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 Freud rejected outcome research (problems too heterogeneous -- "apples vs. oranges") Freud and contemporaries relied on case-studies to illustrate techniques

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%

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 Manualized treatment includes videotaping of sessions in order to monitor and eliminate any spontaneous divergence from the prescribed approach

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)

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

Other meta analyses: Effectiveness of psychotherapy with children and adolescents: a meta-analysis for clinicians. Journal of consulting and clinical psychology Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psychological, educational, and behavioral treatment: confirmation from meta-analysis. American psychologist, 48(12), 1181.

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.

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.

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.

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

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)

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

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

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!

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”

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

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

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

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