Until recently, research examining psychotherapy offered only limited guidance to practicing therapists. The structure of the typical study--from its university setting, to its elaborate controls to assure validity, to its carefully qualified conclusions (e.g. "more research is necessary")--mitigated against the direct application of research findings. Over the past few years, however, we have begun to see the emergence of research that is intended to influence practice and is designed for consumption by care providers. A prime example is the work of Kenneth Howard, a professor at Northwestern University.
Howard has long been on the cutting edge of practice-relevant psychotherapy research. In the 1960s, well before the interest in understanding the client's perspective and current discourse about the client's voice, Howard and his longtime colleague David Orlinsky asked clients and therapists directly about their experiences in psychotherapy. Their book on the results, Varieties of Psychotherapeutic Experience, remains an essential guide to the experience of psychotherapy. For the last decade, Howard has been investigating such vital questions as: "What progress can be expected in therapy?"; "What does an expected course of treatment for a particular problem look like?"; and "When can we say a therapy has had a fair trial and is not working?" This group of studies, which has important implications for clinicians, public-policy makers and those involved in the funding of mental health care, has earned Howard several awards, most recently the Distinguished Professional Contribution to Knowledge Award from the American Psychological Association.
Howard's work strongly supports the efficacy of psychotherapy. In his sample of some 15,000 clients treated in a wide range of settings and modalities, most treatments emerge as highly effective in helping individuals, couples and families resolve their difficulties and achieve their treatment goals. Howard emphasizes that a similar level of effectiveness has been found in numerous other samples (reviewed by Mark Lipsey and David Wilson in American Psychologist in December 1993), making psychotherapy among the most tested and empirically validated health interventions.
Howard has developed what he terms the "Dosage-Response" Model for charting therapeutic progress. The concept behind the model is fairly simple: psychotherapy, like other health care interventions, should be evaluated in relation to its effectiveness at various dosages. Just as milligrams are the most appropriate measures for most medications, Howard argues that the most appropriate measure of dose in psychotherapy is the number of sessions. In charting the relation of sessions to outcome, Howard has uncovered a number of findings with important clinical implications:
* Feeling Better without Treatment. Many clients (5 to 10 percent) feel significantly better even before treatment begins. Change in these clients occurs between the time they make an appointment and the first session. As clinicians, we should remember to ask clients at the beginning of treatment, "How are you doing now?" rather than "What is the problem?" We should take care not to assume there is a current problem, even though there was one when the first appointment was scheduled. Clients who are no longer distressed may still wish to pursue psychotherapy for self-exploration or to improve their coping skills, but they do not require therapy to feel better. As therapists, we must be cautious about taking credit for these clients' improved feeling states (though scheduling a session may well have been critical in beginning the process of feeling better). Instead, these clients may best be thought of as candidates for interventions that help them to better understand and continue the positive steps they have already taken to improve their lives, e. …