The long history of efforts to treat psychological disorders has included a bewildering mix of harsh and gentle methods. Well-meaning individuals have cut holes in people’s heads and restrained, bled, or “beat the devil” out of them. But they also have given warm baths and massages and placed people in sunny, serene environments. They have administered drugs and electric shocks. And they have talked with their patients about childhood experiences, current feelings, and maladaptive thoughts and behaviors.
Reformers Philippe Pinel and Dorothea Dix pushed for gentler, more humane treatments and for constructing mental hospitals. Since the 1950s, the introduction of effective drug therapies and community-based treatment programs have emptied most of those hospitals.
Advice columnists frequently urge their troubled letter writers to get professional help: “Don’t give up. Find a therapist who can help you. Make an appointment.”
Many Americans share this confidence in psychotherapy’s effectiveness. Before 1950, psychiatrists were the primary providers of mental health care. Today’s providers include clinical and counseling psychologists; clinical social workers; clergy; marital and school counselors; and psychiatric nurses. With such an enormous outlay of time as well as money, effort, and hope, it is important to ask: Are the millions of people worldwide justified in placing their hopes in psychotherapy?
The question, though simply put, is not simple to answer. Measuring therapy’s effectiveness is not like taking your body’s temperature to see if your fever has gone away. If you and I were to undergo psychotherapy, how would we assess its effectiveness? By how we feel about our progress? By how our therapist feels about it? By how our friends and family feel about it? By how our behavior has changed?
If clients’ testimonials were the only measuring stick, we could strongly affirm the effectiveness of psychotherapy. When 2900 Consumer Reports readers (1995; Kotkin et al., 1996; Seligman, 1995) related their experiences with mental health professionals, 89 percent said they were at least “ fairly well satisfied.” Among those who recalled feeling fair or very poor when beginning therapy, 9 in 10 now were feeling very good, good, or at least so-so. We have their word for it – and who should know better?
We should not dismiss these testimonials lightly. But for several reasons, client testimonials do not persuade psychotherapy’s skeptics:
As earlier units document, we are prone to selective and biased recall and to making judgments that confirm our beliefs. Consider the testimonials gathered in a massive experiment with over 500 Massachusetts boys, aged 5 to 13 years, many of whom seemed bound for delinquency. By the toss of a coin, half the boys were assigned to a 5-year treatment program. The treated boys were visited by counselors twice a month. They participated in community programs, and they received academic tutoring, medical attention, and family assistance as needed. Some 30 years later, Joan McCord (1978, 1979) located 485 participants, sent them questionnaires, and checked public records from courts, mental hospitals, and other sources. Was the treatment successful?
Client testimonials yielded encouraging results, even glowing reports. Some men noted that, had it not been for their counselors, “I would probably be in jail,” “My life would have gone the other way,” or “I think I would have ended up in a life of crime.” Court records offered apparent support: Even among the”difficult” boys in the treatment group, 66 percent had no official juvenile crime record.
But recall psychology’s most powerful tool for sorting reality from wishful thinking: the control group. For every boy in the treatment group, there was a similar boy in a control group, receiving no counseling. Of these untreated men, 70 percent had no juvenile record. On several other measures, such as a record of having committed a second crime, alcohol use disorder, death rate, and job satisfaction, the untreated men exhibited slightly fewer problems. The glowing testimonials of those treated had been unintentionally deceiving.
Do clinicians’ perceptions give us any more reason to celebrate? Case studies of successful treatment abound. The problem is that clients justify entering psychotherapy by emphasizing their unhappiness and justify leaving by emphasizing their well-being. Therapists treasure compliments from clients as they say good-bye or later express their gratitude, but they hear little from clients who experience only temporary relief and seek out new therapists for their recurring problems. Thus, the same person – with the same recurring anxieties, depression, or marital difficulty – may be a “success” story in several therapists’ files.
Because people enter therapy when they are extremely unhappy, and usually leave when they are less extremely unhappy, most therapists, like most clients, testify to therapy’s success-regardless of the treatment (see Thinking Critically About: “Regressing” From Unusual to Usual on the next page).
