Bruce Wampold

Materialism - Philosophical understanding of matter as the sole basis of reality. Phenomena can therefore be explained through the interaction of various types of matter. -> All Illnesses and physical states have a physical substrate.

           Specificity (corollary of materialism) - The manner in which a treatment manifests itself. Specificity can be achieved by either showing that the treatment is more effective than a placebo treatment or by establishing that the medical treatment operates through its intended mechanisms

1. Illness / disease (report symtomps do physician→ abnormal?→ if yes= diagnosis [preventive interventions])

2. biological explanation (any abnormalities= explained by biological/ anatomical elements/reasons)

3. mechanism of change (due to biological change→treatment→ return back to original state)

4. therapeutic procedures (explanation of illness + its treatment consisting of mechanisms of change→ design a treatment which contains therapeutic actions and alligns with the explanation of the illness [e.g. the right medicine])

5. specificity (show that treatment is more effective that the placebo→ evidence-based-medicine/practice: antibiotica vs. bacteria)

The integration of the best available research with clinical expertise in the context of patient characteristics, cultures and preferences

3 steps:

1. using best research available→ use of evidence (compare effectiveness)

2. clinical expertise

3. characteristics and context of patient→ integrate personal characteristics in intervention

are understand as substances or procedures (without active substances/actions [zuckerkugeln, fake-accupuncture])→ but you tell the patient that its valid (in trials)→ (there is also the option of “CRAZY METHODS“)

use placebo to show that the specific ingerdient has an effect

how→ placebo needs to be identical (extent, size, packaging, color, etc.) with the treatment except for the special ingredient

→ these trials are doubble blinded→ all of them are unaware (patient, experimenters)

efficacy of specific ingredient is etablished (bc only diff. between them was the special ingredient)→ specific effects are physicochemically based, all other effects were controlled (they were the same in both grps.)

may or may not have an effect→ but this is insignifficant→ there are no actuall effects

have two primary components: a discussion of the client’s problems and the manipulation of the belief that one is getting an effective treatment

Placebos= inert substances / interventions which have no specific therapeutic properties but can produce therapeutic effects→ due to psychological mechanisms (expectancy, conditioning, therapeutic relationship)

→ The placebo effect= measured : difference between the placebo response and the natural course of the disorder

(the placebo effect can be influenced by factors such as adherence to treatment protocols + treatment context)

the difference between the active treatment and the placebo at the end of treatment. This is the effect that is necessary for the approval of a drug by the Food and Drug Administration (FDA). The validity of this effect depends on the treatment and placebo being indistinguishable and the double blinding of the treatments

→ common factor of expectation (created trough verbal persuasion. In therapy= build a narrative→ persuade them that sth is good/helpful)

→ This works with pain, feeling of satation, fitness (→ you have to believe in getting better and this mindset alone will change your course of recovery)

→how competent and warm the therapist is perceived

→ the disorder being treated (how→ procedure)

→ research design→ (design enhancing or downgrading placeboeffect)

→ comparison with treatment effect (in wie fern ist Behandlung auf placebo zurückzuführen)

→ nature of measures→ (subjektiv vs. objectiv measures)

1. 1920-30s: The adaptation of randomized study designs in psychotherapy research marked a significant step forward in empirical analysis (S.24).

2. 1951: Carl Rogers and his team created transcripts from audio recordings of therapy sessions. This led to the generation of hypotheses that were tested using research methods from education and psychology. However, these early studies were not conducted cleanly due to small sample sizes, undefined treatments, and poorly specified outcomes (S.23).

3. 1950s: The adaptation of the placebo control group design in psychotherapy research helped establish the specificity of treatment effects (S.24).

4. 1952, 1961, 1966: Eysenck's assertions that psychotherapy (excluding behavioral therapy) was no more effective than spontaneous recovery sparked debate and prompted increased rigor in testing psychotherapeutic effects (S.24).

