The Slaying of a Beautiful Hypothesis: The Efficacy of Counseling and the Therapeutic Process.

Although the efficacy of counseling has been empirically linked to the therapeutic process. the emphasis in much of the literature remains on technique use. This article discusses 3 components of therapeutic efficacy (i.e., common factors, working alliance, and counselor attributes) and provides implications for councelors and counselor training. ********** Thomas Huxley (1873) stated that "the great tragedy of science [is] the slaying of a beautiful hypothesis by an ugly fact" (p. 229). It seems that despite the preponderance of therapeutic effect having been shown to lie in the alliance established between client and counselor, the hypothesis that emphasizes the importance of techniques and modalities will not die. Part of the misplaced emphasis on techniques is a response to preferences from managed care operators and others for empirically supported treatments (ESTs). The demand for ESTs continues despite empirical studies indicating that the greatest percentage of variance in therapeutic outcome results from the counselor-client relationship and not specific techniques (Westen, Novotny, & Thompson-Brenner, 2004). This article provides an overview of the components of the therapeutic process that produce optimal therapeutic outcomes, namely, common factors, therapeutic or working alliance, and counselor attributes. Before presenting research on these components, we define therapeutic outcome and efficacy regarding ESTs and psychotherapy in general. THERAPEUTIC OUTCOME Therapeutic outcome is the measure of the efficacy of any given treatment or intervention. With the advent of concerns regarding ESTs, much attention and energy has been spent trying to determine what therapeutic "ingredients" (e.g., techniques) deliver the most effective and efficacious therapeutic outcomes. Unfortunately, determining what constitutes ESTs is a complex and complicated task. If, as Goldfried and Wolfe (1996) suggested, there are at least 250 types of therapy and 300 disorders, it would be difficult to conceive of research wherein every type of therapy could be tested against every type of disorder to find the most effective therapy. As Wampold et al. (1997) stated, "It is unrealistic to believe that clinical trials will ever be conducted to cover even a portion of the possible Treatment x Disorder cells. Consequently, an omnibus hypothesis about all treatments with all disorders will never be tested" (p. 211). Research on the efficacy of psychotherapy in general is prevalent. Eysenck (1952) suggested that the percentage of people who recover as a result of therapeutic interventions is the same as the percentage who recover spontaneously without intervention. Ahn and Wampold (2001) emphatically refuted Eysenck's hypothesis by stating that "it was established in the 1980s that counseling and psychotherapy are remarkably efficacious" (p. 251). Key meta-analytic studies reflect Ahn and Wampold's (2001) contention. Luborsky, Singer, and Luborsky (1975) compared the outcomes of therapeutic (experimental) and control groups as well as those of specific therapeutic groups. They concluded that not one of the treatment forms achieved significantly better results than did another and that most individuals receiving varied treatments showed greater improvement than did those in the control groups (i.e., 80% of studies). This finding does not suggest that treatments can be used interchangeably, however. Furthermore, Smith and Glass (1977) concluded that treatment group participants (for nearly 400 psychotherapy evaluations) improved more than control group participants did by 0.68 standard deviations. These authors stated that "the average client receiving therapy was better off than 75% of the untreated controls" (Smith & Glass, 1977, p. 754). Additional studies have supported these findings (see Grissom, 1996; Lipsey & Wilson, 1993; Shapiro & Shapiro, 1983; Smith, Glass, & Miller, 1980). …