CBT-PCT-PDT - 1
Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health
Service settings.
Stiles, William B.; Barkham, Michael; Twigg, Elspeth; Mellor-Clark, John; Cooper, Mick
Psychological Medicine, Vol 36(4), Apr 2006, 555-566
[pre-publication version]
17 August 2005
Effectiveness of Cognitive-Behavioural, Person-Centred, and Psychodynamic
Therapies as Practiced in National Health Service Settings
William B. Stiles, Miami University
Michael Barkham and Elspeth Twigg, University of Leeds
John Mellor-Clark, CORE Information Management Systems
Mick Cooper, University of Strathclyde
Text: 4,549 words
Address for editorial correspondence
William B. Stiles
Department of Psychology
Miami University
Oxford, OH 45056, USA
Tel. +1 513 529 2405
Fax +1 513 529 2420
E-mail stileswb@muohio.edu

CBT-PCT-PDT - 2
Effectiveness of Cognitive-Behavioural, Person-Centred, and Psychodynamic
Therapies as Practiced in National Health Service Settings
ABSTRACT
Background.
Psychotherapy's equivalence paradox is that treatments have equivalently positive outcomes despite non-equivalent theories and techniques. We compared the effectiveness of contrasting approaches practiced in routine care.
Method.
Patients (n = 1,309) who received cognitive-behavioural therapy (CBT), personcentred therapy (PCT) and psychodynamic therapy (PDT) at one of 58 NHS primary and secondary care sites during a three-year period completed the Clinical Outcomes in Routine
Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment.
Therapists indicated which treatment approaches were used on an End of Therapy form. We compared outcomes of six groups: three treated with CBT, PCT, or PDT only, and three treated with one of these plus one additional approach (e.g., integrative , supportive , art ), designated CBT+1, PCT+1, or PDT+1, respectively
Results.
All six groups averaged marked improvement (pre-post effect size = 1.36).
Treatment approach and degree of dilution ("only" vs "+1" ) each accounted for statistically significant but comparatively tiny proportions of the variance in CORE-OM scores
(respectively, 1% and .5% as much as pre-post change). Distributions of change scores were largely overlapping.
Conclusions. Results were consistent with the Dodo verdict, " Everybody has won, and all must have prizes". Caution is warranted because of limited treatment specification, nonrandom assignment, lack of a control group, missing data, and other issues.

CBT-PCT-PDT - 3
Effectiveness of Cognitive-Behavioural, Person-Centred, and Psychodynamic
Therapies as Practiced in National Health Service Settings
INTRODUCTION
Three widely influential approaches to counselling and psychotherapy are cognitivebehavioural therapy (CBT), person-centred therapy (PCT) and psychodynamic or psychoanalytic therapy (PDT). Each encompasses a range of techniques and should be considered them a family of treatments rather than a specific treatment protocol.
Nevertheless, they are distinct from each other in terms of their usual repertoires of interventions and their assumptions about the nature and sources of psychopathology, and each is considered by its practitioners to be widely applicable to the problems presented for psychotherapeutic treatment (Feltham & Horton, 2006; Gabbard, Beck, & Holmes, 2005).
We studied the effectiveness of treatments employing varied versions of these three approaches as delivered to 1309 patients in 58 National Health Service (NHS) mental health service settings during a three-year period from January 1999 to November 2001.
There is strong evidence for the efficacy and effectiveness of CBT for a wide variety of disorders (e.g., Dobson, 1989; Hollon, & Beck, 2004; Hollon, Thase,& Markowitz, 2002;
Westbrook & Kirk, 2005). Fewer studies have systematically examined outcomes of the other two approaches, but available evidence similarly supports the efficacy and effectiveness of at least some varieties of PCT (Elliott, Greenberg, & Lietaer, 2004; Greenberg & Watson, 1998;
Goldman, Greenberg, & Angus, in press; Ward et al., 2000) and PDT (Leichsenring, 2001;
Leichsenring & Leibing, 2003; Leichsenring Rabung,& Leibing, 2004). Clinical trials comparing alternative approaches (e.g., Barkham et al., 1996; Elkin et al., 1989; Shapiro et al., 1994) and broadly-based reviews (e.g., Roth & Fonagy, 2004; Wampold, 2001) have concluded that bone fide therapies that have been actively researched tend to be similarly effective. This is the equivalence paradox: many psychotherapies appear to have equivalently