5. 1977: Smith and Glass published a meta-analysis of all studies comparing psychotherapeutic approaches to control groups, demonstrating the efficacy of meta-analyses and establishing them as a standard method of aggregating research results (S.25).

6. 1979: The first treatment manual was used in psychotherapy, primarily to increase standardization and demonstrate procedural differences between alternative treatments in comparative outcome studies.

7. 1980s: Psychotherapy outcome research began to be labeled as clinical trials, which helped establish the legitimacy of the psychotherapy enterprise (S.24).

8. 1990s: The establishment of the Empirically Supported Treatment (EST) scheme, patterned after FDA criteria, required treatments to be validated for specific disorders through at least two studies showing superiority to control groups. Manuals became a requirement for certification as an EST, further aligning psychotherapy with a medical model. This adoption of the EST scheme bolstered the status of psychotherapy

EST Movement

The Task Force of Division 12 (Clinical Psychology) of the APA. They developed criteria, which if satisfied by a treatment would be included on a list published by the task force. “Task Force on Promotion and Dissemination of Psychological Procedures

Common factors→ factors that are prevalent (vorherrschend) in all forms of therapy→ these are responsible for their euqal effectiveness. (therapy effects can not be attributet to them!)

→ they are the critical component tho (are always vorhanden in the studies thats why all treatments are the same effective)→ not related to what the treatment actually does

= common factors are all identical!

contextual model thinks that based on client characteristics(personality, culture, etc) some treatments might suit the patient better than others and therfore also lead to better outcomes. There sould also be a cultural adaption (adaption to ethnicity= better therapy outcomes). therapeutic relationship should be adapted to the clienttype and its needs as well

relationship-based→ benefits of psychotherapy arise through social process (RS between therapist and patient= im Vordergrund)

→ the model posits 3 Ways through which the benefits of psychotherapy are achived:

1. the real relationship between therapist and client (creation expectation through explanation, agreement on goals)

2. client engagement (therapy induce clients to engage in actions that promote health.)

3. focus on therapeutic relationship (RS between therapist and client are massgeblich entscheidend über [mis-]erfolg of the therapy, caus the RS is central for the effect of the therapy)

expectations are primarily created through giving the patient an explanation(goes beyond simple explanation why he needs this kind of therapy→aim is to make the patient realise their psychological distress “folk Psychology“ and change their believes towards this. Psychtherapy gives adaptive explanation which offers a means to overcome/cope w. difficulties)for their problems and offering a treatment(plan) that alligns with the explanation.

after the explanation of the therapist its about the client→ he has to accept the explanation and believ in it (that it will help him→ then therapy has much better outcome→critical!)= engage the patient in therapeutic actions→ contribute to effectiveness

therapist and patient must form an initial bond!→ then they create a real RS(first pathway in clients change)→ explanation and treatment actions = create expectations abt. therapy (second process of change)→ carrying out treatment actions (third and last change)

benefit of psychotherapy entsteht through social process, therapeutic RS is fundamental to its effectiveness.

→ human is a very social spechies with a strong urge to form social bonds/connections.

→healing comes through social means “social immunity“

→expectations r created by providing an explanation for the problem + offering a treatment plan→ alligns with explanation

→ important to build engagement and trust→ first session → therapist needs good skills (remoralisation)

→ if therapy is effective→ depending on RS between client and therapist (tgt with ozher factors as agreements on goals and tasks, participation to tasks, therapeutic allegiance)

→ specific ingredients are less important that the therapists ability to make a therapy suiting to clients personal believes and background

→The therapist's actions, characterized by empathy, understanding, and the formation of a strong therapeutic alliance, are key drivers of therapy effectiveness.

Both models are supported by empirical research, meta-analytic studies, and testing predictions of specific mechanisms.

