is now consiclcrcd a

placebo in rhe trcarment of OCD. f)ocs rhc

cl isc<lvcr t ' thrr t onc t rc i r tmcnt outpe r f i l r r r ts a

sccond r( 'n( lcr that very contpar ison inval i t l i '

In firct, in a rcccnt srirve)' of 1>sychologistsrvho trcat :rnxictl' clisorclcrs and rvho prc-

dominanr ly favor a CBT approach, nrorc

cl in ic ians en. lorscd Lrs ing re laxat i r )n fo t rc: r t

O(-D, than enclorscd using ERP (|rcihcit,

Vye, Swan, c' Cacly, 2004). Surely those

clinicians consider relirxatir>n to bc a bona

fidc trcatmcnt. Horv can it then become

something othcr than a bona f ide t reatment

whcn zr rcsclirchcr uscs iti \\/an-rpoltl ancl

colleagr-res' concern rlrat comp:rrisons he-

t\veen bon,t flcle treirtnrents and shar.ns ,rre

r iggccl and sorrct imes t rn inf i rmat ivc is r i 'c l l

raken- Certa in ly t rcatnrents shclLr ld bc com-

parc. l ro rcal t rcat tncnts iurr l not t r i l r rmccl

c lo ln, thrcc- le i l !cd horses. Ar rhr sanrc

t ime, to concluct componcnt analyst-s that

eva.luirte particular rechniques often pre-

sen te ( l t u8e t l r e r as f J r r s ( ) l ' a l ; r r g r r t r e i r t -

menr package, certa in t rearmenr e lemcnts

musr be excluded. This is part of the bincl .

A re lutecl compl icat ior-r s tcrrs f r ( )m the

stuclr ' - or c l isorder-speci f ic c lassi f icar ion of a

I The binomial elfect size display is a means of deprcting an eflcct size as a relative success r.rre. Based ontltc assumption that the rate oftrcatrrtent success is 5092 overell, the binr-rrial effect sizc displ,ry is usctito t ranslate an associat ion bctq 'een t reatment and outcome into thc Lrronort ion ofsuccesscs in unc rrcat-ment grollp rclative to another.

7 ? I he B eba rtor T lterapis t

Gtreatment as bona fide. Although\Wampold et al. (1997) formulate an opera-tional definition of bona f.ide to identify par-

ticular studies for inclusion in theirmeta-analysis, there is little conceptual jus-

tification for some resultant distinctions.

For example, according to tVampold et al.'sguidel ines, whereas rclaxation is now con-

sidered a placebo for OCD, it is a bona fidc'treatment for GAD because studies havc

demonstrated that relaxation works as well

as other treatments for GAD (and thereforethe r:rpists expcct rclax:rt ion to bc thcralreu-

t ic), br,rt not f i rr OCD (uncl thcrcf irre {stucl l '1thcrapists nos' . lo not cxpc(t rcl :rxation ttrbe t l ' rerapcutic). In othcr s'r>rr ls, rcsearchcrs

expcct somc trcatmcnts to u'ork bccausc

they have found them to clo so, ancl othersto rvork less rvell becausc tlrcy have fbunclthcrn to do so. l t lcrcin l ics anothcr di l f iculty,rvi t l r V/arrr l .ol t l cr:r l- 's cl irssif lcat ion of trc:t t-lrcnts irs bona f l . le: I t is cirrrr lar to cl iscountthc srrpcrior t l l icacy of a trcatr. trcnt on thcgrotrncls that "I kncs' i t u'rrr-r lcl n'ork bettcr." i f that asslrrnption r lcr ivct l fron'r obser-t 'at ion of- thc sanrc sr.rPcrir>r ct l lctcr ' .M ( ) r c { ) \ ' ( r . i l t l r i s r c l s , , r r r r 1 1 - i 5 t , , r r t t t . , , t rn,hat othcr grounds is rclaxation a lxrna f lclctrc:rtmcnt f i rr onc anxiety r l isorclcr ancl notlnothcrl ' Consiclcr ing t lrac ViLnipolci ct al.aggrel latc across disor. lcrs irr)( l trci t trncnts.this poses a particular theorctical diflicLrlty.Is it reasonable to inclurle cornparisons of-CBT and relexation for GAD (as thcy do),but not for OCD2 Wampold ct al. use thenotion oibona f icle treatrncnt to cusurc thirtthe pirtient and thc thcraprst have positiveexpectancics about outcomes, as expectan-cies arc proposcd to bc 'ln essential commonfactor relatcd to olrtcomc. I{orvever, if atlrerapist irnd a p:rtient cxpect ERP to workbettcr thirn rclaxation fbr OCD, for cxam-ple, then they are correct in tl-reir expccta-rion, but it does not mean that expectancyis driving the trcatmenc cffccr. Are the ef-fects causcd by cxpcctancl,, or do people ex-pect more from rrearments that workbetter? Finall.r', Vampold et al.'s criterion ofbona f i . lc tr( irrment comperisons createsthe potential trap thar i f consensus werereached thar exposure-based CBT is thetreirtment oi cl'roicc fbr OCD, then onccould not establish its cfficacl', irs therecould not be a bona f iclc trcatrnent withs'hich to cornprire exposr.rrc-Lrirsecl CBT.