CBT-PCT-PDT - 4 positive outcomes despite manifestly non-equivalent theories and techniques. The paradox is expressed by the Dodo verdict , " Everybody has won, and all must have prizes" (Carroll,
1865/1946, p. 28; italics in original), which has been quoted by psychotherapy researchers for seven decades (e.g., Beutler, 1991; Luborsky, Singer, & Luborsky, 1975; Norcross, 1995;
Rosenzweig, 1936; Seligman, 1995; Stiles et al., 1986).
Despite these indications of equivalent effectiveness across many treatments, the overwhelming quantity of published research on CBT (Roth & Fonagy, 2004; Wampold,
2001) has given CBT a greater credibility than the other approaches. For example, the great majority of approaches on the list of empirically supported treatments (formerly, empirically validated treatments) produced by the American Psychological Association's Division 12
Task force (Chambless et al., 1998) were in the CBT family, having been included because of the quantity and quality of research about them (Chambless & Hollon, 1998) rather than their demonstrated superiority over alternative bona fide treatments.
Holmes (2002) argued that CBT has been oversold within the British NHS. Although
CBT is clearly effective, its dominance is more a function of differential research attention than evidence of differential effectiveness (but see also Tarrier, 2002). Thus, the question arises, are there differences in effectiveness between alternative approaches as they are currently being practiced in NHS settings?
Ward et al. (2000) randomly assigned depressed clients to PCT (which they called non-directive counselling) or CBT, each delivered in doses of up to 12 sessions, at 24 NHS practices in London and Manchester. Results showed both approaches were similarly efficacious. Both psychotherapies outperformed general practitioner care over a four-month interval, though at a 12-month follow-up, the GP care group had caught up, and patients in all three conditions showed similar and substantial improvement. Barkham et al. (1996) randomly assigned clients to PDT (which they called psychodynamic-interpersonal therapy)

CBT-PCT-PDT - 5 with CBT for depression, each delivered in 8- or 16-session doses at 3 NHS sites. Again, results showed both approaches were similarly efficacious, though there was no untreated comparison group. Our study complements these efficacy studies by addressing the effectiveness of different treatments as they are applied in routine practice. The logic of effectiveness research is that the risks of selection biases associated with lack of randomisation and the lack of assurance that the treatments were delivered in a standard way are balanced by the greater realism (cf. Seligman, 1995). Results address the effects of treatments as routinely delivered, using practitioners' versions of the treatments and the patients who typically receive them.
Our study answers calls for clinically representative research (e.g., Shadish, Navarro,
Matt, & Phillips, 2000; Stirman, DeRubeis, Crits-Chrisoph, & Brody, 2003; Street,
Niederehe, & Lebowitz, 2000), drawing on routine treatments and using data collected primarily for clinical and administrative use, rather than for research. Our null hypothesis was that there would be no difference in clinical effectiveness between CBT, PCT, and PDT as delivered in routine practice. We assessed effectiveness by comparing pre-treatment to posttreatment scores on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-
OM; Barkham et al., 1998, 2001, 2005; Cahill et al., submitted; Connell et al., submitted;
Evans et al., 2000, 2002).
METHOD
Participants
We studied data from 1309 patients who received CBT, PCT, or PDT and completed the CORE-OM at the beginning and end of their treatment. The data were collected during a three-year period (January, 1999 – November, 2001) at 58 National Health Service (NHS) sites delivering counselling and psychotherapy services where the CORE-OM was routinely administered. The 58 NHS sites each contributed from 1 to 111 of the patients (mdn=16.5; 24

