3.A.1
Treatment models and how they produce change
ASPPB's competency statement 3.A.1: Evidence-based theories and models of treatment, intervention, and prevention, including treatment techniques and methods across populations
Psychologists draw on several families of evidence-based treatment, among them behavioral, cognitive, interpersonal and psychodynamic therapies. Each model explains how a problem is kept going and so points to different techniques. Knowing a model's mechanism of change lets a psychologist pick and deliver its techniques faithfully, while factors common to all models, above all the working alliance, also relate to outcome. Research on a model is one input; APA policy asks that it be integrated with clinical expertise and the client's characteristics.
Key ideas
- Behavioral models
- Problems are kept going by learning: avoidance, reinforcement and lost rewards. In the inhibitory learning account, exposure works by building new learning that competes with fear, strengthened by violating expectancies, removing safety signals and varying contexts (Craske and colleagues, 2014).
- Cognitive models
- Distress follows from how events are appraised. Cognitive therapy teaches clients to identify, test and revise unhelpful thoughts and beliefs, often through behavioral experiments that gather new evidence (Beck and colleagues, 1979).
- Interpersonal and psychodynamic models
- Interpersonal psychotherapy (IPT) ties symptoms to a current problem area: grief, a role dispute, a role transition or interpersonal deficits. Psychodynamic therapy works with recurring relational patterns and avoided feelings; an umbrella review found moderate-quality evidence that it is as efficacious as other active therapies for common disorders (Leichsenring and colleagues, 2023).
- Common factors
- The working alliance (agreement on goals, agreement on tasks and the bond, in Bordin's terms) relates to outcome across approaches: r = .278 for face-to-face therapy in a meta-analysis of 295 studies (Flückiger and colleagues, 2018).
- Evidence-based practice
- APA defines evidence-based practice in psychology as integrating the best available research with clinical expertise in the context of patient characteristics, culture and preferences (APA Presidential Task Force, 2006). A model's trial record is necessary but not sufficient.
Worked example
A 47-year-old warehouse supervisor has been depressed since he was laid off four months ago. He tells himself he is a failure, has stopped seeing friends, spends afternoons watching television, and argues with his partner about his new role at home.
- A cognitive formulation targets the appraisal 'I am a failure': therapy would test that belief against evidence, such as his long record of good reviews, and through behavioral experiments.
- A behavioral activation formulation targets the loss of rewarding activity: therapy schedules valued activities and tracks mood, working from action to mood rather than waiting for motivation. In one trial, behavioral activation matched medication for more severely depressed adults (Dimidjian and colleagues, 2006).
- An interpersonal formulation sees a role transition: IPT would help him mourn the old role, weigh the new one and build skills and support for it.
- Comparative trials show no large differences among the major psychotherapies for mild to moderate depression (Cuijpers and colleagues, 2008), so the formulation he finds credible, his preferences and the alliance guide the choice.
Each model names a different maintaining process, so the formulation decides which techniques fit and how to explain them.
Check yourself
In the inhibitory learning approach to exposure therapy, which practice is recommended?
Sources
- Craske, Treanor, Conway, Zbozinek and Vervliet (2014), Maximizing exposure therapy: an inhibitory learning approach, Behaviour Research and Therapy (PMID 24864005), Abstract; the eight optimization strategies
- APA Presidential Task Force on Evidence-Based Practice (2006), Evidence-based practice in psychology, American Psychologist (PMID 16719673), Policy statement and definition
- Flückiger, Del Re, Wampold and Horvath (2018), The alliance in adult psychotherapy: A meta-analytic synthesis, Psychotherapy (PMID 29792475), Abstract; overall alliance-outcome association
- Bordin (1979), The generalizability of the psychoanalytic concept of the working alliance, Psychotherapy: Theory, Research and Practice, Goals, tasks and bond
- Beck, Rush, Shaw and Emery (1979), Cognitive Therapy of Depression, Chapters on the cognitive model and behavioral techniques
- Weissman, Markowitz and Klerman (2018), The Guide to Interpersonal Psychotherapy, Updated and Expanded Edition, The four problem areas
- Leichsenring, Abbass, Heim and colleagues (2023), The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders: an umbrella review based on updated criteria, World Psychiatry (PMID 37159376), Abstract; comparison with other active therapies
- Dimidjian, Hollon, Dobson and colleagues (2006), Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression, Journal of Consulting and Clinical Psychology (PMID 16881773), Abstract; results for more severely depressed patients
- Cuijpers, van Straten, Andersson and van Oppen (2008), Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies, Journal of Consulting and Clinical Psychology (PMID 19045960), Abstract; conclusions