Cognitive Behavior Therapy: evidence and new directions

Vol V, No. 1, 2005 Comments (0)

E. Thomas DOWD*
Kent State University, Kent, USA

Psychotherapy is a diffuse, complex, multi-faceted undertaking. It has been practiced and investigated for decades and much of the literature could be summarized as, “It all depends…” That is, after thousands of studies and generations of theorizing, few interventions derived from theory appear to be uniquely successful and none account for the major source of variance in client change. From the beginning, it has based its theory, practice, and research on the medical model, both for historical and professional status reasons. Freud was a physician and only after the Second World War did psychologists begin conducting psychotherapy in significant numbers in the United States. In addition, because the practice and the professional training standards for psychologists were established at that time with powerful assistance from the U.S. Veterans Administration Medical Centers, educational and training parity with physicians was important. Thus, the doctorate (at that time the Ph.D.) was set by the American Psychological Association as the entry-level degree for practice in the United States. I will use two recent and important books to demonstrate the complexity and the equivocal results of psychotherapy theory, research, practice as well as its promise for the amelioration of human distress.

Correspondence should be addressed to: Dr. E. Thomas Dowd, Department of Psychology, Kent State University, Kent, Ohio 44242, USA

What is psychotherapy and why and how does it work? Why doesn’t it always work as intended? These questions are at the heart of psychotherapy theory, research, and practice. I was reminded of them in reviewing two recent and important books in the field. One is the second edition of “What works for whom?,” by Anthony Roth and Peter Fonagy (Guilford, 2005) and “Mindfulness and acceptance: Expanding the cognitive-behavioral tradition,” edited by Steven C. Hayes, Victoria M. Follette, and Marsha Linehan (Guilford, 2004). Each book partially answers the question in its own way and both make strong contributions to the psychotherapy literature. They are also more similar than might be apparent at first glance.

What works for whom?,

by Anthony Roth and Peter Fonagy. Guilford, 2005

Let me begin by briefly summarizing the relative contribution to psychotherapeutic outcome of client variables, therapist variables, and technique variables. There is considerable evidence that psychotherapy in general is effective, at least when compared to no psychotherapy. Both the Consumer Reports study (Seligman, 1995) and the Smith and Glass (1977) meta-analysis showed as much, as did many other investigations. Orlinsky, Ronestadt, and Willutzki (2004), for example, in examining more than 1,000 studies of psychotherapy outcome, found psychotherapy in general to be effective. Lambert (1992) also concluded that psychotherapy is effective. But what accounts for this general level of effectiveness and its variability across clients, therapists, and techniques is open to question.
Lambert (1992) has summarized outcome research indicating the amount of variance accounted for by different classes of variables. He reported that about 40% of outcome variance could be accounted for by extra therapeutic change, including client variables (e.g. ego strength, hardiness) and environmental variables (e.g. fortuitous events, social support). Furthermore, it has been found that clients who are relatively healthy tend to improve more than clients who are less healthy (Garfield, 1994). In other words, those who need psychotherapy the least tend to improve the most! Truly, to them that have shall be given unto!

