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Is Psychotherapy Getting Better?

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MA2012-1A Progress Report on the Science—and Art—of the Psychotherapy Field

By Diane Cole

What do we know today about the effectiveness of psychotherapy that we didn’t know 30 years ago? Even more important, how do we improve our treatments?

This article’s title poses a challenging question, to be sure—one filled with ambiguity and open to multiple answers. Getting better than what? Getting better, in what way? Getting better, according to whom? And the real kicker: Can we get better—and how? But if these tough questions are to be asked, there would seem to be no more fitting occasion than this magazine’s 30th anniversary and the opportunity it provides to reflect on an era in the field of psychotherapy during which systematic efforts to quantify and measure the key factors in the psychotherapeutic process received more attention than ever before.

In a sense, the story of how to assess the effectiveness of therapy and how it might be improved began in 1952, 30 years before the first issue of this magazine appeared. In a classic paper that year, outspoken behavior therapist Hans Eysenck, one of the field’s leading provocateurs at that time, took on psychotherapy. A staunch believer in science, he’d later be the subject of bomb threats and publicly punched in the nose by a protestor for his controversial views on genetics and IQ differences. The paper that concerns us here, “The Effects of Psychotherapy: An Evaluation,” asserted there was no proof that psychotherapy worked. On the contrary, he claimed that surveys showed that patients suffering from clinical neuroses improved after two years, whether or not they were treated by a psychotherapist.

“In the absence of agreement between fact and belief,” he proclaimed, “there is urgent need for a decrease in the strength of belief, and for an increase in the number of facts available. Until such facts as may be discovered in a process of rigorous analysis support the prevalent belief in therapeutic effectiveness of psychological treatment, it seems premature to insist on the inclusion of training in such treatment in the curriculum of the clinical psychologist.” Eysenck concluded that the shortcomings of data “highlight the necessity of properly planned and executed experimental studies into this important field.”

The first blast had been fired, and it was up to the profession to answer the challenge. Whatever its origins in Freud’s grand speculations and couch-based methodology, psychotherapy’s modern quest for scientific legitimacy may be said to have begun here.

From the get-go, however, measurement issues loomed: How do you go about proving psychotherapy really is more effective than a placebo or more helpful than a friendly, sympathetic listener? How do you determine objective measures with which to identify, define, and quantify the variable, and sometimes intangible-seeming, factors and aspects that contribute to a successful course of treatment? Moreover, as you go about establishing the science of psychotherapy, what happens to the intuitive art of psychotherapy? Until recently, this divide between objective science and intuitive art characterizing the uneasy relationship between psychotherapy’s researchers and practitioners has appeared unbridgeable.

A 2009 press release from the Association for Psychological Science, an organization formed by researchers who felt the American Psychological Association (APA) had become more of a guild than a scientific organization, carried the headline “Where’s the science? The sorry state of psychotherapy.” The release’s lead paragraph reads like an indictment: “The prevalence of mental health disorders in this country has nearly doubled in the past 20 years. Who is treating all these patients? Clinical psychologists and therapists are charged with the task, but many are falling short by using methods that are out of date and lack scientific rigor.” It goes on to cite a study suggesting that, in the absence of such scientific rigor, “six out of every seven sufferers were not getting the best care available from their clinicians.”

Ouch. Listen closely and you can hear the echo of Hans Eysenck and déjà vu all over again. So what is the science in psychotherapy? And why is it so important? Set aside obvious reasons of public trust and professional credibility, and, simply put, the quest for psychotherapeutic treatments that can be proven to work is especially important in the current era of accountability and third-party reimbursement. Today, more than ever, time is money, and measured results help determine the allotment of both time and money for patient services and for the professionals rendering those services. In other words, the stakes riding on the answer to the question of psychotherapy’s effectiveness could scarcely be higher.

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  • Comment Link Thursday, 25 June 2015 10:07 posted by Fred Summers

    I think there is a difference between improving and saying we've arrived. There is still so much we don't understand about the mind and people in general that we can't really say we have the best ideas. I think that as long as patient satisfaction is increasing and improving that is what you can hope for. But you can never stop trying to improve care.

  • Comment Link Saturday, 07 April 2012 13:11 posted by Keith Sonnanburg, Ph.D.

    Diane Cole described “scientifically rigorous” ways to study psychotherapy without “randomly controlled clinical trials” (RCT). However, systematically controlling variables of interest and randomizing the effects of uncontrolled variables remains the “gold standard” for scientifically assessing psychotherapy. This methodology does not favor some approaches over others. Wampold’s critique of “the medical model of psychotherapy” that emphasizes “ the right treatment for any given DSM disorder” fails to recognize other possible uses for RCT.

    Psychotherapeutic processes “can be defined in terms of speech, motor movements, physiological response indicators, and the relationship between behavior and the environmental context” (Sonnanburg, Psychotherapy, Vol. 33, No. 2, 1996). Any therapeutic exchange can therefore be tested with RCT. While that article addressed “outcome research,” my analysis applies equally to “process” variables. Measures of emotions, cognitions, social functioning, and standards of performance can encompass evidence from Wampold’s “contextual model” of psychotherapy, from cataloguing “common elements” subsumed by the therapeutic relationship, or from isolating “active ingredients” amidst specific interventions.

    RCT identifies “best practices” for therapists to emulate. Experimentally controlling therapeutic variables does not limit therapist autonomy. Rather, therapists are freed to respond to a client’s emergent needs with reliably effective therapies.

    If Da Vinci knew no chemistry of pigments, or if Michelangelo had not studied autopsied cadavers, their masterpieces would be diminished. I hope Pinsof is wrong about “most therapists” believing they cannot integrate scientific findings into their work without compromising effectiveness. I’m glad Cole ultimately foresees blended roles for both art and science in psychotherapy.

    Keith Sonnanburg, Ph.D.
    Seattle, WA

  • Comment Link Sunday, 18 March 2012 15:11 posted by Richard Katz, Psy.D

    As was said in the 1970's, "Right On". The politics of this field, especially the monetarily driven ones, are tilted towards the medical model, replete with "techniques" for "types" of problems in living, which have, of course, been medicalized into "diagnosable disorders".
    Here in the Chicago area the smug closed hydraulics of psychoanalysis seems to dominate the thinking of social workers in particular, who can neatly (and so authoritatitvely) diagnose and simultaneously demean a person (client)..."I'm so smart and you're so blechhhhhh!"
    Makes me nuts!