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Does psychotherapy work?

Does psychotherapy work?. A review of the research. Definition. Efficacy: A measure of the treatment’s ability to improve whatever condition it is indicated for. Treatment efficacy (does it work?). Historically, therapy efficacy was of little interest until the 1950's

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Does psychotherapy work?

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  1. Does psychotherapy work? A review of the research

  2. Definition Efficacy: A measure of the treatment’s ability to improve whatever condition it is indicated for.

  3. Treatment efficacy (does it work?) • Historically, therapy efficacy was of little interest until the 1950's • Freud rejected outcome research (problems too heterogeneous -- "apples vs. oranges") • Freud and contemporaries relied on case-studies to illustrate techniques

  4. Hans Eysenck’s 1952 “bombshell” • Methodology • 19 peer-reviewed studies • Outcome data for over 7000 neurotic patients • 5 sets of psychoanalytic groups and 14 “eclectic” groups • Findings • Spontaneous recovery rate =72% • Psychoanalytic recovery rate=44% • Eclectic recovery rate= 62% • But Eysenck's study met much criticism • “Apples and oranges” • No control groups • Outcome criteria differences (when criteria restructured and data reanalyzed:) • Spontaneous remission =30% • Psychoanalytic = 83% and eclectic = 65%

  5. The ideal efficacy study • random assignment of patients to treatment and control groups • treatment group • no-treatment controls • placebo controls (see next slide) • patients meet criteria for only one psychiatric diagnosis • treatments are manualized and scripted • patients are seen for a fixed number of sessions (usually 6-12) • outcome measures are unequivocal and quantifiable • raters and diagnosticians are blind (unknowledgeable) as to which group the patient is in • includes both post-treatment and follow-up assessment after a fixed period

  6. Placebos: A Short Detour • Effects are strongest in patients expressing pain, fatigue, depression, and nausea • The placebo effect is getting stronger, making it increasingly harder for both new meds and new psychotherapies to outperform placebos (left) • Placebo effect relatively LESS pronounced when symptoms are more severe (middle) • Meds and PT still outperform placebos over longer time (right) • Ironically, placebos don’t work without a prescription Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med, 5(2), e45. (middle) DeRubeis, R. J., Siegle, G. J., & Hollon, S. D. (2008). Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nature Reviews Neuroscience, 9(10), 788-796. (right)

  7. Smith & Glass (1980) • Methodology: meta-analysis of  475 psychotherapy outcome studies • Findings: People in treatment function better than 75-80% of patients w/ no treatment (on waiting list) • Conclusions: • Psychotherapy works • There are negligible differences between different types of therapy

  8. Other meta analyses: Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psychological, educational, and behavioral treatment: confirmation from meta-analysis. American psychologist, 48(12), 1181.

  9. Some more findings Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L. (1987). Effectiveness of psychotherapy with children and adolescents: a meta-analysis for clinicians. Journal of consulting and clinical psychology, 55(4), 542.

  10. Therapy vs Medication (Depression) DeRubeis, R. J., Siegle, G. J., & Hollon, S. D. (2008). Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nature Reviews Neuroscience, 9(10), 788-796.

  11. Efficacy vs. effectiveness • Efficacy: a measure of the treatment’s ability to improve whatever condition it is indicated for. • Treatment carefully standardized • Therapists highly trained • Patients/clients carefully selected and randomly assigned to treatment vs control group • Effectiveness: a measure of the how well the treatment works in the real world with all of its limitations. • Patients may have multiple problems (comorbidity) • Patients may receive multiple treatments at same time • Treatments may vary as function of therapist of patient characteristics, as well as insurance, time, etc.

  12. Seligman’s 1995 Consumer Reports survey • Methodology • 180,000 readers received issue w/survey • 7,000 filled out survey, of which 3,000 saw mental health professionals • Respondents • educated • middle class • 50% female • median age=46 • Three outcome measures • Specific Improvement • Satisfaction • Global Improvement

  13. Seligman’s 1995 Consumer Reports survey • Findings • Psychotherapy resulted in improvement for majority (90%) of respondents • Psychiatrists, psychologists, and social workers all equally effective but better than marriage counselors (after controlling for severity and type of problem)

  14. Consumer Reports Findings (cont.) • Longer treatment (i.e., more sessions) was related to more improvement The 300-point scale is derived from 3 100-point sub-scales measuring specific improvement, satisfaction with therapist, and global improvement

  15. Consumer Reports Findings (cont.) • Limitations on insurance coverage was associated with less improvement

  16. Consumer Reports Findings (cont.) • People who reported feeling the worst prior to treatment, reported the most improvement • No difference between different types of therapies • No difference between psychotherapy alone and psychotherapy with meds • Active shoppers and active clients did better Conclusion: Psychotherapy works!

  17. Seligman’s 1995 Consumer Reports survey: A critique • Non-random, potentially biased sample • Cognitive dissonance may lead to positive bias in self reports • Improvement may be due to spontaneous remission or “regression to the mean”

  18. 10 major achievements of psychotherapy outcome research (Lambert & Bergin, 1992) • Psychotherapy generally has positive effects • Many therapies > placebo • Research now looks at specific types • Behavior therapies effective for many disorders • Cognitive therapy effective for depression • Different types often equally effective • Therapies have many factors in common • Therapy may have negative effects  • Brief therapy works for many (50%) • Effects are relatively lasting

  19. Is the Dodo bird extinct? "Everybody has won, and all must have prizes." Chapter 3 of Lewis Carroll's Alice's Adventures in Wonderland

  20. Dodo bird effect (graphical form)(Wampold, 2001) (NO significant differences among psychotherapies) (significant differences among psychotherapies)

  21. Revisiting Smith and Glass: Is the Dodo real or extinct?

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