Lambert (1992) reported that about 30% of outcome variance could be accounted for by common therapeutic factors, such as empathy, warmth, and support. These have been well-described by Jerome Frank (1974) as well as others. The quality of the therapeutic or working alliance between the client and the therapist has also been shown to be an important mediator of treatment outcome. But if this is true, why has more research and theoretical attention not been paid to these variables? For a tentative answer, one must look at the sociology of the psychotherapeutic profession. The creators of the major schools of therapy do not advance either themselves or their approach by declaring it to be relatively equal in effectiveness to other schools; rather they advance their cause by declaring it to be strikingly new and effective. This is less true of psychotherapy research, where studies of the effect of the therapeutic alliance by the Second Sheffield Psychotherapy Project (e.g. Stiles, Agnew-Davies, Hardy, Barkham, & Shapiro, 1998) and the effect of the therapeutic allegiance of the researcher (Luborsky, et al.,1999) have been shown to account for significant outcome variance in therapy and research. Indeed, Luborsky et al. reported an impressive correlation in comparative outcome studies between allegiance and the outcome of the treatments compared of .85!
Lambert (1992) reported that expectancy or placebo effects account for about 15% of outcome variance. This includes hope and expectancy arising from the mere fact of being treated as well as the credibility of the specific treatment techniques used. There is a large literature in cognitive psychology indicating that people see what they expect to see and find what they expect to find. For example, Lewicki, Hill, and Czyewska (1992) found that, when faced with ambiguous situations, individuals tend to impose their preexisting cognitive categories and tacit rules on the new situation, in what they call “self-perpetuating algorithms.” Indeed, this variable can be seen as a common factor in psychotherapy (Weinberger & Eig, 1999), leading to the conclusion that common factors may account for an impressive 45% of outcome variance.
Lambert (1992) allots a mere 15% of outcome variance in psychotherapy to the actual therapy techniques used. Certainly the term “technique” can cover a wide variety of interventions, from very specific techniques, such as hypnosis and systematic desensitization, to broader techniques such as therapeutic homework assignments and cognitive restructuring. Some of what are commonly called interventions can be seen as collections of techniques. In view of this however, why has so much attention been paid to research comparing different intervention approaches, both to no treatment or placebo treatment, and to other credible treatments with so few significant results? Although psychotherapy has been found to be more effective than no therapy and to a lesser extent more effective than placebo therapy, there are very few enduring outcome differences across credible therapeutic approaches. Indeed, Wampold (2001) has provided powerful and impressive evidence indicating that the specific ingredients in psychotherapy contribute nothing at all to outcome variance when contextual effects including therapeutic alliance, allegiance, and adherence to treatment are taken into account. Two answers are possible; first, techniques can be more easily manipulated than other therapeutic variables and, second, theoreticians and researchers become famous by developing new systems of therapy, which they then research with confirmatory bias uppermost.

The Empirically Supported (formerly Validated) Treatments (ESTs) movement has further complicated this picture. It originally began with a 1995 Division 12 (Clinical Psychology, American Psychological Association) task force, chaired by Diane Chambless, which was charged with developing criteria for identifying psychological treatments for which evidence of efficacy existed. Almost immediately controversy erupted. Supporters argued that in a managed care environment of accountability it was important to identify those treatments which had been shown to be effective (Chambless & Ollendick, 2001). They also claimed to find evidence for differential efficacy of treatment methods in certain areas while admitting the evidence was far from consistent. They found evidence that standardized treatments, following therapy manuals, were not less and possibly more effective than treatments which therapists designed individually, although few studies have been done. Detractors argued that the Division 12 task force was nefariously biased towards cognitive behavior therapy approaches, as was the research literature. They pointed to the low level of evidence needed (two studies conducted by different investigators) and argued that any potential treatment might eventually be found to be effective. They pointed to the evidence that few comparative outcome differences existed between credible treatments and questioned the need for ESTs at all. More abstractly, some questioned the sole reliance on one research paradigm and the medical model (including a standard diagnostic system, the DSM) and saw the EST movement as primarily political in nature, supporting the managed care movement’s desire to reimburse only for a few treatments of documented efficacy and declare the rest ineffective (Henry, 1998). More tellingly, perhaps, they argued that psychotherapy was fundamentally relationship- and contextually-oriented rather than technique-oriented so that the entire concept of ESTs was useless.
How then is one to evaluate the Roth and Fonagy book in this socio -economic -cultural theoretical -research -practice context? It advocates evidence-based practice. It uses the standard DSM nosological system. It examines the research evidence for different psychological interventions with several traditional disorders and two large population groups. In other words, it follows the standard model of psychotherapy research and practice that has been in place from the beginning, identifying specific methods for specific disorders and evaluating their efficacy and effectiveness. In that sense, it might appear to be antiquated. However, that is not at all the case.
Essentially this book is a monumentally impressive literature search with extensive commentary. Although it is primarily organized around specific disorders, it includes a number of chapters that deviate from this organizational principle. I will describe the individual chapters first, then the organization within each chapter. Chapter one is entitled, “Defining the psychotherapies,” and divides the therapeutic world into the following classes: psychodynamic psychotherapy, behavioral and cognitive-behavioral psychotherapy, interpersonal psychotherapy, strategic or systemic psychotherapies, supportive and experiential psychotherapies, group therapies, and counseling. There are few surprises here because these are historically the most common treatment classes and therefore would have been reflected in more research studies. The last one, counseling, is the most curious because it is defined not by technique but by setting and philosophical emphasis, as a relationship of equals. It seems to be used in the sense of Rogerian client-centered nondirective therapy (was there ever a “therapist-centered directive” therapy?) But few research studies have investigated such an amorphous intervention and, as the authors note, it has evolved as an integrative set of interventions. It is not a unitary construct.
Chapter two is devoted to a discussion of research and methodological considerations. This is a very important, as well as humbling, chapter because it illustrates the trade-offs inherent in any research study. Topics such as clinical efficacy and clinical effectiveness, problems of randomization and control groups, manualization of treatment, diagnostic homogenization, meta-analysis, and single case studies are discussed. The authors also include such newer findings as the allegiance effect, comorbitity, biased representation in theoretical appearance in the literature, and the “file drawer” problem (negative findings tend not to be published and end up in files). There is enough here to temper any conclusions of therapeutic efficacy/effectiveness.
Chapter three is a discussion of psychotherapy research and practice as it relates to health service delivery systems and health service policy. For example, what is the cost-benefit analysis of psychotherapy? How can research inform service management? What are the benefits and limits of Empirically Supported Treatments (ESTs)? The British origin of this book is especially noticeable here because their National Health Service has been concerned for some time with these issues in a way Americans have not until recently. Psychotherapy that is privately contracted and paid for by the client rather than by third party payers or society operates under very different constraints and reinforcers. For example, under the first model client satisfaction becomes at least as important as documented outcomes, though of course satisfaction is not likely to occur in the absence of outcomes satisfactory to the client. Nevertheless, there are differences in perceptions between clients and their therapists regarding acceptable outcomes and in third party payer models the perception of the therapist (and the payer) is paramount. If the client pays, the client is the sole judge.