Clients’ and therapists’ perceptions of therapy’s effectiveness are vulnerable to inflation from two phenomena. One is the placebo effect- the power of belief in a treatment. If you think a treatment is going to be effective, it just may be (thanks to the healing power of your positive expectations).
The second phenomenon is regression toward the mean – the tendency for unusual events (or emotions) to “regress” (return) to their average state. Thus, extraordinary happenings (feeling low) tend to be followed by more ordinary ones (a return to our more usual state). Indeed, when things hit bottom, whatever we try – going to a psychotherapist, starting yoga, doing aerobic exercise – is more likely to be followed by improvement than by further descent.
The point may seem obvious, yet we regularly miss it: We sometimes attribute what may be a normal regression (the expected return to normal) to something we have done. Consider:
In each case, the cause-effect link may be genuine. Each may, however, be an instance of the natural tendency for behavior to regress from the unusual to the more usual. And this defines the task for therapy-efficacy research: Does the client’s improvement following a particular therapy exceed what could be expected from the placebo and regression effects alone, shown by comparison with control groups?
How, then, can we objectively measure the effectiveness of psychotherapy if neither clients nor clinicians can tell us? How can we determine which people and problems are best helped, and by what type of psychotherapy?
In search of answers, psychologists have turned to controlled research studies. Similar research in the 1800s transformed the field of medicine. Physicians, skeptical of many of the fashionable treatments (bleeding, purging, infusions of plant and metal substances), began to realize that many patients got better on their own, without these treatments, and that others died despite them. Sorting fact from superstition required observing patients with and without a particular treatment. Typhoid fever patients, for example, often improved after being bled, convincing most physicians that the treatment worked. Not until a control group was given mere bed rest – and 70 percent were observed to improve after five weeks of fever – did physicians learn, to their shock, that the bleeding was worthless (Thomas, 1992).
In psychology, the opening challenge to the effectiveness of psychotherapy was issued by British psychologist Hans Eysenck (1952). Launching a spirited debate, he summarized studies showing that two-thirds of those receiving psychotherapy for nonpsychotic disorders improved markedly. To this day, no one disputes that optimistic estimate.
Why, then, are we still debating psychotherapy’s effectiveness? Because Eysenck also reported similar improvement among untreated persons, such as those who were on waiting lists. With or without psychotherapy, he said, roughly two-thirds improved noticeably. Time was a great healer.
Later research revealed shortcomings in Eysenck’s analyses; his sample was small (only 24 studies of psychotherapy outcomes in 1952). Today, hundreds of studies are available. The best are randomized clinical trials, in which researchers randomly assign people on a waiting list to therapy or to no therapy, and later evaluate everyone, using tests and assessments by others who don’t know whether therapy was given. The results of many such studies are then digested by means of meta-analysis, a statistical procedure that combines the conclusions of a large number of different studies. Simply said, meta-analyses give us the bottom-line results of lots of studies.
Psychotherapists welcomed the first meta-analysis of some 475 psychotherapy outcome studies (Smith et al., 1980). It showed that the average therapy client ends up better off than 80 percent of the untreated individuals on waiting lists (FIGURE 72.1). The claim is modest – by definition, about 50 percent of untreated people also are better off than the average untreated person. Nevertheless, Mary Lee Smith and her colleagues exulted that “psychotherapy benefits people of all ages as reliably as schooling educates them, medicine cures them, or business turns a profit” (p. 183).
Dozens of subsequent summaries have now examined this question. Their verdict echoes the results of the earlier outcome studies: Those not undergoing therapy often improve, but those undergoing therapy are more likely to improve more quickly, and with less risk of relapse.
Is psychotherapy also cost-effective? Again, the answer is Yes. Studies show that when people seek psychological treatment, their search for other medical treatment drops – by 16 percent in one digest of 91 studies (Chiles et al., 1999). Given the staggering annual cost of psychological disorders and substance abuse-including crime, accidents, lost work, and treatment-psychotherapy is a good investment, much like money spent on prenatal and well-baby care. Both reduce long-term costs. Boosting employees’ psychological well-being, for example, can lower medical costs, improve work efficiency, and diminish absenteeism. But note that the claim – that psychotherapy, on average, is somewhat effective – refers to no one therapy in particular. It is like reassuring lung-cancer patients that “on average,” medical treatment of health problems is effective. What people want to know is the effectiveness of a particular treatment for their specific problems.