outcomes than do specific techniques hasbeen stated by many (e.g., Levant, 2004;Messer & $7ampold, 2002; $7ampold,2001), although with voices of opposition(Beutleg 2004; Huppert, Fabbro, &Barlow, 2006). The claim that techniqueaccounts fcrr approximarcly l07o to I17o ofthe variance of therapy outcome, whereasexpecrancy, relationship factors, and com-mon factors accolrnt for closer to 4O7r'. isfrequently demonstratecl in a pie chart (e.g.,

Lambert & Barley, 2001; 2002). Ht>*'evcr,rhc history t>f this chart rnay givc thc rcaclerpause. C)riginal ly publ ishccl in 19136 byl-:Lrnbcrt, Shapinr, ancl Bergin in t lrcl!undhook oJ Ps1'tbotl,uafl antl Btlr,t ior

Cbange 1\rd edit ion), t l re pie chart rc1>rc-scntcd a summary of L:rmbert 's reading ofthe l i tcrarure from the prcvious 20* ycars;i t rvzrs nor an empir ical dctcrmination. L)ncu',-, tr l r l l roPt t l r i r t s()nle l)rogrcss has Ltcc'rtnraclc in r lre 20 years since, espccial ly * ' i thrcgarcl to trn<lerstanci ing rnccl i l t tors, nrtxlcrators. and l)roccsses in thcrapy, ancl in (-Ll'l-

in lrart ictr lar. ' lb

takc one str-rdy as cxccl)-t ional in tcnr-rs of such l)rr)grcss, Clark rr al.(2(X)(r) slrr>rvccl that (.BT targcting corcco.t4nitit>rrs atid conccms of incliviclr,r:rls rvithsocial anxic' t1' cl isorclcr was nrorc cffer ' t ivcthan exposurc thcrapy (rvit l -r a purcly bchavioral r;r t ionale t>1-habituation) plus rclax-atiun. Clark et al. rc1>ort thc cf iccts ot

technique, alliance, ancl cxltcctancy (see piechart in Figure 2). Not only were therapistcffects not large or signit icant, but thercwere no diffcrcnces betwccn the ts'o tre:rt-ment condit ions in rat ings of al l iancc (/ :

.17), credibi l i ty (! : .261, or expectancy (f i: .22), suggesting that thcse mechanismswe re not responsiblc frrr rhe dif{ircntialtreatmcnt outcome bctwecn CBT and ex-posure. Similar data fiom another rescrrrcl.t

Sroup suggest that thesc CBT techniquesfor social anxiety disorder may be more ef-fective chan exposure alone (Huppert,

Lecllel', & Foa, 2007). At the sarne time,treatment technique did not account forJ07o or B0o/o of the variance, and it is un-iikely that any treatnent will reach sucli athreshold.

Hon'large are techr-rique effects likcly tobei ' Even Lambert 's pie chart indicates rhatup to l5o/,: of treatment eff-ects rnay be dueto tcchniclue, v, 'hereas Vampolcl (200i)

suggesrs U!2. Befbre speculat ing abourtheir magnitude, one nceds to consider howbest to determine technique effects. Onemethod may be to compare active therapyto placebo. Overall, CBT for anxiery disor-ders has in tzrct shown significant supcrior-i ty to placebo (cf Hofmann & Smits, 2008),with an irverage effect size fbr the magni-

Figure 1. Betwecn-groups effect sizes

comparing CBT and Relaxation (a) com-

bining disorders and all outcome [Iea-

sures, (b) lor PD and GAD separatel.v,

but combining all outcome measures,

an. l rc t d ist inguishing hctween pr inrrry

and secondary outcome measures fbr PD

\ d )