The next 10 chapters are concerned with a variety of the more familiar diagnostic category problems. These include the treatment of; depression, bipolar disorder, anxiety disorders I (phobias, generalized anxiety disorder, and panic disorder), anxiety disorders II (obsessive-compulsive disorder), posttraumatic stress disorder, eating disorders, schizophrenia, personality disorders, substance abuse, and sexual dysfunction. I will first describe the outline of these chapters, then discuss some common conclusions that can be drawn from the information presented.
While the chapters follow very similar models, there are some differences. Each chapter is very comprehensive and begins with definitions of the different disorders. Then there is a section on Prevalence and Natural History (sometimes including Co-morbidity). Generally, a description of the different treatment approaches are then discussed, with the studies pointing to their efficacy. Commendably, these approaches go well beyond individual therapy, including such modalities as group therapy, psychopharmacology, and psycho-education. Also discussed are qualitative and quantitative reviews and meta-analyses for each type of treatment, as well as treatment comparisons, combination treatments, and dismantling studies where appropriate. Sometimes there are sections on dropout and relapse (prevention). Because so much work has been conducted on depression, there is a special section in this chapter on Landmark Studies of Efficacy, such as the NIMH studies on cognitive, interpersonal, and pharmacotherapy. At the end of each chapter there is a section entitled, Summary and Clinical Implications. But all chapters have section summaries embedded within. The result is an enormous compendium of information about the disorders themselves, a wide variety of treatment approaches, research findings for each approach, and clinical implications. The authors are not afraid to take a stand on the evidence (sometimes lack of it) for the efficacy of newer and sometimes controversial approaches such as EMDR and non-professional treatments such as the 12-step programs for substance abuse.
The following two chapters are population-based rather than problem-based, on the treatment of child and adolescent disorders and older people respectively. In the former chapter, there is some overlap with previous chapters; for example depression and anxiety are both covered. But many of the problems described are more unique to children and adolescents, such as Autism, Conduct Disorders, and ADHD. Specific issues, such as obtaining parental consent, are also covered.
The chapter on the treatment of older people covers some of the same ground as the problem-based chapters with some different issues such as dementia and sleep disorders along with a section on Interventions for Family Caregivers. The authors state that they discuss this group of people separately for two reasons, first that the response of older people to psychotherapy may be different than younger clients and, second there is a higher proportion of organic problems.
The next chapter (The contributions of therapists and patients to outcome) represents an especially important contribution of this book and a welcome departure from the standard problem-, population-, and technique-based models of the book to this point. I suppose the relative emphasis of the book on technique-based interventions is appropriate, despite Lambert’s (1992) finding that only about 15% of the variance in outcome is due to technique variables, because most of the research studies have investigated specific technical interventions and the standard theoretical approaches are largely technique-based.
This chapter covers a wide variety of topics; the effect on outcome of therapist competence, therapist adherence to technique, and experience (those are not the same), professional training, the therapeutic alliance, patient/client expectancy, treatment credibility, and matching patients/clients to particular therapists. To say the data are inconclusive is an understatement! Not only are the results of studies inconclusive and contradictory, there is not even agreement on what some of the terms mean. For example, the therapeutic alliance is probably not a homogeneous variable, professional training is often conflated with experience, the specific competencies involved in therapist competency are often unclear, and competence itself may refer more to technique delivery than to an individual attribute. Furthermore, the role of professional training in fostering competence is unclear and the evidence for the benefit of adhering to treatment manuals is contradictory, with some research indicating that adherence reduces outcome variance while other research suggests that the overstructuring which may result from manual adherence can hurt outcome. In any event, the relationship between adherence and outcome appears to be weak and the evidence for the impact of training is only suggestive.