So what can we tell people considering psychotherapy, and those paying for it, about which psychotherapy will be most effective for their problem? The statistical summaries and surveys fail to pinpoint anyone type of therapy as generally superior (Smith et al., 1977, 1980). Clients seemed equally satisfied, Consumer Reports concluded, whether treated by a psychiatrist, psychologist, or social worker; whether seen in a group or individual context; whether the therapist had extensive or relatively limited training and experience (Seligman, 1995). Other studies concur. There is little if any connection between clinicians’ experience, training, supervision, and licensing and their clients’ outcomes (Luborsky et al., 2002; Wampold, 2007).
So, was the dodo bird in Alice in Wonderland right: “Everyone has won and all must have prizes”? Not quite. Some forms of therapy get prizes for particular problems, though there is often an overlapping – or comorbidity – of disorders. Behavioral conditioning therapies, for example, have achieved especially favorable results with specific behavior problems, such as bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions (Baker et al., 2008; Hunsley & DiGiulio, 2002; Shadish & Baldwin, 2005). Psychodynamic therapy has helped treat depression and anxiety (Driessen et al., 2010; Leichsenring & Rabung, 2008; Shedler, 2010b). And new studies confirm cognitive and cognitive-behavioral therapy’s effectiveness in coping with anxiety, posttraumatic stress disorder, and depression (Baker et al., 2008; De Los Reyes & Kazdin, 2009; Stewart & Chambliss, 2009; Tolin, 2010).
Moreover, we can say that therapy is most effective when the problem is clear-cut (Singer, 1981; Westen & Morrison, 2001). Those who experience phobias or panic and those who are unassertive can hope for improvement. Those with less-focused problems, such as depression and anxiety, usually benefit in the short term but often relapse later. And those with the negative symptoms of chronic schizophrenia or a desire to change their entire personality are unlikely to benefit from therapy alone (Pfammatter et al., 2006; Zilbergeld, 1983). The more specific the problem, the greater the hope.
But no prizes – and little or no scientific support – go to certain other therapies (Arkowitz & Lilienfeld, 2006). We would all therefore be wise to avoid energy therapies that propose to manipulate people’s invisible energy fields, recovered-memory therapies that aim to unearth “repressed memories” of early child abuse (Module 33), and rebirthing therapies that engage people in reenacting the supposed trauma of their birth.
As with some medical treatments, it’s possible for psychological treatments not only to be ineffective but harmful – by making people worse or preventing their getting better (Barlow, 2010; Castonguay et al., 2010; Dimidjian & Hollon, 2010). The National Science and Technology Council cites the Scared Straight program (seeking to deter children and youth from crime) as an example of well-intentioned programs that have proved ineffective or even harmful. The evaluation question – which therapies get prizes and which do not? – lies at the heart of what some call psychology’s civil war. To what extent should science guide both clinical practice and the willingness of health care providers and insurers to pay for therapy?
On the one side are research psychologists using scientific methods to extend the list of well-defined and validated therapies for various disorders. They decry clinicians who “give more weight to their personal experiences” (Baker et al., 2008). On the other side are nonscientist therapists who view their practice as more art than science, saying that people are too complex and therapy too intuitive to describe in a manual or test in an experiment. Between these two factions stand the science-oriented clinicians, who aim to base practice on evidence and make mental health professionals accountable for effectiveness.
To encourage evidence-based practice in psychology, the American Psychological Association and others (2006; Baker et al., 2008; Levant & Hasan, 2008) have followed the Institute of Medicine’s lead, advocating that clinicians integrate the best available research with clinical expertise and with patient preferences and characteristics. Available therapies “should be rigorously evaluated” and then applied by clinicians who are mindful of their skills and of each patient’s unique situation (FIGURE 72.2). Increasingly, insurer and government support for mental health services requires evidence-based practice. In 2007, for example, Britain’s National Health Service announced that it would pour the equivalent of $600 million into training new mental health workers in evidence-based practices (such as cognitive-behavioral therapy) and to disseminating information about such treatments (DeAngelis, 2008) .