( ) . 1 1

0. '1 i -

0 . I i

o

__ll

UN

FOUuLU

o ) 1

o . I

o : o l

IPD/GAD

t b )

t ) . 5

t ) I 'U\ P ' o s

e iti, IPD

i lPD/GAD GAD

( )

( c )

PO / zUeAD

Figure 2. Brcakdorvn of Clark et al. s

(2006) data by technigue, therapisr

effccts. an.l unkno*'n

CBT vs. Exposure Alone Ef fects

, , 5

Relationship and Therapist Variables,

th Common Factors, and Technique

- The norion that the therapeutic rela-t ionship, therapisr, and/or common fhctorscontribute significantly more ro treatment

April . 2009

Therapist

ffi otherfactors

I Treatmentprocedures

73

o.a

1 0 .

i o r

0 . r

tude of the difference of 0.33 for intent-to-treat and 0.7) for completer analyses.However, there is variability in these eff-ects,with the strongest evidenr in the treatmentof acute stress disorder and OCD, and theweakest in the treatment of PD. \fhymight this be? It has been shown previouslythat OCD is less placebo responsive than isPD or social anxiety disorder (Huppert etal. ,2OO4; Khan et al. , 2001), and techniqueeffects are most demonstrable in the disor-ders that have the smallest placcbo effects.In fact, for somc disorclers (c.g., major cle-pression), significant tecl-rnicluc cffects arcst>mewhat difllcult to (lemonstrrte by com-paring placebo to CBT (DeRubcis ct al. ,200)), althorrgh such effects are more

;rrominent when examining fbl low-up data(e.g., Hol lon et al. , 2001). Similarly, in rhecase of PD, lor rvhicl-r thc magnituclc ofplaccbo resl)onse also appcars to be high(l-ILrppcrt et al. ; Khan et al.) , signif icant bc-twcen-trcatnlcnt cl l i 'cts : l rc rnorc cvidcnt atlong-term fbl low-up (tsarlow, Gorman,Shear, & \Woods, 2000). In sum, it is diffi-cult to detcrmine the ovcrall cffect of tcch-niquc without consiclcring disorcler ancl

1.r4rulat ion, :r conclrrsion reinfbrcecl by otrrt l iscussion of the l)odo Bircl vcrcl ict.

There arc t>ther mcthods by wlr ich onemay examine tcchniqrrc cffccts. For cxanr-ple, Ablon and -fones (2002) showccl thatcognitive therapy techniques accountcd lora significant amount of changc in dcprcssivcsymptoms in the NIMH Tieatmcnt ofDepression Collaborativc Research Pro-gram in both CBT and interpersonal psy-chocherapy trei l tment condit ions. In addi-tion, Cukrowicz et al. (2001) reportcd clacasuSgesting that '*'hen a clinic changecl itspolicy to conduct only ESTs, there was sig-nificant improvement in patient outcomcs.Howard (1999) noted that individuals in amanaged care environmcnt who had spc-cialty training in CBT for anxiety disorderswere more l ikely to retain their patients,and those patients were also less likely ro re-ceive further treatment 1 year latcr. It is im-portant to note that studies that simplyexamine orientation are unlikely to flndsuch effects, as Drny prirctitioners whoiJenr i fy thc r r p r i r r ra ry o r icn ta t ion . rs cogn i -tive-behavioral concinrre to use relaxarion asa treatment of choice for OCD and PD(e.g.. Freiheir er al. . 2Ot)l l .

But what about the contribution of al-liance, common facrors, and therapist e[-fects? On average. studies yield arcorrelat ion of .22 betq,een measures of al-l iance and ouccome (Mart in, Garske, &Davis, 2000), demonstrating that thc for-mer accounts for )7o of the variance in the

latter. Note that this effect size derives fromdata aggregated across studies ofa range oftherapies and treatments, similar to the ef-fect sizes calculated by Wampold and col-leagues, and Luborsky and colleagues.Again, looking at specific therapies and spe-cific populations, the verdict is nruch lessclear. For example, Lindsay, Crino, andAndrews ( 1997) showed that the al l iance inERP and the alliance in relaxation wereequal for patients with OCD, but the differ-ences in efficacy were substantial. Similarly,Carrol l , Nich, and Rounsavi l le (1997)