Nevertheless, some tentative conclusions may be drawn. First, the impact of the therapeutic alliance has repeatedly been shown to be quite robust, although it may function more as a mediating variable than a causal one. Second, therapist experience may be an important predictor of outcome, though possibly with more disturbed patients. Third, therapist competence (however measured) is associated with better outcome and supervision helps. Fourth, there is evidence that more therapy is better than less therapy, although the rate of change is faster in the initial stages and diminishes thereafter. Fifth, patients who are better interpersonally adjusted seem to benefit more from therapy, as if the very characteristics that handicap them in their everyday lives also handicap them in therapy. Sixth, patient expectancies of improvement predict positive treatment response although the impact of treatment credibility is less clear.

The final chapter, Conclusions and implications, summarizes the entire book in a comprehensive fashion. First, it provides brief summary statements concerning treatments which have been shown to be efficacious for particular disorders and which treatments show promise. Second, several methodological caveats are discussed, such as limitations deriving from the Procrustean use of the DSM, the “file drawer problem” (negative findings tend not to be published, thus skewing the evidence), and the relative absence of long-term follow-up data. The authors conclude with sections on translating research into practice and new directions in psychotherapy research.

In summary, this is as extremely impressive book, for its range of scholarship, its comprehensive summaries, its willingness to tackle difficult issues, and its unusual and ground-breaking special chapters. It should not necessarily be read straight through (the way I did) but rather specific chapters could be sampled as the need arises. It is an excellent reference book as well as a textbook and thus can profitably be used both by graduate students and professionals.

Mindfulness and acceptance: Expanding the cognitive-behavioral tradition

Edited by Steven Hayes, Victoria Follette, and Marsha Linehan

I have noted elsewhere (Dowd, 2004) that cognitive-behavior therapy, both in its evolution from behavior therapy, and in its subsequent development has steadily expanded to the point that it is sometimes difficult to determine what is not CBT. It has begun to incorporate a constructivistic and a narrative epistemological framework, what Roth and Fonagy (2005) call post-cognitive behavior therapy. This has both good and bad aspects. If it does not expand, it risks becoming ossified and stagnant; if it expands too much, it risks losing its identity. This book illustrates the latest expansion of the CBT model. For what is has done is to incorporate more experiential, relativist, paradoxical, and contextual approaches into CBT, in the process leaving some readers perhaps to wonder in what sense this is still cognitive (behavior) therapy.
The roots of this expansion may lie both in the evidentiary basis for CBT and the implicit sociology of the profession. Although CBT has been shown to be effective in treating a wide variety of psychological and behavioral disorders when compared to no treatment or a control condition, it has not been shown to be unusually, consistently, or uniquely effective when compared to other treatments (e.g. Dowd, 2004; Roth & Fonagy, 2005), although Dowd cites some evidence that it may be especially promising in reducing relapse or in preventing problems. In addition, CBT has not been effective with everyone; a large number of individuals have proved to be impervious to its interventions. Indeed the support for the role of cognitive change itself in cognitive therapy outcome is tentative (Whisman, 1993), The equivocal nature of the research has encouraged theoreticians, clinicians, and researchers to search for new techniques to add to the existing armamentarium of CBT in an attempt to increase its effectiveness.

