Prioritizing the Development of Evidence-Based Therapists over the Deployment of Evidence-Based Therapies

Dear Editor: We applaud Drs. Gratzer and Goldbloom for advocating greater access to psychotherapy for Canadians. Indeed, considering the research supporting the efficacy of psychotherapy—some of which is cited in their article—we fully agree that funding improved access to effective psychotherapy should be a Canadian public health priority. We have concerns, however, about the authors’ depiction of evidencebased psychotherapy. By focusing their advocacy on the distribution of so-called evidence-based psychotherapies, the authors overlook crucial developments in the psychotherapy research literature—an omission with significant implications for mental health policy and practice. Despite briefly acknowledging that other “forms” of psychotherapy are effective, Gratzer and Goldbloom squarely emphasize cognitive behavioural therapy (CBT) as being “rigorously evidence based” (p. 618), implicitly suggesting that CBT is superior to other approaches. While it is true that CBT researchers have amassed the largest number of clinical trials, many of these studies suffer from a reliance on comparisons with wait-list controls and insufficient statistical power; for instance, when researcher allegiance effects are controlled for, nondirective supportive therapy is shown to be as effective as CBT for depression. Fortunately, researchers have increased their attention to “common factors” that cut across all psychotherapy approaches. The evidence for common factors suggests that enhanced access to psychotherapy should focus not on matching patients to manualized protocols for specific disorders but on expanding the availability of “evidence based therapists.” By this term, we mean clinicians who understand and optimize common factors such as the therapeutic alliance—far and away the most robust predictor of outcome—and who are skilled at adapting psychotherapy to the context and needs of individual patients. A paradigm shift is required to follow the evidence as it leads us away from the tired notion of specific “forms” of therapy (or manualized treatment packages) for specific disorders (e.g., CBT for major depression). We believe that taking this step will contribute—along with the increased funding Gratzer and Goldbloom rightly call for—to improved access to more effective psychotherapy. First, training clinicians to develop and flexibly adapt core therapy principles will likely be less expensive than rolling out specific technical protocols. Second, “evidence-based therapists” would prioritize responsiveness to the patient over adherence to the techniques of a particular model, thus mitigating the problem of premature termination and reducing the risks of side effects or iatrogenic harm from pychotherapy. Common factors like the therapeutic alliance cannot be taken for granted: both clinicians and patients differ in their capacities to develop and maintain effective therapy relationships. These differences are most pronounced in the treatment of patients with personality disorders but are also evident with comorbid conditions and other complex clinical situations. Patients with complex presentations may benefit more from clinicians who can adopt a mentalizing stance—a joint therapeutic focus on understanding mental states that is likely a feature of all effective psychotherapies. Developing clinicians who are adept at mentalizing and sustaining therapy relationships would likely accomplish more than the deployment of brandname therapy packages.