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The Heart & Soul of ChangeReview - The Heart & Soul of Change
What Works in Therapy
by Mark A. Hubble, Scott D. Miller and Barry L. Duncan (Editors)
American Psychological Association, 1999
Review by Keith S. Harris, Ph.D.
Jun 11th 2000 (Volume 4, Issue 24)

According to the editors of this book, the question of whether or not psychotherapy is effective has been positively settled in the affirmative by more than forty years of substantive research. But the question of why it is effective remains a point of contention among both researchers and practitioners. Some researchers assert that specific techniques or treatment approaches can and should be designed for specific disorders or symptoms, and that this "empirically validated treatment" (EVT) approach is what will save psychotherapy in the age of managed care. Other researchers disagree. A primary assertion of this book is that the recent move among some professionals toward EVT is a step in exactly the wrong direction. The authors report that the bulk of the empirical research efforts in this area have failed to correlate positive outcomes with specific techniques, and they suggest that such correlations will likely never be found. The majority of the thirteen articles that make up The Heart and Soul of Change was chosen by the editors to support the position that the effectiveness of psychotherapy is due primarily to client factors and the therapeutic relationship, not to the expertise of, nor the techniques employed by, adherents of specific theoretical orientations.

In the introductory chapter, the editors briefly review previous works and research that have identified what are called "the big four" factors in therapeutic effectiveness. Client factors are reported to make up a substantial 40% of the variance found in treatment outcome; these factors are defined as "what clients bring to the therapy room and what influences their lives outside it" (p. 9), e.g., personal history and personality characteristics. Relationship factors, meaning the pan-theoretical qualities of the therapist, such as warmth, caring, empathy and etc., are said to account for another 30% of outcome variance. Placebo effects, hope and expectancy represent another 15% of outcome variance, with only the last 15% left to account for variance associated with theoretical models or specific techniques. The chapters that follow are broadly divided into four sections: (1) the existing empirical support for the common factors view of therapy effectiveness, (2) a detailed examination of each of the four factors, (3) the role of these factors in a variety of domains and settings, and (4) the implications of the common factors position for reimbursement systems and clinicians.

The first section’s review of the research on therapy outcome affirms that psychotherapy has been shown effective with a broad range of problems and with many types of clients. This is very reassuring news for both clients and therapists and, possibly, for third-party payers. However, an effectively operationalized definition of positive outcome is not provided in this book, and a serious consideration of this issue would have been very welcome to the reader. Treatment success is global and abstract rather than specific and clear, as shown in the explanation in one of the book’s chapters that "[i]n most cases, clients are not ‘cured,’ but helped to achieve improved functioning . . . and more productive or meaningful relationships" (p. 165).

In fact, although this book does not take up the issue, the definition of treatment success is a matter of some abstraction in the professional literature as well. Major sources of difficulty involve definition and measurement. Is success to be measured in client satisfaction? One author in this book observes, "there is no reason to believe that a high degree of [client] satisfaction is necessarily a sign of successful outcome" (p. 395). Functional or real-life changes would be a more precise indicator of success, but because of the obvious and numerous problems to be overcome in the measurement of such real-life outcomes, the primary tool used to measure therapy success is client self-report. Unfortunately, the serious threats to validity in self-report methods are difficult, perhaps impossible, to adequately manage. (See, for example, Schwarz, 1999.) In managed care and community mental health settings, successful outcome is also often couched in terms of cost containment the client who requires significantly fewer services this year than last has received successful treatment.

The second section of Heart and Soul provides chapters that address in more detail the most relevant client factors, the therapeutic relationship, and the role of hope or expectancy. An additional article discusses the usefulness of therapy models, even in the absence of empirical data that supports one model over another. Of particular note in one chapter is the claim that "it is now possible to predict who signs up, shows up, finishes up, and ends up better off as a result of therapy" (p. 228). If one accepts the premise that certain client characteristics are essential to predicting therapy success, and if it is truly possible to identify which clients currently show such characteristics, then the client recruitment and selection processes can be refined and treatment success rates can be maximized. This would be of equal interest to therapists, researchers and managed-care funding sources.

The chapters of the "Special Applications" section of the book are not as directly relevant to the general psychotherapist but are interesting nonetheless. The role of the placebo effect is explored and related to the positive client characteristics of optimism, expectancy and hope. The use of psychoactive medications is discussed, and the correlations of their effects with other therapeutic and situational factors are noted: "Medication response can be readily altered by who delivers the drug, how its properties are described [to the patient], the degree of familiarity with the setting in which it is presented, and the ethnic identity or socioeconomic status of the person ingesting it" (p. 301). This may help explain why medications and therapy are sometimes found to be more effective than either alone.

The final section of the book highlights the growing importance of therapy outcome research to managed care and third party reimbursers. Important findings derived from the rapidly growing therapy client database include the remarkable variability of therapy success overall, the unhelpfulness (so far at least) of the EVT approach, the significant differences among the outcomes achieved by different therapists and systems, and the predictability of eventual therapy outcome after only a few sessions.

One nagging question that remains after finishing this provocative book, if the authors’ claims about the centrality of client factors are correct, is whether there is really much value in the rigorous training of therapists, at least in the areas of technical skills and theoretical models. Perhaps training programs could more profitably select trainees based on their personal characteristics and provide to this select group of apprentices an abbreviated course of preparation largely focused on general relationship skills and professional ethics, and that would be enough. Both the increasing demand of the marketplace to know the value of what is bought, and the growing predilection of public mental health departments to design programs around paraprofessionals suggest this question is not just academic.



Schwarz, N. (1999). Self-Reports: How the Questions Shape the Answers. American Psychologist, 54(2), 93-105.


Keith Harris, PhD, is a clinical psychologist and supervisor of Victor Valley Behavioral Health Center in San Bernardino county, California. Hisinterests include clinical supervision, the empirical basis forpsychotherapy research (and its design), human decision-making processes,and the shaping of human nature by evolutionary forces.


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