Second, the developers of the current systems of psychotherapy became famous and influential by creating new approaches, not by describing what they do as similar to what has been done in other approaches. In truth, a number of supposedly “new” psychotherapeutic interventions are only “variations on a theme;” similar in most regards to what has come before but differing in certain additions and emphases. But, with the exception of Jerome Frank, no theoretician has ever become famous by systematically describing the common elements of psychotherapy and suggesting that what they do is similar to what others do. In this, they are encouraged by a public mindset that constantly demands something new and more effective. “New” is what sells in the marketplace of ideas.

This book is new and the approach does appear to be selling in the marketplace of ideas, although it incorporates some ways of thinking and being that are hundreds of years old. Essentially, what Hayes and his colleagues have done is to incorporate into CBT aspects of Buddhist thought and meditation, paradoxical interventions, contextualism (e.g. constructivism and hermeneutics), Korzybski’s Theory of General Semantics, and experiential therapy. Not all of these influences are explicitly acknowledged in the book but they implicitly pervade it.
The book combines two recent “post CBT” efforts into one volume, Mindfulness cognitive therapy for depression (Segal, Williams, & Teasdale, 2002) and the burgeoning Acceptance and Commitment Therapy (ACT) literature (Hayes, Strosahl, & Wilson, 1999). It also fits well into the prevailing cultural “Zeitgeist” (spirit of the times), which has itself become more relativist and contextual. As Hayes notes in his introductory chapter, “Assumptions about the questions, issues, methods, and forms of evidence appropriate to a field are often more important to maintaining a dominant paradigm than are specific theories, studies, principles, or technologies” (p. 4). The assumptions underlying theories and methods of psychotherapy are often metaphorical in nature and these metaphors change in response to cultural and scientific worldviews. Thus, the machine (hydraulics and mechanics) served as Freud’s metaphor of repression, technology served as the metaphor for early behavior therapy, information processing was important in early CBT, and post-modern philosophy and motor theories of the mind are guiding metaphors in constructivistic, narrative therapy (Dowd, 2004). This post-modern relativism is being accelerated by the world-wide “clash of cultures” which undermines tacit and rigid cultural assumptions as disparate societies come in close contact with each other.
The book contains a variety of chapters sometimes written by professionals one would not normally associate with this approach (e.g. Terry Wilson, Tom Borkovec). After an introduction by Steve Hayes, there are chapters on Dialectical Behavior Therapy, Mindfulness and Meditation, Functional Analytic Psychotherapy, Behavioral Activation, anxiety, trauma, eating disorders, substance abuse, values work, and couples therapy. Some of these topics are covered in more than one chapters. They are authored or co-authored by some of the most respected writers in the broad field of cognitive behavior therapy. At the very least, the book provides a good insight into the way different professionals view this new area and work with it.
So what is this book really about? Hayes refers to the new behavior therapies as defined by three aspects; 1) less reliance on first-order change (although that term is never defined), 2) a more contextualistic approach, and 3) a broadening of the focus of change. In addition, Hayes stresses the function of behavior, not necessarily the form of behavior and encourages clients to live according to their values, rather than pursuing “truth.” Relativism is the hallmark here, as it increasingly is in contemporary American society. But the one concept which, to me, seems to permeate the book is acceptance. The term is found in most of the chapter titles and in all the chapter contents.
But what do the chapter authors mean by acceptance? There seem to be several aspects to it. First, there is an acceptance of what one is as part of the change process, echoing the Alcoholics Anonymous slogan, “To change what we can change, to accept what we cannot change…” Embedded in this is the acceptance of suffering as inevitably a part of life, a Buddhist concept for centuries. Second, there is a strong advocacy of acting and thinking in the Present, the Now. Third, there is an emphasis on Mindfulness (full awareness of what one is experiencing, contacting, seeing, hearing, etc.) as a means to acceptance. Some chapter authors include Mindfulness Meditation explicitly, others do not. Mindfulness is considered by some to be at the heart of The Buddha’s teachings. A cynic might claim that, since we have discovered we often cannot assist our clients to change, we might as well help them accept themselves the way we are. But there is more, much more, to it than that. Acceptance can be truly transformational in our lives, rather than conservational. It is an opening up rather than a holding in.
There are also echoes of paradoxical interventions, although the term is never used. There is an entire literature on this topic (e.g. Dowd & Trutt, 1988; Watzlawick, Weakland, & Fisch, 1974). The most common paradoxical intervention is symptom prescription, in which clients are asked to exacerbate their symptoms in order to put them in a double bind (either they can, in which case it is under their control, or they cannot, in which case it is less of a problem). Another intervention is reframing, in which a problem re-interpreted as positive rather than negative (the glass is half full rather than half empty). A third is restraining, in which clients are asked to refrain from trying to solve their problem for a period of time, essentially a form of temporary acceptance. This has been used most notably in sex therapy. These paradoxical techniques are seen as fostering second order change because they help to change the context in which the problem operates (second order change), rather than continuously and fruitlessly using the same change strategies as before (first order change). Essentially second order change interventions decontextualize the problem. Paradoxical thinking pervades this book and it is more of an Eastern concept than a Western one.
There are occasions throughout the book where chapter authors refer to language as not being reality; one of Hayes’ techniques is repeating a word rapidly until it loses all meaning. Too often we reify language so the words become the reality. Isabel Caro in Spain (1996) has used Alfred Korzybski’s Theory of General Semantics to develop an approach to therapy that emphasizes detaching words from reality (“The map is not the territory”) which is echoed at places throughout this book. Reality itself is seen as relative and constructed by the individual.
If there is one aspect of this book that is especially prominent, however, it is the experiential emphasis. Experiential processes in CBT are not new, of course; indeed they could be said to be a part of Beck’s original cognitive therapy of depression because of the importance of homework and behavioral activities. As far back as 1962 Nicholas Hobbs argued that behavior change precedes insight, rather than the reverse as was assumed in psychoanalysis. In this book, however, the experiential aspect is magnified, though more so in some chapters than in others. Associated with this is the openness and acceptance of all client psychological events, even if they have been previously thought of as negative. This is similar to the paradoxical strategy of reframing, described earlier, in which the problem becomes the solution.

