The following article, by Giancarlo Dimaggio, was originally published in the SEPI newsletter, “The Integrative Therapist”, Issue 6(4).
Times are changing in the world of psychotherapy. Over the last 15 years, empirically supported treatments are more and more including experiential practices, which in the past were mostly confined to non-empirically supported orientations. If you had asked your best friend in your psychotherapy school about guided imagery and rescripting, two-chairs, role-play, or experiencing vivid, painful scenes while making the patient follow your fingers or while tapping on their legs, she would have answered: “I have heard they exist, somewhere”. And if she did know them, she sure was not enrolled in either cognitive or psychodynamic training. Chances are she was into a humanistic school, gestalt-oriented, or some psychodrama. And, with some exceptions, neither gestalt nor psychodrama could be labeled under the category of scientifically based psychotherapies. So, if you were a self-defined ‘serious’ therapist, your sessions with your patients were all about talking. Unless you were a behavioral therapist, so you gave them exposure exercises, or you learned hypnosis which, honestly, was a scientific practice long before its pupil, i.e. EMDR.
Well, hypnosis together with emotion-focused therapy (EFT; Greenberg, 2002) and prolonged exposure for PTSD (Foa et al., 2007) were almost the only three practices which: a) were based on an empirically testable paradigm and b) included experiential work, meaning asking patients not just to remember problematic episodes, associate from those, reason differently about those, but also to re-live them in the here and now of the session.
What is happening now? Let me mention a series of empirically supported treatments, besides the aforementioned hypnosis and EFT: compassion focused therapy (Gilbert, 2010), schema-therapy (Arntz & Jacob, 2012), EMDR (Shapiro, 2001), dialectical behavior therapy for complex trauma (Bohus et al., 2020) and metacognitive interpersonal therapy (Dimaggio et al., 2020). Are they all empirically supported or aiming at empirically support? Yes, they are, but what do they share? They share a large use of experiential techniques: role-play, guided-imagery and rescripting, two-chairs, bodily work.
This means, that if you are at the café with your best friend during the psychotherapy training today, and a colleague of another orientation meets you and asks if you have ever heard of those techniques, you and your friend are now more likely to answer in chorus: “Yes, we do!”.
Why is this happening? I can tell what I witnessed over the last 25 years. First, the empirically supported movement was mostly about CBT. And CBT therapists mostly talked, unless when delivering behavioral homework. Their main rival was the family of dynamic therapies and sure the latter folks only talked with their clients and cared very little about empirical testing. With time, empirical support grew for many modalities, and psychodynamic therapies jumped on board. With empirical support came the awareness that success was always limited: the percentage of dropouts, non-responders, and partial responders was significant, and relapse was a serious issue. So, therapists willing to deliver something backed up by science realized their work was insufficient, albeit for the majority of their patients.
Second, interest in treating severe clients, like one with personality disorders and complex trauma, grew, and again it becomes a matter of empirical investigation. Clinicians in this area knew for decades that promoting change in these persons was difficult. So, with a more and more tactful regulation of the therapy relationship, they were more able to limit dropouts, but many therapies stalled. DBT, I have to acknowledge, was a game-changer in that domain. It included a heavy behavioral element when treating borderline personality disorder, and it made clear that in order to change, these patients had to do something actively.
The third driver of what I am naming ‘the experiential revolution’ is a change in theory. Developmental psychology, neurosciences, and experimental psychopathology consistently showed that the largest part of maladaptive cognitive-affective processes unfold themselves at a level which you may name: implicit, tacit, procedural, unconscious (e.g. Bargh, 2017). Patients suffer not just for their maladaptive conscious attributions about self and others, but because of learned patterns involving behavioral procedures, implicit attributional biases, and quick and intense somatic responses involving hyper- or hypo-arousal.
Summarising, to my view such a revolution happened because of the combination of these 3 factors: a) growing impact of the empirically supported therapies movement; b) growing interest in therapies of patients with more severe pathology; c) advancement in basic psychological and neuropsychological sciences.
But the revolution did not come for free, knights of old-fashioned schools raised their barriers, launched their anathemas to the revolutionaries. Their main argument was a concern about safety: experiential techniques are risky, if you use them you are likely not respecting the subjectivity of your clients and their need to be empathically listened to. Some considered introducing these practices (e.g. behavioral experiments; Gaylin, 2000) as intrusive. Giving that most of these techniques have the primary effect to let patients’ arousal mount, concerns about safety were expressed with sentences like: “They risk dysregulation”, “They will end up out of their window of tolerance”, “They will dissociate”. Then a more basic criticism: in light of the Dodo verdict, we know that common factors are what you need to play a good game, and therefore: why the need to add these “risky” paraphernalia to your toolbox?