CBT-PCT-PDT - 6 of the sites each contributed 20 or more of the patients). Most of the patients (n=844; 64.5%) were seen in primary care counselling services; the others were seen in sites described as
Secondary Care/Psychology Service (n=87; 6.6%), Tertiary Care/Specialist (n=43; 3.3%),
Primary Care Psychology/Secondary Care in Primary Setting (n=128; 9.8%) or Psychology &
Counselling Service (n=207; 15.8%). The data were anonymised at the sites and forwarded to the University of Leeds. Data collection complied with data protection procedures for the use of routinely collected clinical data. Therapist characteristics were not forwarded; however, based on the 878 patients for whom therapist ID numbers were recorded, 251 therapists each saw from 1 to 29 of the patients (mdn = 2; 15 of the therapists each saw 10 or more of the patients). These patients were a subsample of the patients described by Barkham et al. (2005); selection procedures are described later.
Of the 1309 patients, 29.3% (n=383) were male; 2.8% (n=36) were aged under 20 years, 19.6% (n=257) were aged 20-29 years, 29.7% (n=389) were aged 30-39 years, 24.7%
(n=323) were aged 40-49 years, 15.2% (n=199) were aged 50-59 years, and 8% (n=105) were aged over 60 years. Patients presented a variety of psychological problems, as described later.
Nearly half of the patients (n=638; 48.7%) were taking prescribed medication at the start of therapy, and data on medication was missing for 44 patients (3.4%). Of those who were taking psychotropic medication, 42.7% (n=555) were prescribed only one type of medication;
5.3% (n=69) were prescribed 2 types, and .8% (n=10) were prescribed 3 types. Most of those prescribed medications were taking anti-depressants (88.7%), while 14.7% were taking anxiolytics/hypnotics, 4.7% were taking anti-psychotics, and 2.7% were taking other psychotropic medications.
Measures
Self-report outcome measure . The CORE-OM comprises 34 items addressing domains of subjective well-being, symptoms (anxiety, depression, physical problems,

CBT-PCT-PDT - 7 trauma), functioning (general functioning, close relationships, social relationships) and risk
(risk to self, risk to others). Half the items focus on low intensity problems (e.g. ‘I feel anxious/nervous’) and half focus on high intensity problems (e.g. ‘I feel panic/terror’). Eight items are positively keyed. Items are scored on a 5-point scale, scored from 0 to 4 (anchored
Not at all , Only occasionally , Sometimes , Often , and All or most of the time ). CORE clinical scores are computed as the mean of all completed items, which is then multiplied by 10, so that clinically meaningful differences are represented by whole numbers. Thus, CORE clinical scores can range from 0 to 40. Forms are considered valid if up to three items are omitted (Evans et al., 2002). Internal consistency reliability for the 34-item scale in clinical (n
= 713) and non-clinical (n = 1009) samples were .94 and .94, respectively (Barkham et al.,
2001). The one-week test-retest correlation was Spearman's rho = .90 (n = 43) in a student sample (Evans et al., 2002).
Therapist assessments . The CORE Assessment (Mellor-Clark et al., 1999; Mellor-
Clark & Barkham, 2000) comprises two practitioner-completed sections, the Therapist
Assessment form, completed at intake, and the End of Therapy form. On the Therapist
Assessment form, therapists gave referral information, patient demographics, and data on the nature, severity, and duration of presenting problems using the following 14 categories: depression, anxiety, psychosis, personality problems, cognitive/learning difficulties, eating disorder, physical problems, addictions, trauma/abuse, bereavement, self-esteem, interpersonal problems, living/welfare and work/academic.
On the End of Therapy form, therapists indicate which type(s) of therapy was (were) undertaken with the patient; categories were psychodynamic, psychoanalytic, cognitive, behavioural, cognitive/behavioural, structured/brief, person-centred, integrative, systemic, supportive, art, and other . Therapists were asked to indicate as many as were appropriate.
They also reported the number of sessions attended and other aspects of the treatments.

CBT-PCT-PDT - 8
Procedure
Data collection . All patients attending for psychological assessment or therapy at participating services were asked to complete a CORE-OM before treatment began. Forms were completed during screening or assessment by 77.1% of the patients and immediately before the first therapy session by the remaining 22.9%. Patients were allocated to treatments and therapists following normal procedures at these sites. Sites were instructed to give the post-treatment CORE-OM at the last session; the timing and specific procedures were determined by what worked best for each service administratively and were not recorded.
Therapists completed the Therapist Assessment form after the intake session and the End of
Therapy form when the patient was discharged or stopped attending for therapy. Patients completed a consent form at the start of therapy stating that they agreed to their data being processed. Completed measures were sent to the University of Leeds for processing with no patient identifiers. Each patient was allocated a unique code number by the site.
Selection of patients . At least one CORE-OM or CORE Assessment form was returned regarding 10,351 patients seen at these sites during the three-year data collection period (see Barkham et al., 2005, for further details of this sample). Of these, 1345 were excluded because they did not return a pre-treatment CORE-OM form, and 138 were excluded because their pre-treatment form had more than three items missing (most of these apparently failed to turn over the page on the form). A further 5444 failed to return a posttreatment CORE-OM form, including those who did not attend any sessions and those who had not ended their treatment by the closing date; 14 more returned a post-treatment CORE-
OM that was incomplete; and the therapists of 359 more failed to complete an End of
Therapy form. This left 3051 patients who completed reliable pre- and post-treatment CORE-
OM forms and whose therapists completed End of Therapy forms.
From these 3051, we selected six treatment groups based on therapists' reports on the