shorvcd that irlliance was corrclatcd witlrolrtcome in a sr.rpportive therapy firr sub-stance abtrse, but not CBT. In CBT for de-pression, the data fiom DeRubcis andcolleagucs' studies havc consistentlysl-rowed that the thcrapeutic alliancc is betterfbr paticnts rvhosc symptoms and cogni-t ions havc already changed ftrr the better(c.g., Tang & L)cRubeis, 1999); that is. earlyi ln;>rovenrent in trcatnrcnt leads to :r nrorcposit ive al l iancc. FIowever, in Cognit iveBehavioral Analysis Systcm of Psycho-thcralry, whcrc thc al l iancc is an expl ici tfircus of trciirment, alliance appetrrs to bcprc. l ict ive of outcome (Klcin ct al. . 2001).Ovcral l , al l iancc may have the grcatcst rela-t ionship to ol l tcome if the thcrapist rnnrkesit a ccntr lr l focus of treatment. H()wever, insuch treatments, thc cl ist inct ion betwcen al-l iance and technique is blurred. As othcrshave noted (Beutler, 2002; Crits-Christophet al.. 2006). if onc addresses alliance di-rectly in trcatment sessions, thc vcry focuson al l iancc bccomes a treatnrent teclrnique.Therc is only one pilot stuc{y to date that at-tempts t() imlrrove alliance by using specificalliance-enhancing techniques (Crits-

Christoph et al.), and the results are equivo-cal. The effects of alliance-enhancingtechniques in certain areas (e.g., change inalliance and improvement in quality of life)are l .rrge, but che impacc on symptoms issmall, and the results are dilficult to inter-pret without a comparison group of newtrainees who may have learned to improvealliance without additional techniques.However, the study is seminal in i ts atemptdirectly to improve alliance, and fi-rrtherstrch studies are needecl to evirluate thecausal in-rpact of alliance on outcome.

Therapist eflects have been discussed onand off for over 30 years. More recently,some have shown that differences betweentherapists in treatment ourcome may be de-creased with n-ranualized trearmenrs (Crits-

C h r i s t o p h e t a I . , 1 9 9 1 ) , a l t h o u g h n o tel iminated (e.g., Huppert et al. , 2001).How large are therapist effecrsi' Overall,they seem to range from 17c to 75Va (see

also Crits-Christoph & Gallop, 2006;Lutz,Leon, Martinovitch, Lyons, & Stiles, 2007).

However, the question of what makes ther-apists different from each other remains,and one answer may be technique. Sometherapists are likely more adept than othersar using some techniques, formuiatingtreatment plans, encouraging their patients

to do difficult exposures, etc., even within

CBT. Of course, therapists also differ on

ability to form an alliance, but the therapist

who is able to art iculate a scrong treatmentrat ionale tai lored to the part ient 's slrecif icpresentirt ion and to explain u'hy thc treat-ment citn hclp (or the thcrapist who is ablc

to provit ic an cxample of an imaginir l expo-

sure that direcly taps into an OCD pa-

tient's fears) will likely bc cxpcriencecl bythe patient as empathic ancl uncicrstanding.Thus, techniclues may be part of thcrapisteffects (or vice versa), and not somcthingthat can be truly scparatccl frt>n'r thcrn.

Jrrst as al l iancc and thcrapist cl fcctssonretimcs may be accounte(l fbr by tech-nicluc, so may othcr putzrcive common fac-tors (consider, firr cxrrmplc, how clatl onoutconrc proviclecl during psychoeducationprobably influcncc both therapist ancl pa-t icnt cxpectancy). Indeed, thc notion ofconrmon ftrctors itself l-ras broadenecl to thcpoint that sornc u'oult l inclucle the tech-nicltrc of exposure as a common factor(Lambert a Ogles, 2004). Howcvcr, as\Weinbcrgcr (1995) notcd, common factorsmay not be so common after all. The extentof focrrs on alliance dilfers between trcat-ments, and so does thc amount, type, orquali ty ofexposure. And i f the goal ofpsy-chotherapy research is to determinc the bestways to relieve suffering for the most peo-plc, researchcrs need to continue to locus onthe areas that are most manipulable, such astechnique. In fact, Lambert's latest researchis an excellent example of high-quality re-search thac incegrates the arguments for theimportance of techniquc, alliance, and tl-rer-apist factors. In brie[ Lambert has im-provcd rhc qual i ty of treatment outcomc intherapy by providing therapists with feed-back on parient progress and whether rher-apists are off track with their parients'predicted crajectories (Lambert, 2001\.Notably, rhe feedback inclucles specificrechniques that may help puc them back ontrack. One may r'",onder aloucl whether useo[ other types of disorder-specific infbrn.ra-tion could fi-rrther enhance the efficacy ofsuch interventions.