→ Contextual Model =represent a progressive research program→ focus on therapeutic processes (st and longitudial studies).→ therapist skills are ausschlaggebend→ therapisteffects change effectiveness of therapy significantly. →offers a more comprehensive understanding of psychotherapy outcomes by considering the complex interplay of social, psychological, and therapeutic factors.→ its about HOW the treatment is delivered!

→Medical Model shows signs of being degenerative→ somehow inacurrate→relies more on experimental testing and the assessment of treatment effects through randomized clinical trials (RCTs)→ umstritten, validity is questionable bc they have their limits

Absolute efficacy refers to the effects of treatment vis-à-vis no treatment and is best addressed by a research design where treated patients are contrasted to untreated patients.

→ that means: the absolute efficacy refers to the effect a treatment has in comparison to no treatment. This is best reaserched by comparing treated patients with untreaded ones (generally speaking → psychotherapy should be more effective than no therapy!)

the role of the therapist is significantly important to the efficacy of psychotherapy→ achiving positive outcomes.

→ the outcome of the therapy depends more on WHO delivers the treatment than on what kind of treatment (specific ingredients or techniques used) they use.

→ to summarize→ competence of the therapist and his abilities to form a strong bond (alliance) with the patient is more important to the efficacy of psychotherapy

→ 68% of therapy is working ig

80%→ average client receiving therapy would be better off than 80% of untreated clients

→NNT (Number Need to treat)= 3

relative efficacy= is the comparison of therapy outcomes between 2 different therapeutic approaches. how good works one therapy in comparison to an other one in terms of effectiveness or success→ acheiving therapeutic goals?

e.g. KVT vs. PDT→ 2 grps→ each grp gets treated by one therapy form→ compare the outcomes (symptom reduction, improvement in functioning, or other relevant measures)

aim is to figure out which therapeutic approach is more effective/ beneficial for addressing specific mental health concerns when compared to alternative treatment options

suggests that there are only little/ no differences among treatments.

→ allegwiance-effects: the greater the allegiance (loyality) of the therapist to a particular therapeutic approach, the better the outcome→ r= .65

→Wampold's Meta-Analysis: supports the Dodo bird conjecture, which suggests that all psychotherapies are roughly equivalent in terms of their benefits. → there was no evidence for differences found

→ Component Studies: didnt find evidence for specific effects (studie examined the effect of removing/ adding specific components from therapy→ did not in-/decrease the outcomes significantly)

Heterogeneity and Robustness: results only little heterogenity→ impies that results are robust→ are not influenced much by moderating variables→results from these meta-analyses are reliable and applicable across different contexts

therapist effects exist because therapists who are more effective are doing something that makes them more effective (theres a variance in outcomes among therapists)—for example, they are better at forming alliances, personality, techniques, relationships, role expectations, etc.

→Variability Among Therapists: there is a big difference between a good and a bad therapist→ 3-7% worth of the outcome (thats bigger than effects of specific ingredients)

→Impact of Therapist on Treatment Outcomes: therapist effects→ cumulatively, these effects can be significant→ also over Time: small effects can have a big impact

→Characteristics of Good Therapists: certain therapist characteristics e.g. interpersonal skills, competence, warmth, humility→ contribute to therapist effectiveness. [However, factors such as age, personality, professional degree, and attitudes towards the etiology of illnesses or therapy techniques do not significantly impact therapist outcomes.]

→Placebo Effect and Therapist Impact: the placebo effect works better when administered (given) by the best therapists compared to the worst therapists administering actual medication= significant impact of therapist on treatment

3 Components:

1. agreement about the goals of therapy

2. agreement about the tasks of therapy

3. the bond between the therapist and the client.

bevore herapist + patient work tgt= initial bond needs to be created→ the agreement about the goals and tasks of therapy→ predictive for outcom of treatment→ aceptance of model of patient = significantly important for outcome of all therapiesss

→the probability of ppl dropping out of therapy is the biggest on session #1 (zwischenmenschliches beurteilen)→ after the first session→ dropout rate decreases drastically

There is a robust association between the therapeutic alliance and treatment outcome→ strong therapeutic alliance tends to lead to better treatment outcomes.

