The Science-Art-Research Controversy and Your Practice

Many of you know that Pete and I have devoted our careers to continually searching for more effective ways to help couples develop loving relationships. We challenge partners to move beyond their ineffective coping strategies, to manage their emotional reactivity, and to pursue the dreams that brought them together. We also facilitate couples in navigating the balance between closeness/attachment and effective differentiation. We’ve chosen to work in the trenches teaching classes, presenting workshops, leading couples groups and doing ongoing therapy. Over the years we’ve learned a lot first-hand about what works and what doesn’t work to bring about change! At professional meetings, Pete and I are sometimes criticized or dismissed for not doing “traditional research.” But science has absolutely proven that “a bumblebee can not fly.” And we take that as proof that not all mysteries of the world can be explained by traditional research at this point in time. A few weeks ago I received the following refreshing newsletter from Scott Miller, a colleague whose work I respect. He has given me permission to reprint it for you. I also encourage you to become familiar with his web site and the articles he writes for therapists. ( To lead into the article, I’d like to share a quote from Scott. “I’m aghast frankly at the way research results are being portrayed…we’re willing to accept that research supports some models and not others…but not that certain models are MORE effective than others. To me, making claims of differential effectiveness trades on the ignorance of most clinicians regarding research design…”

Evidence-based Practice: Is it “all that?”

Despite the overwhelming support for the dodo bird verdict and all the research endorsing client and alliance factors, the mental health field remains dangerously enamored of flashy techniques and the promise of miracle cures. Clinicians are regularly bombarded by what’s new and different by workshop brochures and book announcements. Of late the call has been for the ultimate, all-powerful silver bullet: the evidence based treatment. This is the empirically bankrupt notion that for a particular problem, there is a specific treatment that is best. In actuality, to be designated “evidence based,” the developer of a given approach need only prove it's superiority to placebo in two studies. Superiority over placebo, however, is not really saying that much; psychotherapy has demonstrated its superiority over placebo for nearly 50 years! Therapy is about twice as efficacious as placebo, and about four times better than no treatment at all. This research, for all its pomp and circumstance, tells us nothing that we already do not know: Therapy works! Further, demonstrating efficacy over placebo is not the same as demonstrating efficacy over other approaches. Recall the dodo bird verdict. There is no differential efficacy among approaches. Why are studies funded that tell us what we already know? Why do EBT proponents seem to pretend that efficacy over placebo means that they are better than other treatments?  When differential efficacy is claimed, be suspicious. In reality, studies which find a difference are actually no more in number than one would expect from chance. Further, closer inspection of studies that claim superiority reveals two major issues that must be considered: allegiance effects and unfair/indirect comparisons (Wampold, 2001). Allegiance effects are those in which superior outcomes are attributable to the therapist or researcher’s affinity for the treatment being assessed.  By the way, allegiance effects account for as much as 70% of treatment effects.  As an example, consider Emotionally Focused Therapy (EFT), the EBP queen of marital therapy.  In a testament to hyperbole, EFT is being touted as “the revolution in couple therapy” because it demonstrates “the best outcomes” (Johnson, 2003, p. 363). The developer cites but four studies to support the claim that the dodo bird verdict is dead (2003, p. 367). Setting aside the obvious overstatement regarding a revolution – recall, model factors account for just 1% of outcome variance – let’s consider the claim of “best outcomes.”   First, all but two EFT studies involve demonstrations of efficacy over placebo or no treatment, and are not comparisons with other bona fide couples treatments. All therapies can make similar claims of best outcomes when compared to no treatment. The remaining two studies did look at differential effects. The first pitted EFT against problem-solving intervention (PS) (Johnson & Greenberg, 1985), a questionable direct comparison to another model of therapy. In this study, EFT showed a significant difference over PS – but only on 4 of 13 measures at termination!   Moreover, at 8-week follow-up, these meager results became even less remarkable – only 2 measures showed superiority of EFT over PS. Underwhelming, huh?  Now consider the claims of “best outcomes.” With one exception, ALL of the studies published to date have been conducted by the very person who developed the approach. Can you say, “allegiance” here? Finally, the one study not conducted by the developer (Goldman & Greenberg, 1992) (conspicuously absent in the “revolution” article by the way) was a head-to-head comparison between EFT and an integrated systemic approach (IST) and – suprise, surprise – found no difference in outcome – although at follow-up, IST had an advantage.  Bottom line: the dodo bird still rules. Goldman, A., & Greenberg,L. (1992). Comparison of integrated systemic and emotionally focused approaches to couples therapy. Journal of Consulting and Clinical Psychology, 60, 962-969 Johnson, S.M. (2003). The revolution in couple therapy: A practitioner-scientist perspective. Journal of Marital and Family Therapy, 29, 365-384. Johnson, S.M., & Greenberg, L.S. (1985). The differential effects of experiential and problem solving interventions in resolving couple conflicts. Journal of Consulting and Clinical Psychology, 58, 175-184. Johnson, S., Hunsley, J, Greenberg, L, & Schindler, D. (1999). Emotionally Focused Couples Therapy: Status and challenges.  Clinical Psychology, Science, and Practice, 6, 67-79. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum. *   *   *   *   * In closing, I’d like to say that this discussion is not meant to disparage EFT. I value the contributions of EFT and Attachment theory. I also continually invite Sue Johnson to couples conferences and participate in forums and panels to discuss with her the interweaving of our theories. It is, however, meant to ask us as clinicians not to swallow research whole. We must remember that good psychotherapy is as much art as science, and is frequently based in our capacity to care, to connect and lead our couples out of pain.

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Dr. Ellyn Bader

Dr. Ellyn Bader is Co-Founder & Director of The Couples Institute and creator of The Developmental Model of Couples Therapy. Ellyn is widely recognized as an expert in couples therapy, and since 2006 she has led innovative online training programs for therapists. Professionals from around the world connect with her through internet, conference calls and blog discussions to study couples therapy. Ellyn’s first book, "In Quest of the Mythical Mate," won the Clark Vincent Award by the California Association of Marriage & Family Therapists for its outstanding contribution to the field of marital therapy and is now in its 18th printing. She has been featured on over 50 radio and television programs including "The Today Show" and "CBS Early Morning News," and she has been quoted in many publications including "The New York Times," "The Oprah Magazine" and "Cosmopolitan."

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