Overall, many researchers-ourselvesincluded-attempr ro quantify the relativecontributions of technique and other ef-fects. Frequently such data are presented so

tbe Behaior Tberapist

as to support the exclusive role ofone oftheaforementioned effects (e.g., alliance, thera-pist, common factors, technique) in influ-encing treatment outcome. It is equallyimportant, however, to demonstrate howsuch partisan divisions are not reflected inthe real world, where all of these effectsmeet in a complex series of interactions. Infact, the patient 's contr iburion to outcome(including diagnosis, insight, motivation,severity, psychosocial background, etc.) islikely rhe greatest. One may conclude thateffectivc techniques arc likely to positivelyinf luencc not only treatmcnt ouccomes, butalso therapy relationships. Fcw r.l'ould arguethat onc shoukl conduct therapy in thc con-tcxt ofa hosti lc or negative rherapeutic rela-tionship. Howcvcr, tecl.rniques are ubiqui-tous and need to be studicd in order to de-terminc how to best improve them and,therci'ry, paticnt outcomes.

DiGiusclrpe (2(X)7) suggesterl r lrat Lrn-less thc Dodo tsird vercl ict and conrcnrionsregarding grcatcr cflccts oi rherapist, al-liancc, and common firctors arc addressedempir ical ly, psychologists who value scien-t i f ic inquiry mrrsr ncccpr rhe irnpl icat ions ofthose assertions. In [act, these notions havebeen arguecl against for ycars, and manycontinuc to cxamine the clata. In this rcvierv,

/ ) wc l r : rv t 'aurmpte( l t ( ) L { )nvcy thc fo l low ing .\ t F i r s t . r h e D , x k , B i r . l v r r . l i c r i s p r t c l r t a t e . l . r n

meta-analyses tlrat aggregate data acrosstreatments, clisorc{ers, and outcome mca-sures, and such aggregation likely masks orarrenuarc rrcarm€nt diflerences betn'cenparticular treatmcnts lor parcicular disor-ders on primary outcomes, even thoughsuch differences have the most direct impli-cations for trcarment. Second, thcre are nu-merous logical difficulties wirh theclassification of treatments :rs bona fide, arcquisire criterion ibr inclusion in somc ofthe aforementioned meta-analyses. Third,tl'rere is empirical er.idence rhat techniqueeffcccs are sometimes grearcr chan effects ofcommon factors. More gcnerally, the mag-nitude of technique effects depends on dis-order and population, bolstering theassertion char broad judgmenrs abouc cherelative importance o[ technique and com-mon factors are insufficient and can be mis-leading. Insread, more nuanced accountsthat do not aSlgregare across moderatingvariables are necessary to cclnduct and eval-uilre psychotherapy outcome research.Finally, putative common factors such astherapist skill, the therapeutic alliance, and

i rh treatment expcctancy are likely influenced' - by technique. Hence, their effects are nor

ezsily separable from rhose of active ingredi-ents, but instead are explained by series of

complex interactions. Nevertheless, therewill always be others who critique theanalyses, draw different conclusions, andadvocate for those stances, and efforts todisseminate ESTb are limited in part becauseopponents ofESTs have presented their per-spective more aggressively to wide-spreadaudiences. W'e must continue to addresstheir arguments with empirically baseddata and logic and make our voices heard inthe broad court ofprofessional opinion.

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\ \ ' r inrpoLl , I i . L. , I f t>rrr l i r r , ( i . \Xl , NIrr r r lv , N{. .

St i r i r , | . , Bcnson, K. , r t Ahn, H. ( l r ( )7) . A

nrctr r -atr i t lys is o l or t tc t t t . t rc stLr t { ics crrmlrar ing

lr r r t r r f l , lc 1>s; ,c l rot l terapi ts: i :nr l - i r rcal ly , "a l l

rnrist li,rrc prizcs." I't1;/t,,lu,qint/ Iltllttiu. I l-1,

2 0 1 , 2 I 1 .

\\/cinbcrgcr. J. ( I995). Cornn'rotr f:ictors .rrcn't so

conrnror l : ' I I rc cotnnrotr l : rc tors . l i lentmr.

L/tniu/ [t1.'r.Iolog1'; Stientt'nd l)r,r/itt, 2, 1t1-

69.

Conespondence /o Jcdicliah Sier', lJniversitv of

Pcnnsylvaniir, Dept. of Psychologli )i20

Va lnu t S t . , Ph i l ac l c l l r h i a , PA l 9 t0 i ; c - r na i l :

jsier,(ri psych. upenn.cdu

CE CALENDAR ,r:ru' rc ABCT5ubmityour www.obcl.org

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P http://www.obct.org

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