The emphasis on meditation is interesting because it overlaps with an entirely different set of therapeutic interventions. Recently I (Dowd, in press, a) described the similarities among a variety of imagery-based interventions, including meditation, prayer, and hypnosis. These phenomena have much in common. They engage the phylogenetically older, more holistic, more encompassing, and less linear and analytical aspects of human cognition. They are less tied to what is commonly called concrete reality and allow the possibility of more creative cognitive processing and openness to new possibilities. They rely less on linear thinking processes. They tend to bypass the human cognitive censoring mechanism, that part of our mind which critically evaluates, rationally processes, and channels information. They are aspects of what might be called primary (or primitive) cognitive processing rather than secondary (or rational) cognitive processing. In summary, they rely more on what has commonly been called “right brain thinking,” as opposed to “left brain thinking. Technically, they include Buddhist meditation, Christian prayer, covert sensitization, guided imagery, Rational-Emotive Imagery, Imagery Rescripting (Smucker, Dancu, Foa, & Niederee, 2002), Mindfulness, and hypnosis. Hypnosis in particular may help foster the openness to change advocated by Hayes, Follette, and Linehan (2004) by helping individuals suspend their usually critical, evaluative, and censoring cognitive processes (Dowd, 2000) and become more receptive to new experiences. In a process known as trance logic, some people can hold somewhat contradictory ideas in their minds simultaneously, thus encouraging new associations and perceptions.
Hypnosis, or indeed any imagery or meditative technique, may also be able to access nonverbal tacit knowledge structures (Dowd, 2000). Much of our tacit knowledge (what in cognitive therapy is called core cognitive schemas) was developed and laid down before the use of language and thus is relatively inaccessible verbally. But this early knowledge can often be represented in images when it cannot be represented in words. The Ericksonian hypnotherapists in particular (e.g. Erickson & Rossi, 1979) have developed techniques to assess and change structures of tacit knowledge, called the “unconscious mind” in Ericksonian metaphorical terminology. Since many client problems appear to result from early learning, imagery techniques of all kinds may be more useful than has been thought.
There is tentative evidence that hypnosis and by extension other types of imagery-based techniques may provide added value to other psychological interventions. Kirsch and his colleagues (Kirsch, 1996; Kirsch, Montgomery, & Sapirstein, 1995), in recent meta-analyses, found that hypnosis added significantly to the therapeutic effect size of cognitive behavior therapy alone. Bowers (1982) even argued that individual differences in process response and outcome in cognitive behavior therapy may at least partially be accounted for by individual differences in hypnotic susceptibility. But there are significant and relatively enduring individual differences in this variable, or, as it is alternatively called, hypnotizability, hypnotic ability, or trance capacity, that limit the extent to which all clients can benefit from hypnosis, and perhaps meditation and imagery techniques. There is evidence that people high in hypnotic ability are also high in their ability to engage in vivid imagery (Dowd, in press, a).
Despite the different organizational format and purpose, these two books have much in common. First, they are both excellent examples of innovative and forward thinking. Roth and Fonagy (2005) have provided a state-of-the-art comprehensive analysis of the evidence base for psychotherapy practice with important suggestions for the future. Hayes, Follette, and Linehan (2004) have done the same for an entirely new look at the practice of cognitive behavior therapy. Both books remind us that the process of knowledge acquisition and development never ends. Second, they are both mindful (if I may use that word) of the limits of our knowledge and cautious about being overconfident. Third, they are both fundamentally technique-based in their analysis and further development of psychotherapy practice and research. However, there is another literature that may be helpful.

