The Effectiveness of Psychotherapy

1. The Effectiveness of Psychotherapy The Consumer Reports Study Martin Seligman American Psychologist 12/95

2. Does Psychotherapy Work? • Two methods of answering this question: • Efficacy Study • rigorous (gold standard) • Effectiveness Study • naturalistic (but suspect because of lack of controls)

3. Efficacy Studies • Patients randomly assigned to treatment and control conditions • Rigorous controls (no treatment + placebos to control for nonspecific) • Manualized treatment • Fixed # of sessions • Patients meet criteria for single diagnoses

4. Effectiveness Study • Psychotherapy not of fixed duration • Psychotherapy self-correcting (not manualized) • Patients are active shoppers (believe in and committed to treatment) • Patients have multiple problems • Improvement in general functioning

5. Key Results of Efficacy Studies • Cognitive, Interpersonal and Medication tx all successful with depression • Exposure (in vivo desensitization) and medication effective with OCD • Cognitive Tx successful with Panic D/O • Flooding + medication better than either alone with agoraphobia • Cognitive tx better than meds for bulimia

6. Key Results of CR Study • Treatment by Mental Health Professionals usually works • 87% of “very poor” at least “so-so” after tx • 92% of “fairly poor” at least “so-so” • Dose-Response Curve • longer in tx, the more the improvement • No difference between psychotherapy + medication and psychotherapy alone

7. More Key Results of CR Study • All mental health professionals were helpful • Psychologists, psychiatrists and social workers superior to marriage & family therapists • No one tx approach better than others • Patients whose choice and duration of therapy limited by insurance did worse

8. Efficacy Vs Effectiveness Conclusions • Both support the success of psychotherapy • EF = Causal inferences; CR = Ecological Validity • EF  superiority of targeted interventions CR  general success of professional Tx • EF  briefer Tx; CR  success of long-term Tx

9. “Can Psychotherapy Help?” • TX is better than something else • Because it lacks control groups CR Study can not answer this question • But Note two indirect controls: • Superiority of psychiatry, psychology and SW to MFCC • Equivalence (and sometimes superiority) of psychotherapy with medication (which has been shown to be superior to controls).

10. “Can Psychotherapy Help?” • TX is better than something else • Because it lacks control groups CR Study can not answer this question

11. “Can Psychotherapy Help?” • TX is better than something else • Because it lacks control groups CR Study can not answer this question • TX returns patients to normal

12. “Can Psychotherapy Help?” • TX is better than something else • Because it lacks control groups CR Study can not answer this question • TX returns patients to normal • Because no measure of normality, CR Study can not answer this question

13. “Can Psychotherapy Help?” • TX is better than something else • Because it lacks control groups CR Study can not answer this question • TX returns patients to normal • Because no measure of normality, CR Study can not answer this question • Patients have fewer Sx & better life after Tx

14. “Can Psychotherapy Help?” • TX is better than something else • Because it lacks control groups CR Study can not answer this question • TX returns patients to normal • Because no measure of normality, CR Study can not answer this question • Patients have fewer Sx & better life after Tx • Because it studies Tx as it occurs in real life CR Study answers this, clearly, “Yes”

15. Response to The Consumer Reports Study “The Efficacy & Effectiveness of Psychotherapy Relative to Medications” Steve Hollon American Psychologist, October/96

16. What the CR Does & Does Not • Tells us clients tend to feel better after therapy • Does NOT tell us that therapy is what made them feel better • Very important Difference

17. Limitations of CR Study • Based on retrospective self-report • perspective and 3rd party reports would be nice • Not a representative sample • limits generalizability • Assumes accurate attribution • Humans beings notoriously bad at figuring out what the causes of their own internal states are

18. The Eysenck Danger • Hans Eysenck’s critique of psychotherapy was very productive, but ultimately wrong • He stimulated Efficacy studies that used appropriate and rigorous controls tht showed therapy does work • If now abandon efficacy (controlled) studies in order to support long-term and eclectic therapy, risk discrediting all of therapy

19. Safe & Effective • Medication traditionally held to a higher standard than psychotherapy - must be both. • HMOs demanding same standard for psychotherapy

20. Role of Training & Expertise • Dirty Little Secret: Empirical data consistently suggests clinical training has little effect on outcomes • Strupp & Hadley’s (1979) study showed kind college teachers as god as experienced therapists working with troubled students • But a little unfair because teachers selected because of natural talent and experience with population, therapists were not.

21. Use of Empirically Validated Treatments • Efficacy studies have established a small but growing number of empirically validated treatments • Clinicians own judgement about treating conditions are inferior to EVTs • Most Clinicians do not use EVTs • Seligman’s Response • Real Life more complicated than EVTs

22. Conclusion • Competent & ethical clinicians will be informed by EVTs, but must still be able and willing to deal with real-life complexity.