Over the past 25 years in the typically low-key, conflict-avoidant world of academic psychology, University of Pennsylvania professor James Coyne has been no stranger to controversy and debate. Although a therapist himself and a proponent of psychotherapy, he specializes in debunking what he considers the hype and exaggerated claims for the efficacy of a range of treatment approaches, advocating for higher standards of scientific rigor than is generally accepted as evidence for therapy’s effectiveness. For example, he’s challenged the findings purporting to show that support groups and alternative psychological treatment extend the life of cancer patients, cast doubt on some of the positive findings in the field of behavioral medicine, and raised the provocative question of whether the benefits of positive psychology—an approach that often ignores the influence of class and social factors on behavior—are “mainly for rich white people.”
Coyne’s latest target is the influential work of psychologist Irving Kirsch, bestselling author of The Emperor’s New Drugs, an expose of the psycho-pharmaceutical industry, and author of two much-cited meta-analyses testing the effectiveness of antidepressants against placebos for treating depression. Rather than relying solely on published studies that rarely include reports of unsuccessful clinical drug trials, Kirsch used the raw data that pharmaceutical companies are required to submit to the Food and Drug Administration. By eliminating the skew toward exclusively positive antidepressant research, he concluded that there was no significant difference between placebos and drugs in the treatment of depression, a finding that garnered him a great deal of media attention, including a featured spot on 60 Minutes.
In his 2008 study, Kirsch and his coresearchers had found an effect size for antidepressants of .32 in comparison with placebos. Since this was below the .50 effect size that they claimed was the cut-off for clinically effective results, they concluded that antidepressants were only negligibly more effective than sugar pills. In other words, a little over seven patients would’ve had to be treated to find one who was helped more by antidepressants. In a June blog post for Mind the Brain, Coyne criticized Kirsch’s .50 figure as an arbitrary and unrealistically high bar, and even quoted a noted British researcher who said that any study finding an effect size of .50 or greater is likely to have a flawed or biased methodology. Thus, says Coyne, Kirsch’s meta-analysis actually made a moderate case for antidepressants.
In his blog posts, Coyne challenged the complacency of his clinical colleagues who believed that Kirsch’s studies, by debunking antidepressants, somehow vindicated psychotherapy. He suspected that if therapy were subjected to a comparison trial against placebos, it wouldn’t do any better than antidepressants. So he contacted Pim Cuijpers of the University of Amsterdam, a researcher with an extensive database of psychotherapy and depression clinical trials, and suggested they do a meta-analysis that matched an antidepressant placebo against psychotherapies. They chose 10 studies comprising 12 therapies that had done this—including cognitive behaviorally based therapies (straight cognitive behavioral therapy, problem-solving, and behavioral activation) and short-term psychodynamically oriented therapies (supportive-expressive and interpersonal psychotherapy). Their meta-analysis, published in April as an online advance article for Psychological Medicine, found that the effect size of psychotherapy over a placebo came in at about .25—worse than what Kirsch had found in his comparison of antidepressants to placebos, but in statistical terms, roughly the same effect size as antidepressants over placebos.
Ever the intellectual provocateur, Coyne insists that he isn’t dismissing psychotherapy in the same way that Kirsch downplayed the effect of antidepressants by concluding they’re no better than a placebo. In fact, he notes that the statistical leveling of meta-analyses can disguise the fact that within a large sample size, some people are helped hugely by a treatment. His study suggests, he says, that psychotherapy is as effective as antidepressants, and that both outperform placebos. Although that’s a modest claim for psychotherapy, it is, he insists, better than Kirsch’s conclusion that the effective ingredients of both psychotherapy and placebos—the positive expectations of patients and, in the case of therapy, the therapist’s belief in the efficacy of therapy—are the same. Taking a cognitive behavioral bent, Coyne goes on to say that therapy also works by helping clients actively test the environment against their depressing beliefs and discover that their thoughts and gloomy expectations don’t match up with reality. According to Coyne, this kind of reality-based learning enhances the possibility of future change in a way that placebos cannot.
In fact, Cuijpers and Coyne’s meta-analysis found an overall effect size near .50 for psychotherapy that shrinks to .25 only when the highest quality of the 10 studies are considered. That effect size is still less than .8—an impressive average effect size, which psychotherapy researcher and Family Process editor Jay Lebow says many studies of psychotherapy typically achieve when comparing it to other active treatments or to no treatment.
Ultimately, however, many psychotherapy advocates agree with psychologist and author Michael Yapko, a strong proponent of short-term therapy for depression, who says that any study focused on broad methods and general treatment effects is missing the point. According to Yapko, there are too many variables involved in doing therapy for depressed individuals to set up objective research conditions that ignore the overriding impact of the practitioner on the results—give a half dozen therapists the same manual to follow, and their effectiveness with clients will be widely divergent. Says Yapko, “You can’t treat depression globally or apply psychotherapy as a global construct and expect to find any meaningful results or differences.”