CBT-PCT-PDT - 9
End of Therapy form regarding the type(s) of therapy undertaken. Most therapists indicated more than one of the 12 categories provided (M = 2.06; range = 1-10). For the purposes of this study, we classified the three targeted approaches as follows:
CBT = cognitive, behavioural, and/or cognitive/behavioural
PCT = person-centred
PDT = psychodynamic and/or psychoanalytic.
Using these targeted approaches, we defined six groups of patients. Three groups were those whose therapists specified therapies belonging to one and only one of the targeted approaches--CBT, PCT, or PDT. The other three groups were those whose therapists specified one of the targeted approaches plus one treatment not included in the targeted approaches (i.e., one of the following: structured/brief, integrative, systemic, supportive, art, or other ), abbreviated CBT+1, PCT+1, and PDT+1, respectively. We reasoned that the latter three groups offered comparisons among the targeted approaches that were parallel to, but more diluted than, the former three groups.
Of the 3,051 patients who completed pre- and post-treatment CORE-OM forms, 1309 met specifications for one of the six groups. Numbers in each group are shown in Table 1.
Patients who received either none of the targeted approaches (n = 685), or more than one of the targeted approaches (n = 305), or who received more than one treatment in addition to one of the targeted approaches (n = 752) were not considered further in this study.
RESULTS
Effectiveness of treatment in NHS Settings
Patients in these treatments showed very substantial gains, with patients improving, on average, from 17.41 (sd = 6.52; internal consistency alpha=.93) to 8.50 (sd = 6.27) on the
CORE-OM, a difference of 8.9 (sd = 6.81). The overall treatment effect size, calculated as the mean pre-post difference divided by the pre-therapy sd was 1.36.

CBT-PCT-PDT - 10
Table 1 shows the mean pre-treatment and post-treatment CORE-OM clinical scores for each of the six groups, mean differences across treatment, and effect sizes. A one-way analysis of variance (ANOVA) comparing the pre-therapy means across the six groups was not significant, F(5, 1303) = 0.66, p=.654, partial η
2
= .003, indicating that all groups began treatment with equivalent levels of disturbance.
To assess treatment effectiveness, we conducted a repeated-measures (pre-treatment vs post-treatment) ANOVA, with treatment approach (CBT vs PCT vs PDT) and degree of dilution (pure vs "+1") as fixed factors. Results showed a very large overall within-patients main effect of treatment, F(1, 1303) =1905.70, p < .001, partial η
2
= .594, indicating that improvement across treatment accounted for a large proportion of the variation in the obtained CORE-OM scores. In this analysis, a differential treatment effect appears as a treatment by occasion of assessment (pre-post) interaction The results showed that this effect was significant but very small, F(2, 1303) = 3.94, p = .020, partial η
2
= .006; none of the posthoc comparisons among group means were significant. The comparative effectiveness of the pure vs diluted forms of treatments (the dilution by occasion of assessment interaction) was also significant but very small F(1, 1303) = 4.02, p = .045, partial η
2
= .003. The three-way treatment by dilution by occasion interaction, which would have indicated that purity versus dilution was differentially important for the therapies, was not significant, F(2, 1303) = 1.40, p = .248, partial η
2
< .001.
Figure 1 depicts the distributions of the pre-post differences in CORE-OM clinical scores for each group in the form of notched box plots, which indicate the median, middle
50%, and range. Although these change scores ranged widely (from -21 to 32 out of the possible CORE-OM range of -40 to 40), the medians were similar, and the distributions of all six groups were largely overlapping.
Following Jacobson and Truax (1991), we distinguished patients who had achieved