The tendency of many abnormal states of mind to regress to normal, combined with the placebo effect, creates fertile soil for pseudotherapies. Bolstered by anecdotes, heralded by the media, and broadcast on the Internet, alternative therapies can spread like wildfire. In one national survey, 57 percent of those with a history of anxiety attacks and 54 percent of those with a history of depression had used alternative treatments, such as herbal medicine, massage, and spiritual healing (Kessler et al., 2001).
Testimonials aside, what does the evidence say? This is a tough question, because there is no evidence for or against most of them, though their proponents often feel personal experience is evidence enough. Some, however, have been the subject of controlled research. Let’s consider two of them. As we do, remember that sifting sense from nonsense requires the scientific attitude: being skeptical but not cynical, open to surprises but not gullible.
EMDR (eye movement desensitization and reprocessing) is a therapy adored by thousands and dismissed by thousands more as a sham – “an excellent vehicle for illustrating the differences between scientific and pseudoscientific therapy techniques,” suggested James Herbert and seven others (2000). Francine Shapiro (1989,2007) developed EMDR while walking in a park and observing that anxious thoughts vanished as her eyes spontaneously darted about. Offering her novel anxiety treatment to others, she had people imagine traumatic scenes while she triggered eye movements by waving her finger in front of their eyes, supposedly enabling them to unlock and reprocess previously frozen memories. Tens of thousands of mental health professionals from more than 75 countries have since undergone training (EMDR, 2011). Not since the similarly charismatic Franz Anton Mesmer introduced animal magnetism (hypnosis) more than two centuries ago (also after feeling inspired by an outdoor experience) has a new therapy attracted so many devotees so quickly.
Does it work? For 84 to 100 percent of single-trauma victims participating in four studies, the answer is Yes, reports Shapiro (1999, 2002). Moreover, the treatment need take no more than three 90-minute sessions. The Society of Clinical Psychology task force on empirically validated treatments acknowledges that EMDR is “probably efficacious” for the treatment of nonmilitary posttraumatic stress disorder (Chambless et al., 1997; see also Bisson & Andrew, 2007; Rodenburg et al., 2009; Seidler & Wagner, 2006).
Why, wonder the skeptics, would rapidly moving one’s eyes while recalling traumas be therapeutic? Some argue that eye movements serve to relax or distract patients, thus allowing the memory-associated emotions to extinguish (Gunter & Bodner, 2008). Others believe that eye movements in themselves are not the therapeutic ingredient. Trials in which people imagined traumatic scenes and tapped a finger, or just stared straight ahead while the therapist’s finger wagged, have produced therapeutic results (Devilly, 2003). EMDR does work better than doing nothing, acknowledge the skeptics (Lilienfeld & Arkowitz, 2007b), but many suspect that what is therapeutic is the combination of exposure therapy – repeatedly associating with traumatic memories a safe and reassuring context that provides some emotional distance from the experience – and a robust placebo effect. Had Mesmer’s pseudotherapy been compared with no treatment at all, it, too (thanks to the healing power of positive belief), might have been found “probably efficacious,” observed Richard McNally (1999).
Have you ever found yourself oversleeping, gaining weight, and feeling lethargic during the dark mornings and overcast days of winter? There likely was a survival advantage to your distant ancestors’ slowing down and conserving energy during the dark days of winter. For some people, however, especially women and those living far from the equator, the wintertime blahs constitute a seasonal pattern for major depressive disorder. To counteract these dark spirits, National Institute of Mental Health researchers in the early 1980s had an idea: Give people a timed daily dose of intense light. Sure enough, people reported they felt better.
Was this a bright idea, or another dim-witted example of the placebo effect? Research sheds some light. One study exposed some people with a seasonal pattern in their depression symptoms to 90 minutes of bright light and others to a sham placebo treatment – a hissing “negative ion generator” about which the staff expressed similar enthusiasm (but which was not even turned on). After four weeks, 61 percent of those exposed to morning light had greatly improved, as had 50 percent of those exposed to evening light and 32 percent of those exposed to the placebo (Eastman et al., 1998). Other studies have found that 30 minutes of exposure to 10,OOO-lux white fluorescent light produced relief for more than half the people receiving morning light therapy (Flory et al., 2010; Terman et al., 1998, 2001) . From 20 carefully controlled trials we have a verdict (Golden et al., 2005; Wirz-Justice, 2009): Morning bright light does indeed dim depression symptoms for many of those suffering in a seasonal pattern. Moreover, it does so as effectively as taking antidepressant drugs or undergoing cognitive-behavioral therapy (Lam et al., 2006; Rohan et al., 2007). The effects are clear in brain scans; light therapy sparks activity in a brain region that influences the body’s arousal and hormones (Ishida et al., 2005).