I began this chapter by pointing out that there is considerable evidence that techniques account for only about 15% of the variance in psychotherapy outcome (Lambert, 1992). Later estimates of technique variance ranged all the way from “considerable” (Chambless & Ollendick, 2001) to “none” (Wampold, 2001). No one, however, has claimed recently that techniques account for the largest source of variance, yet that is precisely where the theory and research has focused over the decades. Roth and Fonagy address this topic in their chapter on “The contributions of therapists and patients to outcome,” and concluded, “Although variance in outcome attributable to therapists appears to be large and reasonably consistent across studies, it is surprisingly hard to account for these differences.” (p. 475). Once again, the evidence is unclear.
There is another paradigm in psychotherapy research and practice that is relevant and that is the social influence model of change. Dowd (in press, b) has described three therapeutic forces that interact to cause change – the therapist’s social power, opposition forces in the relationship, and resistance forces in the client. Therapist social power is based on legitimate power (e.g. credentials, status differential, social sanction), therapist expert power (deriving from perceived and actual knowledge and skills), and therapist attractiveness (based on perceived similarity and liking). These sources of power provide the therapist with credibility and social influence within the context of a specific culture. Acting against this social power are opposition forces that result from too much discrepancy in therapist communications and consequently client opposition towards too great a change. The content of what the therapist says is simply too different from what the client currently thinks. Resistance forces arise from therapist activities that the client thinks are illegitimate; that is, more with how the therapist operates. The amount of resistance generated is also a matter of client individual differences. Within this system, a major therapeutic change-producing intervention is discrepancy which refers to the difference between the therapist’s interpretation or explanation of the client’s experiences and difficulties and the client’s own explanation and is a way of fostering cognitive dissonance. Research has shown that the content of the interpretation is of little importance as long as it is accepted by the client; what is more important is discrepancy. Discrepancies which are too low will have little change-producing potential; discrepancies which are too great will overly threaten the client’s tacit cognitive meaning-making system, thus increasing opposition forces. A moderate level of discrepancy is best but it is often difficult to decide what is moderate and what is not.

These two books have provided much information for cognitive behavior therapists, one by summarizing the evidence and the other by extending CBT practice into very different territory, in the process beginning an integration with a different set of ideas and literature. What is needed now is a fuller integration of technique variables with therapist variables.


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