CBT-PCT-PDT - 11 reliable and clinically significant improvement (RCSI) as those who met two criteria: (a) reliable improvement , defined as a pre-post difference that, when divided by the standard error of the difference, is equal to 1.96, which was a decrease of 4.8 points on the CORE-
OM, based on this sample, and (b) clinically significant improvement --entering treatment in a dysfunctional state and leaving treatment in a normal state--defined as moving from above to below the recommended CORE-OM clinical cut-off score of 10 (Connell et al., submitted).
Table 2 shows the number and percentage of patients in the each treatment group who
(a) achieved RSCI, (b) achieved reliable improvement only, (c) showed no reliable change, and (d) showed reliable deterioration, defined as an increase of 4.8 or more points on the
CORE-OM. We restricted this analysis to the 1129 patients whose pre-therapy CORE-OM scores were 10 or higher, insofar who patients whose initial scores were below the clinical cut-off could not, by definition, achieve clinically significant improvement. The results showed substantial rates of improvement in all groups. A 2 x 3 chi-square test comparing the rates of RCSI versus non-RCSI (combining the other three cells in each row of Table 2) across the three pure treatment groups (CBT, PCT, PDT) was nearly significant, χ
2
(2) = 5.89
(p = .053, n = 641), reflecting the 13.9% spread in RCSI rates across groups (CBT highest,
PDT lowest). The parallel test across the three diluted groups (CBT+1, PCT+1, PDT+1) was not significant, χ
2
(2) =1.92 (p = .382, n = 488). The 2 x 2 chi-square test comparing RCSI rates across the combined pure versus diluted groups was significant, χ
2
(1) = 8.38 (p = .004, n
= 1129), reflecting a somewhat higher RCSI rate in the groups given diluted versions of the therapies than in the groups given pure versions (66.2% vs 57.7%).
Characteristics of patients allocated to treatment groups
Table 3 shows distribution of treatment groups across types of NHS settings in this sample. Most notably, CBT was delivered at a variety of settings, whereas the other treatments were delivered mainly in primary care counselling services.

CBT-PCT-PDT - 12
Table 4 shows the distribution of presenting problems across treatment groups, as reported by the therapists just following their first contact with the patients. Note that therapists could indicate multiple problems, so the columns sum to more than the number patients in each group. Broadly similar distributions of problems were treated within each group, but there appeared to be a few differences. For example, patients presenting with interpersonal problems seemed differentially likely to be seen in PCT.
Table 5 shows the gender, age, mean number of problems indicated, and mean number of sessions attended for patients in each treatment group. Gender was somewhat unevenly distributed across groups, χ
2
(5) = 29.07, p < .001, n = 1309, with a relatively higher percentage of male patients in the CBT group. Mean age was similar in the three groups; a one-way ANOVA was not significant, F(5, 1303) =0.72, p = .607, partial η
2
= .003. The numbers of presenting problems across treatment groups varied significantly across the six groups, F(5, 1270) =13.76, p<.001, partial η
2
= .051, reflecting somewhat larger numbers of problems being attributed to patients in the PDT and PDT+1 groups. There was also a modest but significant variation in numbers of sessions attended, F(5, 1266) =8.90, p<.001, partial η
2
= .034, as patients in PDT averaged a somewhat higher number of sessions than patients in other groups.
DISCUSSION
These therapies were effective, on average, with effect sizes on the CORE-OM comparable to effect sizes observed on similar measures in previous efficacy and effectiveness trials (Barkham et al., 1996; Dobson, 1989; Lipsey & Wilson, 1993; Roth &
Fonagy, 2004; Shapiro et al., 1994; Wampold, 2001; Ward et al., 2000; Westbrook & Kirk,
2005). The mean differences among the three targeted approaches, CBT, PCT, and PDT, though statistically significant, were small in relation to this substantial change across treatment. Mean improvement across treatment accounted for approximately 100 times as

CBT-PCT-PDT - 13 much of the variance in CORE-OM scores as did the differential effects of the three approaches. As Figure 1 shows, the distributions of change scores were largely overlapping, with little difference among the groups' median scores. All of the treatment groups had substantial RCSI rates, though there was a nearly-significant trend toward a lower rate in the
PDT group (Table 2). In summary, our results tended to support the Dodo verdict for these three treatment approaches as practiced routinely across a range of NHS settings.
The diluted treatment groups (CBT+1, PCT+1, and PDT+1) averaged slightly greater effectiveness than did the undiluted treatment groups in this sample (see Tables 1 and 2), though the size of this effect was also very small. It is worth remarking, nevertheless, that, at least across the range of purity represented by the comparisons in this study, greater purity of
CBT, PCT, or PDT did not appear to yield greater effectiveness. Advocates of therapy integration might describe the "+1" groups as enhanced rather than diluted. There was a great deal of variation in outcomes within each group (see Figure 1), contrasting with the minor differences between groups.
Our results extend Ward et al's. (2000) and Barkham et al's. (1996) findings by showing that the equivalence of these treatments within the NHS may be observed in routine practice as well as in randomized trials. Our results may be of particular interest to practitioners of PCT and PDT, insofar as these approaches' comparable effectiveness to CBT in routine practice may have been unappreciated (cf. Holmes, 2002).
Limitations
Our design's limitations, though common in research on routine treatments (Shadish et al., 2000; Westbrook & Kirk, 2005), place restrictions on how results can be interpreted.
Limited specification of treatments
We had no independent check on whether or how the therapists delivered the treatments they indicated and, indeed, no precise definitions of what these treatments

