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The sleeper effect between psychotherapy orientations: a strategic argument of sustainability of treatment effects at follow-up

Published online by Cambridge University Press:  28 October 2016

C. Flückiger*
Affiliation:
Department of Psychology, Division of Psychological Interventions and Psychotherapy, University of Zürich, Switzerland
A. C. Del Re
Affiliation:
VA Palo Alto Health Care System, Center for Innovation to implementation, USA
*
*Address for correspondence: Professor C. Flückiger, Ph.D., SwissBPP, Department of Psychology, Division of Psychological Interventions and Psychotherapy, University of Zürich, Binzmühlestrasse 14/04, CH-8050 Zürich, Switzerland. (Email: christoph.flueckiger@psychologie.uzh.ch)
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Abstract

Type
Letter to the Editor
Copyright
Copyright © Cambridge University Press 2016 

Over the past 100 years, claims that specific psychotherapeutic orientations produce more sustainable outcomes, when compared with other orientations or interventions common across psychotherapies, have been pervasive and influential. This kind of differences in relative efficacy over follow-up time periods is referred to as the ‘sleeper effect’, i.e., the effects of psychotherapy A against psychotherapy B produces larger treatment differences at follow-up than at post-assessment (see Fig. 1).

Fig. 1. Example of the sleeper effect: More sustainable outcomes at follow-up in favour of psychotherapy A in comparison with psychotherapy B.

Background

Psychotherapeutic treatments conducted by trained professionals that are intended to be therapeutic (i.e., bona fide psychotherapy) are shown to be highly effective for treating many mental health conditions. Interestingly, there are marginal to small differences in efficacy between the various bona fide psychotherapy orientations (e.g., cognitive behavioural therapy v. Psychodynamic therapy) at post-treatment, so attention has turned towards examining any potential sleeper effects that might favour one treatment over another. The sleeper effect has been formulated in the following ways:

  • The depth psychodynamic therapies: Lasting structural personality changes will only be achieved by a profound look into the depths of the mind. In comparison with more behaviourally oriented treatments, insight-oriented psychodynamic therapies work through the subconscious and therefore the effects are more sustainable (Shedler, Reference Shedler2010).

  • The carefully controlled evidence-based (mostly cognitive-behavioural) therapies: Disorder-specific evidence-based therapies with close adherence to treatment manuals/guidelines under randomised controlled study conditions have been carefully developed and tested. Therefore, their effects will be more sustainable in comparison with less controlled treatments (Tolin, Reference Tolin2010).

  • The specificity of additive component designs: Additive intervention components address specific therapeutic aspects, which may result in broader patient competencies and more sustainable treatment effects in comparison with treatments with less systematic focus on the specific ingredient (Bell et al. Reference Bell, Marcus and Goodlad2013).

Empirical evidence

To test the presence of the sleeper effect, the statistical results of randomised controlled psychotherapy trials should indicate a treatment (psychotherapy A v. B) by time (post v. follow-up) interaction. In parallel, longitudinal meta-analyses can test these treatment by time interactions in direct treatment comparisons.

We searched the term ‘longitudinal meta-analysis’ and ‘psychotherapy’ and ‘follow-up’ in PsycINFO and MEDLINE (September 30, 2016) and found 18 hits from which three meta-analyses of the direct treatment comparisons provided a statistical test of the sleeper effect (Flückiger et al. Reference Flückiger, Del Re, Munder, Heer and Wampold2014, Reference Flückiger, Del Re and Wampold2015; Kivlighan et al. Reference Kivlighan, Goldberg, Abbas, Pace, Yulish, Thomas, Cullen, Flückiger and Wampold2015). In addition, one longitudinal meta-analysis tested the longitudinal course within a treatment (Hanrahan et al. Reference Hanrahan, Field, Jones and Davey2013):

Conclusions

Historically, the argument that some psychotherapy orientations produced more sustainable outcomes at follow-up than others contributed to the split of the psychotherapy community into different camps. The most up-to-date meta-analytic evidence indicates a surprisingly different, yet consistent picture: There is marginal empirical evidence for the presence of a sleeper effect in comparative psychotherapy research. None of the meta-analyses found a growth of relative efficacy at follow-up assessment. While the theoretical arguments for differences in efficacy (depth, carefully controlled, specificity) are reasonable, there is little theoretical reason for why these effects would only notably appear at follow-up assessment points. Clearly, there is variation in the sustainability. However, the attribution of such an effect to a single psychotherapy orientation is not justified based on the evidence. Methodologically, potential confounds such as dropout rates, external events over time and additional treatments may have made it difficult to detect differences in relative efficacy at follow-up (Knekt et al. Reference Knekt, Lindfors, Härkänen, Välikoski, Virtala, Laaksonen and Virtala2008; Durham et al. Reference Durham, Higgins, Chambers, Swan and Dow2012).

Nevertheless, the sleeper effect as a lasting theoretical claim has survived over the past 100 years. The sleeper effect might be thought of as a strategic effect in the sense that the dominant and most powerful orientations in this time (earlier psychodynamic therapies, now maybe evidence-based psychotherapies) are ‘pulled’ to claim sustainability of their own approach; maybe in the hope of further decades of data collection to get an empirical proof of the claim.

Financial support

None.

Conflict of interest

None.

References

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Figure 0

Fig. 1. Example of the sleeper effect: More sustainable outcomes at follow-up in favour of psychotherapy A in comparison with psychotherapy B.