RESPONSE TO ‘THE FUTURE OF THETRANSFERENCE-BASED THERAPIES’

Georgia Lepper

Lesley Murdin’s paper starts from the presumption that clinicians, andresearchers too, are concerned with fostering the development of goodpsychotherapy practice, and the delivery of better treatments to patients,and indeed the ethical imperative to do so.The paper sets out to address ‘themeaning of the requirement for an evidence base that emanates from theNHS and the universities’. In this response, I propose to examine somequestions which arise from the issues raised in the paper. What is ‘evidence’and how does it relate to the term ‘evidence base’? What is ‘required’? Whatdoes ‘research’ do, and does it have anything to offer the clinician? I will thenapply the ‘findings’ of my enquiry to the research cited in Murdin’s paper,which is reported in the article ‘Comprehensive process analysis of insightevents in cognitive–behavioural and psychodynamic–interpersonal psycho-therapy’ by Elliott et al. (1994).

What Is Evidence, and How Does It Become an ‘Evidence Base’?

Evidence is a multifaceted term which may be used in philosophical, judicialor scientific contexts. What it shares in all these contexts is the notion that itrelates what is observed or discovered to the understanding of what isobserved. Evidence is the foundation stone of systematic enquiry, whetherphilosophical, judicial or scientific: what do our observations/discoveries tellus about the nature of the experienced world, the object of enquiry? Ques-tions then arise: what counts as evidence? How can it be verified, or falsified,as supporting a theory? What part does ‘interpretation’ play in the evalu-ation of evidence? These are on-going questions for scientific method andare articulated in a variety of forms, as new methods evolve and enquirydeepens. The discussion of the ‘Comprehensive Process Analysis’ methodbelow shows how one method evolved to address some of these questions.

What, then, is an ‘evidence base’? Used popularly, as it is in this paper, itrefers to the very recent phenomenon of ‘evidence-based medicine’. Theideal of supporting and critically evaluating clinical practice through thesystematic evaluation of evidence has a long history, dating back to the earlydays of modern scientific enquiry, when physicians Thomas Beddoes (in

georgia lepper phd is Senior Lecturer in Psychotherapy at the University of Kent,and an active clinical researcher. She is a member of the UKCP Practice ResearchNetwork. Address for correspondence: [g.lepper@kent.ac.uk]

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1808) and Pierre Louis (in 1834) proposed the use of ‘numerical methods’ torecord and evaluate clinical experience (Goodman 2002). What followedthese early calls for evidence in clinical practice was ‘an industry that pub-lished the cases and observations of clinicians, often in journals linked toprofessional societies’ (Goodman 2002, p. 6). The current explosion of‘evidence-based medicine’ has its origins in more recent developments, andin particular in the first systematic attempt to bring together clinical evi-dence for easy reference undertaken by Cochrane, who spearheaded thecollection and review of all available medical evidence into one database –the Cochrane Library.

The explosion of scientific activity, publication and, more recently, the useof electronic databases has developed a radical new system for the dissem-ination and evaluation of clinical evidence and knowledge. Knowledge isglobal. Indeed, some of us, researchers as well as clinicians, would say that ithas spawned a globalized industry.Growing exponentially,as it has during the20th century,the demand for and delivery of healthcare has become a politicalmatter as well.‘Evidence-based medicine’ is now a term for a political process,the foundation upon which the distribution of healthcare resources can bebased.That is the focus of the discussion of ‘evidence base’ outlined in LesleyMurdin’s paper, in its effects on the delivery of psychotherapy.

An editorial in the British Medical Journal, arguing the case for systematicimplementation of available evidence in day-to-day clinical practice, offeredthe following definition of evidence-based medicine: ‘The conscientious andjudicious use of current best evidence from clinical care research in themanagement of individual patients’ (Sackett et al. 1996). Psychotherapistsare not alone in their doubts and uncertainties about the ‘gold standard’ ofthe RCT:‘Evidence based medicine is not restricted to randomised trials andmeta-analyses. It involves tracking down the best external evidence withwhich to answer our clinical questions’ (Sackett et al. 1996, p. 72). Sackettand his colleagues argue that good clinical practice comes from a wide rangeof sources of evidence; doctors, any more than psychotherapists, do not wantto practise ‘cookbook’ medicine. The question arises: how do we gather,synthesize and assess the evidence available to us? In this response toMurdin’s concerns, I would like to change the terms of the debate somewhatand return to the original spirit of ‘evidence-based practice’, using theexample of the study by Robert Elliott and colleagues, cited by Murdin, toillustrate how a process of the development of evidence can be understoodin a different light.

Building A Comprehensive Evidence Base

The article ‘Comprehensive process analysis of insight events’ (Elliott et al.1994) makes use of the data, which included recorded sessions, which wasgathered for a structured ‘cross-over’ design outcome study undertaken in

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1980s – the Sheffield Psychotherapy project, which compared 40 clientsdiagnosed with mild to moderate anxiety and depression, each of whomreceived 8 sessions of psychodynamic–interpersonal therapy (see Hobson1985) or cognitive–behavioural therapy. A second, similar study compared 8session and 16 session versions of the same therapies (Shapiro et al. 1990)and incorporated some measures of the process, inviting clinicians to con-tribute to the developing evidence base. These studies (undertaken by anMRC/ESRC-funded unit) found that there were no significant differences inoutcomes between the two modalities, but found a small variance betweenthe shorter and longer term therapies. These findings are consistent with thesubsequent and very substantial set of outcome studies, now gathered andreviewed as a body of research: ‘We have to recognize that, in a majority ofstudies, different approaches to the same symptoms (e.g. depression) showlittle difference in efficacy’ (Lambert 2004, p. 809) . . . ‘when symptoms arenot too severe, they seem to respond to the influence of common factors thatfacilitate change’ (p. 810). The authors go on to note that there is alsoevidence that some problems respond better to one rather than another kindof intervention. What we don’t know is what the ‘ingredients of change’ are:‘. . . there are, as yet, no precise descriptions of all these factors . . .’ (Lambert2004, p. 810).