CBT-PCT-PDT - 14 comprised or details of the therapists' qualifications. The observed approximately equivalent effectiveness could, in principle, reflect a lack of differences in how the treatments were conducted. Or, systematic failure to implement a treatment correctly could account for its having failed to prove superior.
On the other hand, we know of no reason why the therapists would have misrepresented the theoretical approach from which they worked. The most plausible assumption, we suggest, is that they sincerely sought to implement the approach they specified. To put it another way, for better or worse, these treatments represented the way
CBT, PCT, and PDT are currently practiced in these settings.
Each of these approaches is based on distinct literature, lore, and experience shared among its practitioners (e.g., though training, supervision, workshops, and conferences). Each claims conceptual and technical resources to respond to a wide variety of problems and circumstances encountered in routine practice. Even in a randomized controlled trial, each approach must be flexible; even protocol-driven psychotherapies are far from standardised.
More than most medical treatments, psychotherapies must be adapted to the emerging needs of patients in ways that are not specified in a protocol but depend on the skill and interpersonal responsiveness of the therapist (Hardy, Stiles, Barkham, & Startup, 1998; Stiles,
Honos-Webb, & Surko, 1998).
Non-random assignment of patients to treatment groups
We did not randomly assign patients to treatments, so we cannot rule out differential selection as an explanation for our results. In principle, the observed approximate equivalence could reflect non-random assignment that placed the most difficult patients in the most effective therapies and vice-versa , compensating for effectiveness differences that would have otherwise emerged. For example, a relatively larger number of CBT patients were treated in secondary care settings (Table 3). If secondary care treatment were systematically

CBT-PCT-PDT - 15 more effective than primary care treatment, then this selective assignment could have masked a greater CBT effectiveness.
On the other hand, there was no statistically significant difference among groups on the pre-treatment CORE-OM, indicating that the groups began with similar overall levels of disturbance (Table 1). There were significant differences in the patient mix across groups, including a relatively larger proportion of males in the CBT group (Table 5), a relatively larger number of interpersonal problems in the PCT group (Table 4) and a relatively larger total number of problems in the PDT group (Table 5). If patients with more problems tended to be assigned to PDT, this might help explain their trend toward a lower RCSI rate and their tendency to receive more sessions than patients in the other groups (Table 5). Of course, data on the number and nature of problems were drawn from therapists' reports and thus could reflect differences in case conceptualization across approaches.
Absence of a control group
Although the pre-post change scores indicated substantial improvement (see Table 1 and Figure 1), there was no comparison group of untreated patients. Consequently, we cannot attribute the improvement to the treatments with certainty (cf. Corney & Simpson, 2005).
Control groups are often not feasible in routine settings. Ethically, it would be hard to justify withholding treatment from comparable patients seeking care within the NHS, and restricting consideration to patients who agreed to be randomised would undermine the clinical representativeness. In this respect, it is reassuring that the pre-post effect sizes in these therapies were comparable to those observed in efficacy studies where superiority to comparison groups was observed (e.g., Ward et al., 2000). Our results may be considered as complementary to such studies.
Missing data
As is typical in routine practice settings (e.g., Gilbert, Barkham, Richards, &

