HOW TO HEAL
BEYOND EVIDENCE-BASED PSYCHOTHERAPY
by George Rosenfeld
Routledge, 2008
Review by Robert L. Weisman
The psychotherapy-curious and therapists at all levels of experience will appreciate a recently published treasure, George Rosenfeld's Beyond Evidence-Based Psychotherapy: Fostering the Eight Sources of Change in Child and Adolescent Treatment. The book describes therapeutic moments from individual treatment cases and offers overall conclusions the author has drawn from his 40,000 hours of psychotherapy sessions. Rosenfeld uses direct, plain English to explain what he does and relate his work to psychotherapy research and principles. In nontechnical language, he repairs souls. Experienced therapists will wish they had read this earlier in their careers and will particularly enjoy the brave descriptions of psychotherapy by a practitioner who frequently makes the interventions seem obvious or easy.
Descriptions of clinical work and its research-based rationales seem like they should be readily available, but in fact, this has not been a favored topic for publication. Rosenfeld's book represents a step forward in demystifying psychotherapy, because it has previously been quite difficult for practitioners who are outside of academia to be published by major professional publishers. Typically academics produce research that is harnessed by the nature of their methodology; to make their findings more reliable, they conduct tightly controlled research, which results in work that is less relevant to direct clinical practice. Often when practitioners do write about their treatment approaches, they describe treatments that can be idiosyncratic, are unsupported by research, and may not have general application. Rosenfeld has presented a clinically necessary integration of knowledge from research with knowledge from personal experience derived over a full career, an integration that the professional literature has generally avoided. However, with the anticipated retirement of the huge wave of baby boomers struggling with Erikson's seventh stage of "Generativity versus Stagnation," we can expect this type of literature to flourish.
Fifty years ago it was shown that different psychotherapy approaches do not differ greatly in effectiveness. This realization that most forms of psychotherapy do about equally well is known as the "Dodo bird verdict," based on the Dodo bird's quote in Alice in Wonderland that "everybody has won so all shall have prizes." These research findings have led to the belief that the most powerful forces in treatment are not the unique aspects of the therapist's theoretical school or specific interventions (which actually account for less than 15 percent of the variance in the treatment outcome), but the factors that effective treatments have in common. The research indicates that 30 percent of outcome variance is accounted for by the therapeutic relationship; client characteristics and other extra-therapeutic elements contribute 40 percent of the outcome variance; and 15 percent is accounted for by placebo effects (the client's expectations). To recap, since different schools of psychotherapy are equally effective, their common factors probably account for most of their effectiveness.
Attention to these intriguing and disturbing findings has waxed and waned.
In adult psychotherapy there is increasingly a viewpoint that emphasizes the common factors in successful therapies — factors such as establishing a helping relationship, setting boundaries, instilling hope, and so on. These are necessary for positive results, whether or not a particular school of therapy emphasizes them. Therapy has frequently been a fractious endeavor, in part because therapists arguing over differences in method have not acknowledged that broader factors underlie various "methods." Beyond Evidence-Based Psychotherapy establishes a strong beginning for a common-factors outlook in the treatment of young adults and youth.
Within the health care field, there is an increasing interest in having factual, evidence-based information for choosing drugs and therapeutic treatments for particular clinical problems. "Evidence-based" is a catchphrase of the moment, as well as a longtime aspiration. Whereas it can be relatively straightforward to design a trial for a newly proposed drug treatment, it is much more difficult to compare the suitability and effect of a variety of psychotherapeutic interventions for psychosocial problems. A lofty hope for psychotherapy is to be able to specify a treatment that can be clearly matched to person, personality, personal background, and current moment. This is some goal.
Rosenfeld's review of recent research concludes that aside from a strong finding that, overall, psychotherapy helps, more specific findings about the superiority of particular treatments of choice do not hold up well. For example, a re-examination of questionnaires used to support the superiority of cognitive-behavioral therapy for depression reveals that many have been constructed with language excessively favorable to cognitive-behavioral techniques. Furthermore, a day-to-day clinical practice presents patients with more severe and numerous problems than the healthier research subjects chosen to test the effectiveness of particular treatments. In examining another widely held belief, that the latest anti-depressant drugs effectively treat depression, research actually suggests that placebo effects account for much of the client's improvement. Rosenfeld concludes that the generally assumed superiority of many therapies, medications, and psychotherapy techniques is not based on sound research, but is the result of political and economic forces.
Rosenfeld concludes that the psychotherapy research actually supports an integration of evidence-based treatments with a common-factors orientation. This challenges the trend of modern psychotherapy to idealize evidence-based treatments, which are predominantly cognitive-behavioral because of the ease with which they adapt to the research paradigm. This integration of two of the major theoretical approaches in psychotherapy characterizes healing as a process that is energized by the needs, strengths, and beliefs of the client and conducted within the context of the client's social, economic, and cultural networks. This approach respects the healing power of client characteristics and the client's social and cultural context, which have been marginalized in the evidence-based movement. Healing can depend on the client's capacities and motivation, as well as the skill of the therapist to engage the client and his or her networks into a healing relationship, which research indicates is often based on mutual respect, mutual trust, mutual hope, and the client's theory of change. Rather than relying on the therapist's theory of change and the over-reliance on techniques supplied by the therapist, the core of healing is described as a unique journey in which a successful outcome lies in fostering at least one of the eight sources of change. There is not one treatment road. Therapy can be client directed, mutually constructed, or therapist directed. The therapeutic relationship or an evidence-based treatment can be sufficient or irrelevant in this process. Rosenfeld describes the process as akin to inventing a treatment or several treatments for each client. This model contrasts with the present medical model, in which contemporary political and economic forces have defined healing as a therapist-directed process in which treatment is supplied to an ideally compliant patient stripped of his or her uniqueness.
Robert Weisman practiced almost thirty years as a clinical psychologist in Northern California, primarily with UC Davis and Kaiser Permanente. From Adelphi University, his degree is Ph.D. in clinical psychology (1973).