Elliott and his collaborators set out, in this study, to undertake a precisedescription of one ingredient of change postulated by many modalities, andparticularly by psychoanalytic theory: insight. What is insight? Can it bedescribed? What do insight events tell us about the therapeutic process? Dothey occur in the therapies in this Sheffield study? The ‘outcome’ measuresobtained in the original study were used to provide ‘an index of the clinicalsignificance of the events’ (p.451).The insight events identified for study werederived using the ‘Comprehensive process analysis’ technique (Elliott 1993).Possible insight events were first identified by the research team listening tothe recorded sessions. Then the identified sessions were completely tran-scribed and studied in detail. The researchers were also the clinicians whoprovided the therapies. They first explicated the meaning of each identifiedevent independently; next they met as a team to develop a consensus expli-cation; then each researcher applied the agreed criteria to each event, wid-ening their investigation to the wider context of the sessions using the CPAprocedures. Finally, they reconvened to develop a typology of insight events:what common factors appeared to operate across both modalities; whatfactors distinguished the modalities (discriminating factors)?

A common factor in all ‘insight events’ proved to be the creation of a‘meaning bridge’, a construct originally proposed by Rice and Sapiera (1984)– the forging of links between a reaction and its context, enabled by anintervention by the therapist. This concept was later developed and elabo-rated by Stiles (one of the authors of this study) in his development of the‘Assimilation of Problematic Experiences’ (APES) model, using this same

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data set (Stiles et al. 1990). This technique provides a means of identifyingand tracking changes in the client’s capacity for recognizing and understand-ing problematic experiences in any kind of psychotherapy. The team alsoidentified differences between the two modalities. The psychodynamic–interpersonal insight events were characterized by painful awareness, whilethe cognitive–behavioural insight events were characterized by causalre-attributions.An interactional event common to the therapeutic process inboth modalities is distinguished by a difference in the content which is beingattended to.

This team of clinician/researchers found that, through a disciplined andsystematic approach to the data, they can distinguish and describe significantevents in the therapeutic process and link them reliably to clinical theory. Asmall (but average sized) study of psychotherapy modalities and their out-comes has yielded a variety of findings which have been subsequently usedto build further evidence which can be used to build a model of therapeuticprocess and effectiveness.

Conclusion

The future of the transference–based therapies depends on the developmentof a rich and relevant evidence base. It will involve the collaborative effortsof clinicians and researchers with an open, systematic and enquiring attitudetowards what works for whom in psychotherapy, and for how it works.Methods for the systematic description and exploration of clinical events,how they help and how they hinder the clinical process, and how they relateto outcomes, already exist. We need to use them.

If you are interested in getting involved in clinical research, you canjoin the UKCP’s Practice Research Network. For details contact:[alan.mcconnon@ukcp.org.uk]

References

Elliott, R. (1993) Comprehensive process analysis: Understanding the changeprocess in significant therapy events. In: M. Packer and R.B. Addison (eds),Entering the Circle: Hermeneutic Investigation in Psychology, pp. 165–84. Albany,NY: State University of New York Press.

Elliott R, Shapiro, D.A., Firth-Cozens, J., Stiles, W.B., Hardy, G.E., Llewelyn, S.P.& Margison, F.R. (1994) Comprehensive process analysis of insight eventsin cognitive–behavioural and psychodynamic–interpersonal psychotherapies.Journal of Couselling Psychology 41: 449–63.

Goodman, K.W. ( 2002) Ethics and Evidence-Based Medicine: Fallibility and Respon-sibility in Clinical Science. Cambridge: Cambridge University Press.

Hobson, R. (1985) Forms of Feeling: The Heart of Psychotherapy. London:Routledge.

Lambert, M. (2004) Bergin and Garfield’s Handbook of Psychotherapy and Behavi-our Change. 5th edn. New York, NY: John Wiley & Sons.

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Rice, L.N. & Sapiera, E.P. (1984) Task analysis and the resolution of problematicreactions. In: L.N. Rice and L.S. Greenberg (eds), Patterns of Change, pp. 29–66.New York, NY: Guilford Press.

Sackett, D.L., Rosenberg, W.J., Muir Gray, A., Haynes, R. & Richardson, W. (1996)Evidence-based medicine: What it is and what it isn’t. British Medical Journal 312:71–2.

Shapiro, D., Barkham, M., Hardy, G.E. & Morrison, L.A. (1990) The second SheffieldPsychotherapy Project: Rationale, design and preliminary outcomes. BritishJournal of Medical Psychology 63(2): 97–108.

Stiles, W.B., Elliott, R., Llewelyn, S.P., Firth-Cozens, J.A., Margison, F.R., Shapiro,D.A. & Hardy, G. (1990) Assimilation of problematic experiences by clients inpsychotherapy. Psychotherapy 27: 411–20.

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