CBT-PCT-PDT - 16
Cameron, submitted; Greasley, & Small, 2005; Stiles et al., 2003), many patients who completed a pre-therapy CORE-OM subsequently failed to appear for treatment or failed to complete a form after treatment. There is evidence that, even among patients who do receive treatment, those who complete post-treatment measures are (a) more likely to have agreed with their therapist about when treatment should end (Barkham et al., in press) and (b) likely to have improved more during treatment (Stiles et al., 2003) than are patients who fail to complete them. Our results may not generalize to patients who leave treatment without completing post-treatment measures.
Restriction to a single self-report measure
As a self-report instrument, the CORE-OM does not provide a clinician-rated or external assessment. In principle, self-report instruments are vulnerable to distortions.
Patients may have exaggerated their distress before treatment or exaggerated their improvement following treatment. The CORE-OM is a broad spectrum measure and does not focus on the specific problems. Qualitatively different results of the different treatments might have shown up on more targeted measures.
Arguably, however, subjective symptoms and distress define the need for psychotherapeutic treatment in most cases; in this sense, self-report could be considered as a criterion. We note that the CORE-OM is highly correlated with other self-report and clinician rated measures that have been widely used to assess psychotherapy outcome (Leach et al., in press-a, in press-b; Cahill et al., submitted; Evans et al., 2002). It would, of course, be useful and informative to additionally examine external measures of functioning in future research.
Investigator allegiance
In a review of psychotherapy outcome studies, Luborsky et al. (1999) reported that the investigator's allegiance, assessed by ratings of previous publications, ratings by colleagues, and self ratings, was strongly correlated with the outcomes of the treatments in

CBT-PCT-PDT - 17 published reports (r = .85, p<001, n = 29 studies). The present study's first author has published papers dealing with the equivalence paradox, so in a sense this report fits the pattern. He, along with the fifth author, has a particular interest in the PCT approach. The second author is an accredited CBT therapist and has delivered manualised versions of both
CBT and PDT in randomized efficacy studies. The third and fourth authors are not qualified therapists and profess no differential allegiance to any one of these three approaches
Responsiveness and the Dodo verdict
Equivalent outcomes are often ascribed to common factors in the relationship, such as the alliance, empathy, and collaborative involvement (Norcross, 2002). There may also be self-regulatory processes that cut across treatment approaches, as therapists and patients respond to optimize gains, given limited time and resources, within each approach's framework (Stiles et al., 1998). For example, participants appear to regulate the dose of therapy to achieve a good enough level of outcome--in terms of number of sessions, if that choice is available (Barkham et al., in press), or in terms of intensity of process, if the number of sessions is fixed (Reynolds et al., 1996). This logic of appropriate responsiveness does not argue against the theoretical accounts. Instead, it suggests that all provide concepts and techniques that the participants use to achieve what they seek or what they will settle for, given the context, resources, and constraints.

CBT-PCT-PDT - 18
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AUTHOR NOTES
Authors affiliated to the Psychological Therapies Research Centre, University of Leeds, were supported by the Priorities and Needs Research and Development Levy from Leeds
Community Mental Health & Teaching Trust.

CBT-PCT-PDT - 25
Table 1. CORE-OM clinical scores for treatment groups: Pre- and post-therapy means, differences and confidence intervals for the differences
Treatment group n Pre-therapy Post-therapy Pre-Post Difference
CBT
PCT
PDT
Mean sd Mean sd Mean sd 95% CI Effect size
298 16.9 7.0 8.1 6.4
332 17.6 6.6 8.9 6.1
122 17.6 6.3 9.9 6.8
8.9
8.7
7.7
CBT+1 181 17.9 6.3 7.9 5.6 10.0
PCT+1 249 17.3 6.4 7.8 6.3 9.5
PDT+1 127 17.3 5.9 9.1 6.3 8.2
7.1
6.6
6.4
6.5
6.9
6.9
8.1-9.7
8.0-9.4
6.5-8.8
9.1-11.0
8.6-10.3
7.0-9.4
1.27
1.32
1.23
1.59
1.48
1.38
Note: CBT = cognitive, behavioural, or cognitive/behavioural therapy; PCT = person-centred therapy; PDT = psychodynamic/psychoanalytic therapy; CBT+1 = CBT combined with one other therapy; PCT+1 = PCT combined with one other therapy; PDT+1 = PDT combined with one other therapy; CI = confidence interval. Effect size calculated as the mean difference divided by the pre-therapy standard deviation.