→Measurement Issues: due to them the korr can be lower

→Therapist Contribution to Alliance-Outcome Correlation: Therapists contribute to the alliance-outcome correlation→Better therapists tend to have stronger alliances with their patients, leading to better treatment outcomes. (aligns with what the contextual model says)

→Client Confidence and Therapist Belief→Therapist belief in the efficacy of the treatment plays a crucial role in building client confidence and enhancing the therapeutic alliance.

= therapeutic alliance plays a significant role in treatment outcomes (beitrag von therapeuten auf korr. sehr wichtig)

several key-factors.

1. Desire for Relief or Pleasure: this desire is like a motivational factor which helps for the effectiveness of the placebo

2. Expectation Induction: important to raise the expectation in client taht the placebo can bring the desired relief→ this sets the stage for the placebo-effect to occur (influencing the individual's belief in the treatment's efficacy)

3. Emotional Arousal: plays a role → enhancement of the Placebo-effect (more intense reaction to the treatment)

4. Attribution to One's Own Efforts: enhancement of placebo-effect when when individuals believe that their efforts are responsible for improvement, they are more likely to experience positive outcomes, even in the absence of therapeutic ingredients.

   →(Controlled Incidental Factors: Placebo effects can be influenced by incidental factors that are not directly related to the treatment itself→ controlling them→ evaluate the specific effects of placebo interventions)

5. Creating Supportive Environment: a supportive and empathetic environment can enhance the placebo effect.→ therapist can create this atmosphere→ enhance trust in treatment

1. Role of Expectations:Expectations play a major role in psychotherapy outcomes→patients' expectations are predictive of treatment outcomes→ their beliefs and anticipations about the therapy affects their response to the treatment.

2. Interaction with Conditioning:Expectations and conditioning→ interact in influencing treatment effects (e.g. inform patients abt positive effects of cream).

3. Expectancy and Treatment Interaction: power of expectations influencing treatment outcomes. (e.g. fake-accupuncture)

4. Change in Response Expectancies: Placebos and psychotherapy induce changes in response expectancies→ This change in response expectancies is self-confirming and contributes to the effectiveness of treatment.

5. Importance of Cultural Compatibility: expectations are created through the explanation of disorder→ but they are only effective if the patient accepts the explanation.The explanation and treatment must be compatible with the patient's cultural beliefs for expectations to be formed effectively.

Empathy, understanding (following things that the client might go through have to be understood by the therapist), ability to create alliance (therapist is congruent, provides unconditional positive regard, shows an empathetic understanding) with client

-       Facilitative Interpersonal Skill (FIS)

• competence

• warmth

  → affective expression (display emotion which fit to the situation and which is either complimentary to the client’s or the one the client is avoiding )

  →creating hope

→ Weak or Nonexistent Effects:no significant differences between complete treatments and treatments without critical ingredients. This suggests that the removal of specific ingredients may not substantially impact treatment outcomes.

→Augmentation with Additive Ingredients: Adding an ingredient to an existing treatment may augment the effects for targeted variables, but the size of these effects tends to be small.

→Complexity of Treatment Effects: The efficacy of treatments may depend on various factors, including patient characteristics, treatment adherence, competence of the therapist, and mediators of change. → complex interaction→ hard to isolate specific effects of individual treatment components.

= while some studies suggest that removing specific ingredients may not substantially affect treatment outcomes, the evidence is mixed and contradictory.

• Contextual Model Perspective: Contextual Model→adherence to a manualized treatment is not considered necessary for treatment outcome.( prioritize having a coherent rationale for treatment rather than strict adherence to a protocol)→ grundprinzipien are important but not to use 1:1

• Complex Relationship with Outcome:relationship between adherence (Therapietreue) and treatment outcome. Allience can compensate for lower adherence to the treatment.→ if allience is weak→ better outcomes when higher adherence

• Influence of Patient Characteristics: rating of adherence and competence can be influenced by patient characteristics (therapist may appear less competent if patient is aggressive)

• Variability in Adherence and Competence:significant variability in adherence and competence → may decrease over the course of therpy→ is influenced by factors such as patient characteristics and therapist persistence.

