Tuesday, December 23, 2008

"Does Psychotherapy Work?"

For this blog the opening lines of Scott Stossel's review of Jonathan Engel's "American Therapy" are a holiday gift. Link to review here.

Stossel opens his review with a question: "Does psychotherapy work?" He follows with this line: "Depends on what you mean by 'psychotherapy,' and what you mean by 'work.'"

Where Engel concludes that psychotherapy does work, Stossel spends the first part of his review showing that the evidence Engel offers leads to a different conclusion.

The first problem with the question is the infinite variety of therapies. Some forms take years and pretend that insight cures. Some take weeks and focus on counterproductive mental habits. And others involve strange practices that range from primal screams to est training to beating on pillows with sticks.

Since these different therapies have little of nothing in common, the question of whether therapy works must be qualified: which therapy are we talking about?

Next is the question of what it means to "work?" Most studies base their conclusions on interviews where patients can assert their opinion about whether their therapy has helped them.

Is this really a reliable indicator of clinical success? If you go out and interview Tom Cruise and ask him whether scientology works, you will receive a heartfelt, albeit deluded, exposition about how the teachings of L. Ron Hubbard have freed him from the malevolence of Xenu. Would you then conclude that scientology works?

Beyond that, someone who has invested considerable time and money in therapy has a vested interest in believing that it works. Would you take his or her word at face value?

Engel bases his claim that therapy works on the fact that 59% of those who consult a therapist report that they were helped.

To which Stossel replies that 78% of those who consult a clergyman feel that they were helped. Better yet, 77% of those who discussed their problems with a lawyer found something therapeutically beneficial in the experience.

The difference between 59% and 77% is not trivial. Talking it over with a trained therapist is significantly less likely to be helpful than talking it over with a professional who has no training in psychology.

Today most therapists agree that therapy works when the therapist makes a human connection with his or her patient. Since many patients are suffering from feelings of isolation, anomie, and disconnection... then connection would certainly count as therapeutic.

But the data also suggest that professional training tends to make it more difficult for therapists to connect with their patients. Other professionals, even non-professionals, have a much higher level of connection.

Surely, Freudian training, with which I have more than a passing familiarity, teaches people how not to connect with people. In fact, psychoanalysts are taught that it is bad to have anything resembling a human connection with a patient.

Perhaps this is why psychoanalysis has fallen out of favor. The group I used to belong to, the Lacanians, resembles what Engel called: "... a fanatical Essene sect, living apart in the wilderness where they could continue to seek truth in the master's writings."

That is the most extreme case. Yet, Freud continues to influence the profession, and some therapists still believe that connecting with a patient is a technical error. Perhaps this is why you will do better to talk it over with a friend and why people today are turning away from insight-oriented therapy and toward coaching.

As for the question of what works, I recall a comment by Dr. Gail Saltz in a televised interview a month or so ago. A reporter asked Dr. Saltz what people should do to deal with their anxiety over the current financial crisis.

I paraphrase Dr. Saltz's reply: "I shouldn't be telling you this because I am a psychiatrist, but the best and quickest treatment is aerobic exercise."

Since it is the holiday season, let's ignore the implicit notion that a group of professionals might even imagine not telling you what really works, and let us simply add exercise to human connection on the list of what works.


Dan B. said...

As a longtime fan of your blog, and as a therapist, I must quibble a bit with some of your conclusions. The reality is that therapy works very well. The average treated patient is better off than 80% of an untreated sample. The more uncomfortable reality for therapists, however, is that some therapists are, quite simply, better than others, with the best therapists effective with @ 75% of cases and the least effective therapists effective @ 25% of the time. The best therapists can also be more powerfully effective than medications and come at a fraction of the cost with none of the side effects. What one should look for are the best treaters, not the best treatments, because the reality is also that all brands of therapy work equally well, because all brands will work some of the time with some patients. And as a therapist who has also spent a not inconsiderable amount of time among the various sects of the psychoanalytic community, and contrary to their myths and traditions, the reality is that if change is going to happen in therapy, it is often seen early. Things do not “have to get worse before they get better,” and if things are getting worse after 4-8 sessions, it may be time to look for a new therapist. Therapy can go on as long as it needs to, as long as it is being helpful, but if it is not helping early, it is unlikely to help later. What your post does reveal is that what makes going to a therapist so effective are the very things that are common to all brands of therapy, and sometimes even going to the gym, the lawyer, or the priest, namely relationship, hope, and a plan. The specific technical ingredients of different models of therapy contribute very little to overall outcome, but going to a professional is different, and more effective, than just going to a friend. After all, what friend will take all the grief a professional is obliged to? Thanks.

Dr. Andrew Thorn said...

I agree with this in so many ways. As a therapist, I decide to be a person more than a robot so I get involved and share who I am. Because I like to work this way, I made a decision a long time ago to only work with healthy people who are experiencing some level of disfunction in their life. Therapy is too good to be only used for the very sick. It works and I love the chance to be such a human while working with other humans.

Stuart Schneiderman said...

Thank you, Dr. Thorn. I will be posting later today about an article in this weeks NY Times Magazine that makes similar points.