Why have studies found little correlation between therapists’ training and experience and clients’ outcomes? In search of some answers, Jerome Frank (1982), Marvin Goldfried (Goldfried & Padawer, 1982), Hans Strupp (1986), and Bruce Wampold (2001,2007) have studied the common ingredients of various therapies. They suggest that all therapies offer at least three benefits:
The emotional bond between therapist and client – the therapeutic alliance – is a key aspect of effective therapy (Klein et al., 2003; Wampold, 2001). One U.S. National Institute of Mental Health depression-treatment study confirmed that the most effective therapists were those who were perceived as most empathic and caring and who established the closest therapeutic bonds with their clients (Blatt et al., 1996). That all therapies offer hope through a fresh perspective offered by a caring person is what also enables paraprofessionals (briefly trained caregivers) to assist so many troubled people so effectively (Christensen & Jacobson, 1994).
These three common elements are also part of what the growing numbers of self-help and support groups offer their members. And they are part of what traditional healers have offered Gackson, 1992). Healers everywhere – special people to whom others disclose their suffering, whether psychiatrists, witch doctors, or shamans – have listened in order to understand and to empathize, reassure, advise, console, interpret, or explain (Torrey, 1986). Such qualities may explain why people who feel supported by close relationships – who enjoy the fellowship and friendship of caring people – are less likely to need or seek therapy (Frank, 1982; O’Connor & Brown, 1984).
* * *
To recap, people who seek help usually improve. So do many of those who do not undergo psychotherapy, and that is a tribute to our human resourcefulness and our capacity to care for one another. Nevertheless, though the therapist’s orientation and experience appear not to matter much, people who receive some psychotherapy usually improve more than those who do not. People with clear-cut, specific problems tend to improve the most.
All therapies offer hope, and nearly all therapists attempt to enhance their clients’ sensitivity, openness, personal responsibility, and sense of purpose Gensen & Bergin, 1988). But in matters of diversity, therapists differ from one another and may differ from their clients (Delaney et al., 2007; Kelly, 1990).
These differences can become significant when a therapist from one culture or gender meets a client from another. In North America, Europe, and Australia, for example, most therapists reflect their culture’s individualism, which often gives priority to personal desires and identity, particularly for men. Clients who are immigrants from Asian countries, where people are mindful of others’ expectations, may have trouble relating to therapies that require them to think only of their own well-being. And women seeking therapy who are from a collectivist culture might be doubly discomfited. Such differences help explain minority populations’ reluctance to use mental health services and their tendency to prematurely terminate therapy (Chen et al., 2009; Sue, 2006). In one experiment Asian-American clients matched with counselors who shared their cultural values (rather than mismatched with those who did not) perceived more counselor empathy and felt a stronger alliance with the counselor (Kim et al., 2005). Recognizing that therapists and clients may differ in their values, communication styles, and language, American Psychological Association-accredited therapy training programs now provide training in cultural sensitivity and recruit members of underrepresented cultural groups.
Another area of potential conflict related to values is religion. Highly religious people may prefer and benefit from religiously similar therapists (Masters, 2010; Smith et al., 2007; Wade et al., 2006). They may have trouble establishing an emotional bond with a therapist who does not share their values.
Albert Ellis, who advocated the aggressive rational-emotive behavior therapy (REBT), and Allen Bergin, co-editor of the Handbook of Psychotherapy and Behavior Change, illustrated how sharply therapists can differ, and how those differences can affect their view of a healthy person. Ellis (1980) assumed that “no one and nothing is supreme,” that “self-gratification” should be encouraged, and that “unequivocal love, commitment, service, and ... fidelity to any interpersonal commitment, especially marriage, leads to harmful consequences.” Bergin (1980) assumed the opposite – that “because God is supreme, humility and the acceptance of divine authority are virtues,” that “self-control and committed love and self-sacrifice are to be encouraged,” and that “infidelity to any interpersonal commitment, especially marriage, leads to harmful consequences.”