• Measurement Challenges: Measurement of therapist adherence and competence is challenging due to the influence of patient characteristics and variability across sessions→ there is little/ no significant association with the treatment outcome

Adherence = extent to which the therapist sticks to a protocol/manual

a warm, friendly manner, active listening ,empathy, 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation

→positive expectations can transform substances with no active ingredients into meaningful health outcomes

• Healthcare Provider's Warmth and Competence→ significantly impact placebo responses. Patients are more likely to trust and be influenced by the expectations set by a likable and credible provider→ can enhance the treatmenteffects

• Impact of Positive and Negative Expectations→ positive and negative expectations about a treatment can affect treatment outcomes. → positive expectations can decreas the symptoms (given from warm person).

• Moderation of Expectations by Provider Interaction Style→ interactionstyle important→influence treatment outcomes. when warmth and competence→ positive expectations are strenghtend→ less allergic reaction. However, negative expectations are not similarly strengthened.

• Effectiveness of Positive Expectations: positive expectations from a warm + competent person= reduce allergic reaction= placebo effect can be boosted by social context

  =the placebo effect can be both boosted and diminished by the social context, particularly by the warmth and competence of the healthcare provider.

effective psychotherapy relies on several common factors:

1. therapeutic relationship→emotionally charged, confiding rs between the therapist and the client.→ needs a healing context→ believe therapist to have ability to help/ assist them

2. Rationale or Conceptual Scheme: rationale or conceptual scheme that provides a plausible explanation for the client's symptoms→ must be accepted by both sides (can contain myths/explanations of clients worldview)

3. Ritual or Procedure:includes rituals or procedures that require active participation from both the client and the therapist→ are believed as effective from client pov in adressing clients issues.

4. Combating Alienation→ create a rs which goes beyong the disclosure of feelings (gefühloffenbarung)→client feels connected and supported

5. Maintaining Expectation of Help: maintains the client's expectation of being helped by linking hope for improvement to the therapy process. → positive change is possible

6. Providing New Learning Experiences: new learning experiences→allowing them to gain insights and develop new coping strategies. These experiences contribute to therapeutic progress and personal growth.

7. Arousing Emotions (essential for therapeutic change)→therapy process= arousal of emotions= mindset shift easier + sensitivity for environmental influences

8. Enhancing Sense of Mastery →The therapist enhances the client's sense of mastery or self-efficacy, empowering them to take control of their lives and overcome challenges.

9. Providing Opportunities for Practice: opportunities for the client to practice new skills and behaviors in real-life situations. This practice reinforces learning and promotes lasting change.

   =psychotherapy is a form of personal influence characterized by a healing relationship, a specific rationale, and therapeutic procedures that address the client's needs.

→Outcome Questionnaire System (OQ-System): involves administering the Outcome Questionnaire-45 (OQ-45)=a 45-item self-report measure designed for repeated administration throughout the course of treatment and at termination with adult clients. → based on these info, it creates an expected recovery curve, identify patients who are not recovering like the curve said in early treatment stages. it can also predict final deterioration in a high percentage of cases

→Partners for Change Outcome Management System (PCOMS): PCOMS uses two ultrabrief scales - the Outcome Rating Scale (ORS→ focussing on mental health) and the Session Rating Scale (SRS→ focussing on therapeutic alliance). → ratings made in seshin→ make it easier to discuss→ get real life feedback → work on relationship

= these assesment methods help clinicians monitor client progress throughout the course of therapy, identify clients at risk for poor outcomes, and adjust treatment strategies accordingly to enhance positive outcomes.