CBT-PCT-PDT - 26
Table 2. Reliable and clinically significant improvement in treatment groups
Treatment group
CBT
PCT
PDT
CBT+1
PCT+1
PDT+1
RCSI Reliable improvement
No reliable change Deterioration
Count Row % Count Row % Count Row % Count Row %
152 62.0
167 57.6
51 48.1
46
63
23
18.8
21.7
21.7
44
55
31
18.0
19.0
29.2
3
5
1
1.2
1.7
0.9
116 70.3
136 64.5
71 63.4
28
35
17
17.0
16.6
15.2
18
39
23
10.9
18.5
20.5
3
1
1
1.8
0.5
0.9
Note: n = 1129 patients whose pre-therapy CORE-OM scores were at or above the recommended cutoff of 10 (Connell et al., submitted). RCSI = reliable and clinically significant improvement. CBT = cognitive, behavioural, or cognitive/behavioural therapy;
PCT = person-centred therapy; PDT = psychodynamic/psychoanalytic therapy; CBT+1 =
CBT combined with one other therapy; PCT+1 = PCT combined with one other therapy;
PDT+1 = PDT combined with one other therapy.

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Table 3. Distribution of treatments across types of services
Type of service
Primary Care Counselling
Secondary Care/Psychology
Tertiary Care/Specialist
Primary Care Psychology/
Secondary Care in Primary Setting
Psychology & Counselling
CBT PCT PDT CBT+1 PCT+1 PDT+1
83 298 91 120 149 103
53
11
90
0
0
21
Treatment group
13
13
2
17
17
3
0
1
12
4
61 13 3 24 87 19
Note. CBT = cognitive, behavioural, or cognitive/behavioural therapy; PCT = person-centred therapy; PDT = psychodynamic/psychoanalytic therapy; CBT+1 = CBT combined with one other therapy; PCT+1 = PCT combined with one other therapy; PDT+1 = PDT combined with one other therapy.
1
0

CBT-PCT-PDT - 28
Table 4. Allocated therapy by presenting problem
Presenting problem Treatment group
Anxiety
Depression
Interpersonal Problems
Self Esteem
Bereavement/Loss
Work/Academic
Trauma/Abuse
Physical Problems
Living/Welfare
Addictions
Personality Problems
Eating Disorder
Cognitive/Learning
Psychosis
Other
CBT
252
200
99
120
34
51
42
32
27
12
10
7
2
4
9
PCT
236
220
169
132
119
66
51
65
40
11
2
9
8
3
10
5
5
2
3
1
33
15
10
10
PDT CBT+1 PCT+1 PDT+1
95 144 194 109
91
75
126
90
190
147
107
86
54
50
30
89
49
45
33
35
32
6
8
3
2
0
6
129
81
54
6
7
4
1
4
45
47
29
15
Note: CBT = cognitive, behavioural, or cognitive/behavioural therapy; PCT = person-centred therapy; PDT = psychodynamic/psychoanalytic therapy; CBT+1 = CBT combined with one other therapy; PCT+1 = PCT combined with one other therapy; PDT+1 = PDT combined with one other therapy. Columns add to more than the number of patients in each treatment because therapists indicated multiple problems for some patients..
2
2
1
1
8
25
24
14
2
74
51
31

CBT-PCT-PDT - 29
Table 5. Demographics and mean numbers of presenting problems and sessions attended by treatment groups
Treatment group
CBT
PCT
PDT
CBT+1
PCT+1
PDT+1
Percent male
40.9
22.9
25.4
28.4
29.3
23.6
Mean age Mean of number of Mean number of sessions
41.1
40.4
40.9
39.1
39.7
40.6 presenting problems
3.13
3.52
4.20
3.80
3.86
4.23 attended
6.52
6.11
8.53
6.03
5.62
6.11
Note. CBT = cognitive, behavioural, or cognitive/behavioural therapy; PCT = person-centred therapy; PDT = psychodynamic/psychoanalytic therapy; CBT+1 = CBT combined with one other therapy; PCT+1 = PCT combined with one other therapy; PDT+1 = PDT combined with one other therapy.

CBT-PCT-PDT - 30
Figure Caption
Figure 1. Notched box plots showing pre-post differences in CORE-OM clinical scores. The notch shows the 95% confidence interval around the median. The boxes show the middle
50% of the distribution. The whiskers show the range, except that observations falling 1.5 times the interquartile range or more away from the top or bottom of the box are considered outliers and are shown separately. CBT = cognitive, behavioural, or cognitive/behavioural therapy; PCT = person-centred therapy; PDT = psychodynamic/psychoanalytic therapy;
CBT+1 = CBT combined with one other therapy; PCT+1 = PCT combined with one other therapy; PDT+1 = PDT combined with one other therapy.

CBT-PCT-PDT - 31
0
-20
-40
40
20
CBT PCT PDT CBT + 1
PCT+1 PDT+1