Bergin and Ellis disagreed more radically than most therapists on what values are healthiest. In so doing, however, they agreed on a more general point: Psychotherapists’ personal beliefs influence their practice. Because clients tend to adopt their therapists’ values (Worthington et al., 1996), some psychologists believe therapists should divulge those values more openly. (For those thinking about seeking therapy, Close-up: A Consumer’s Guide to Psychotherapists offers some tips on when to seek help and how to start searching for a therapist who shares your perspective and goals.)
We have seen that lifestyle change can help reverse some of the symptoms of psychological disorders. Might such change also prevent some disorders by building individuals’ resilience – an ability to cope with stress and recover from adversity? Faced with unforeseen trauma, most adults exhibit resilience. This was true of New Yorkers in the aftermath of the September 11 terrorist attacks, especially those who enjoyed supportive close relationships and who had not recently experienced other stressful events (Bonanno et al., 2007). More than 9 in 10 New Yorkers, although stunned and grief-stricken by 9/11, did not have a dysfunctional stress reaction. By the following January, the stress symptoms of those who did were mostly gone (person et al., 2006). Even in groups of combat-stressed veterans and political rebels who have survived dozens of episodes of torture, most do not later exhibit posttraumatic stress disorder (Mineka & Zinbarg, 1996).
Psychotherapies and biomedical therapies tend to locate the cause of psychological disorders within the person with the disorder. We infer that people who act cruelly must be cruel and that people who act “crazy” must be “sick.” We attach labels to such people, thereby distinguishing them from “normal” folks. It follows, then, that we try to treat “abnormal” people by giving them insight into their problems, by changing their thinking, by helping them gain control with drugs.
There is an alternative viewpoint: We could interpret many psychological disorders as understandable responses to a disturbing and stressful society. According to this view, it is not just the person who needs treatment, but also the person’s social context. Better to prevent a problem by reforming a sick situation and by developing people’s coping competencies than to wait for a problem to arise and then treat it.
A story about the rescue of a drowning person from a rushing river illustrates this viewpoint: Having successfully administered first aid to the first victim, the rescuer spots another struggling person and pulls her out, too. After a half-dozen repetitions, the rescuer suddenly turns and starts running away while the river sweeps yet another floundering person into view. “Aren’t you going to rescue that fellow? “ asks a bystander. “Heck no,” the rescuer replies. “I’m going upstream to find out what’s pushing all these people in.”
Preventive mental health is upstream work. It seeks to prevent psychological casualties by identifying and alleviating the conditions that cause them. As George Albee (1986) pointed out, there is abundant evidence that poverty, meaningless work, constant criticism, unemployment, racism, sexism, and heterosexism undermine people’s sense of competence, personal control, and self-esteem. Such stresses increase their risk of depression, alcohol use disorder, and suicide.
We who care about preventing psychological casualties should, Albee contended, support programs that alleviate these demoralizing situations. We eliminated smallpox not by treating the afflicted but by inoculating the unafflicted. We conquered yellow fever by controlling mosquitoes. Preventing psychological problems means empowering those who feel helpless, changing environments that breed loneliness, renewing the disintegrating family, promoting communication training for couples, and bolstering parents’ and teachers’ skills. “Everything aimed at improving the human condition, at making life more fulfilling and meaningful, may be considered part of primary prevention of mental or emotional disturbance” (Kessler & Albee, 1975, p. 557). That includes the cognitive training that promotes positive thinking in children at risk for depression (Brunwasser et al., 2009; Gillham et al., 2006; Stice et al., 2009). A 2009 National Research Council and Institute of Medicine report – Preventing Mental, Emotional, and Behavioral Disorders Among Young People – offers encouragement. It documents that intervention efforts often based on cognitive-behavioral therapy principles significantly boost child and adolescent flourishing. Through such preventive efforts and healthy lifestyles, fewer of us will fall into the rushing river of psychological disorders.