These criticisms come to a cost, that is they ignite fear and limit dissemination of experiential practices in psychotherapy. The most striking example is what happens to a heavily experiential treatment, that is prolonged exposure for PTSD (Foa et al., 2007). It has very solid empirical support, but its implementation is largely insufficient (Cahill et al., 2006). As Cahill and colleagues note, among the reasons for insufficient dissemination are concerns that patients will decompensate. Spoiling the finale of my café story: the two friends sipping their espresso know experiential techniques, but at least one of them does not apply them. And who knows if the other does?
One may skeptically ask: is there ground to say that experiential therapies are both safe and more effective than talk therapies? Here I have to acknowledge that the question is not solved once and for all. We have not sufficient ground to say that these experiential-based and empirically supported therapies are faster, more powerful, and equally safer than non-experiential therapies. The Dodo may still hoover in the air, in spite of its inability to fly.
But data are growing backing up these ideas. I will only report a few examples. Tripp and colleagues (2020) found that exposure did not exacerbate symptoms in a trial on patients with PTSD. In a trial of DBT vs Cognitive Processing Therapy for women with complex trauma, the DBT arm was exposure-based unlike the CPT one. The DBT arm had fewer dropouts (25% vs 39%) and better symptom responses. No concerns about safety could be raised from this study and no Dodo flying in the air, DBT clearly outperformed CBT, non-exposure based. Of note, do not think that exposure therapies ignore the issue of safety. Bohus and colleagues (2020) pay plenty of attention to that, and exposures only start by session 17-20. But let see that from the other angle: even with a very severe population, therapists did not wait more than 5 months to start with exposures.
Another study compared two experiential-based therapies for adults with childhood trauma: Imagery Rescripting vs EMDR (Boterhoven de Haan et al., 2020). It is a population with intense suffering and, according to theory, with some difficulties in trusting a therapist on the ground of their developmental history. Well, dropouts were very low in both groups (7.7% overall), again indicating that treatment was safe and well-tolerated. Treatments were equally effective on all outcomes, not surprisingly as they shared many similarities. In Metacognitive Interpersonal Therapy, the experiential element is fundamental, a combination of role-playing, imagery rescripting, and bodily work. Preliminary studies had very low dropout rates and good outcomes (Dimaggio et al., 2017; Gordon-King et al., 2018; Inchausti et al., 2020; Popolo et al., 2019).
Finally, a couple of studies on the psychotherapy process are promising. Stiegler and colleagues (2018) have found that anxiety and depression changed more in their sample after the two-chair technique was used, than during the first sessions which were only focused on alliance-building, empathic attunement to affect, and other common factors. Similarly, Romano and colleagues (2020) investigated a sample with Social Anxiety Disorder. Clients were randomly assigned to 3 conditions, a single session of a) imagery rescripting (IR) b) imagery exposure (IE) c) supportive counseling. Only the two imagery-based conditions yielded changes in memory details, which were absent at all in supportive counseling.
Are these studies enough to say that the revolutionaries are right, that therapists in the future have to be and will be trained in using experiential techniques, as they are safe and more powerful? Such an answer is premature. And I have to say that some heavily experiential therapies, like sensorimotor therapy (Ogden & Fisher, 2015) and coherence therapy (Ecker et al., 2012) lack empirical support at all.
We need to work hard in testing these ideas, before concluding that experiential psychotherapies will be more than the new sensation, and we eventually have empirical evidence backing up what evolution said 400 years ago: the Dodo is extinct, with good reasons.
Giancarlo Dimaggio, psychiatrist, psychotherapist, lives in Rome and works at the Centre for Metacognitive Interpersonal Therapy. He has published over 200 papers and book chapters in English (Scopus h index=47). He has co-authored many books including: “Metacognitive Interpersonal Therapy: Body, Imagery and Change” (Routledge), “Metacognitive Interpersonal Therapy for Personality disorders” (Routledge), and edited with J. Livesley and J. Clarkin “Integrated treatment for personality disorders” (Guilford). He is editor in chief for the Journal of Clinical Psychology: In-Session, senior associate editor for the Journal of Psychotherapy Integration and associate editor for Psychology and Psychotherapy: Theory, Research & Practice. Metacognitive Interpersonal Therapy (MIT) has received empirical support in Italy, Australia, and Spain and is currently applied also in Norway, Denmark, and Portugal.
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Bohus, M., Kleindienst, N., Hahn, C., et al. (2020). Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial. JAMA Psychiatry. Advance online doi:10.1001/JAMA psychiatry.2020.2148
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