J. Coyne. “Is Psychotherapy for Depression Any Better than a Sugar Pill?” Mind the Brain Blog, June 25, 2013; P. Cuijpers and others.
“Comparison of Psychotherapies for Adult Depression to Pill Placebo Control Groups: A Meta-analysis,” Psychological Medicine/FirstView Article, April 2013; I. Kirsch and others.
“Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration, PLoS Med 5, February 2008.
Captain Tim Hoyt has a PhD in clinical psychology, but during his time as an embedded behavioral health provider in Afghanistan, his office was a tent where confidentiality was ensured by a few pieces of plywood partitioned into the shape of a small room. In a combat zone where clinician and client both carry weapons, and a siren could wail at any second to alert them of an attack, the environment was about as far from the average psychotherapist’s office as Kandahar, Afghanistan is from Hoyt’s unit’s home base, near Tacoma, Washington.
With post-traumatic stress disorder (PTSD) affecting 20 percent of troops who’ve been stationed in Afghanistan and more than 300,000 veterans, the military has focused increasing attention on mental health issues. Over the past few years, the army has been assigning therapists like Hoyt to accompany combat units on missions and provide psychological services in the field. Such therapists have been responsible for supporting soldiers who, in a controversial decision by the military, have been redeployed to Afghanistan to keep up necessary troop levels despite being diagnosed with PTSD.
As an embedded behavioral health provider, Hoyt quickly found himself performing a number of roles for his team, from helping to solve marital disputes via webcam to working with an entire unit to process the loss of fellow soldiers after an attack on their base. But his primary task was to test whether empirically supported treatments for PTSD, like cognitive processing therapy and in vivo exposure—originally developed for use in more traditional treatment environments—were effective on the frontlines. Although definitive studies remain to be reported, Hoyt feels unequivocally that these approaches work, and adds that being around terrain similar to the location of an attack can be an advantage in using exposure therapy to work with soldiers struggling with PTSD.
For example, to help one soldier suffering from intense anxiety after witnessing a friend lose a leg from an improvised explosive device, Hoyt took him on a walk around the base. They stopped near a safe piece of ground that had been torn up from construction, at which point Hoyt said to him, “How close can you get to that patch of earth?” The solider replied, “I can stand 10 feet away, but I’m really nervous about it.” Hoyt then worked with him to relax and bring his anxiety down. Then he said, “Let’s take a step closer. How certain are you that there’s a bomb right there?” Eventually, they worked up to the point where the soldier could literally jump up and down on that patch of earth.
For some soldiers, however, not even the most immediate and intense of exposure techniques can quell the storm of symptoms following a traumatic incident, leaving Hoyt and his behavioral health team with the task of determining who should stay and who needs to go home. As he states, “The question for me with every patient was ‘Are they going to point their rifle in the right direction when they leave my office? Are they going to engage the enemy where they’re supposed to? Or are they going to point it at themselves, one of their teammates, or an unarmed civilian?’”
For critics of the redeployment of soldiers with PTSD, the presence of therapists like Hoyt begs the fundamental question of whether soldiers with mental health symptoms should even be in combat zones. “The army does a pretty good job of not drafting people who are at risk because of a bad back, allergies, or a variety of things that could cause them to be less effective on the battlefield,” says Jeffrey Jay, a clinical psychologist in Washington, DC, who’s worked with veterans and victims of trauma for more than 40 years. “Since the first principle in trauma treatment is to gain and maintain safety, sending somebody who’s been exposed to trauma back into a dangerous situation contravenes best treatment.”
Hoyt, however, questions the assumption that all cases of PTSD are crippling and should disqualify a soldier from combat duty. “I think that’s an overly fragile view of soldiers,” he says. “They’re much stronger than people might give them credit for. We have a senior noncommissioned officer who’s been to Iraq and Afghanistan five or six times. That’s the job he’s always known, and he’s really good at it. And interfering with his service, with what gives him meaning and purpose, that’s far worse than what he’s going through if he has some PTSD symptoms and has an occasional nightmare from what he’s been through in combat.”
Jay acknowledges that the sense of spirit and mission is an important part of military culture. “Still,” he says, “I’m not sure that keeping somebody with PTSD in combat is a good way to help them deal with their sense of purpose and moral questions.”
Having returned home from Afghanistan this January, Hoyt clearly feels a sense of accomplishment about his service in the field. “We had a bare building when we got there, and we were able to build up to a fairly functional clinic. As long as I had a clipboard and a place to sit down with my soldiers, that was enough for me. That’s really the basics of psychotherapy—the opportunity to sit down and talk to somebody one on one.”
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