Many Americans have great confidence in psychotherapy’s effectiveness. “Seek counseling” or “Ask your mate to find a therapist,” advice columnists often advise. Before 1950, psychiatrists were the primary providers of mental health care. Today’s providers include clinical and counseling psychologists; clinical social workers; pastoral, marital, abuse, and school counselors; and psychiatric nurses. With such an enormous outlay of time as well as money and effort, it is important to ask: Are the millions of people worldwide justified in placing their hopes in psychotherapy?

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44-8 Does psychotherapy work? How can we know?

Asking whether psychotherapy has worked is not as simple as asking whether antibiotics have worked to treat an infection. So how can we assess psychotherapy’s effectiveness? By how we feel about our progress? By how our therapist feels about it? By how our friends and family feel about it? By how our behavior has changed?

CLIENTS’ PERCEPTIONS If clients’ testimonials were the only measuring stick, we could strongly assert psychotherapy’s effectiveness. Consider the 2900 Consumer Reports readers who reported on their experiences with mental health professionals (1995; Kotkin et al., 1996; Seligman, 1995). How many were at least “fairly well satisfied”? Almost 90 percent. Among those who recalled feeling fair or very poor when beginning therapy, 9 in 10 now were feeling very good, good, or at least so-so. We have their word for it—and who should know better?

But client testimonials don’t persuade everyone. Critics note reasons for skepticism:

CLINICIANS’ PERCEPTIONS If clinicians’ perceptions were proof of therapy’s effectiveness, we would have even more reason to celebrate. Case studies of successful treatment abound. Furthermore, therapists are like the rest of us. They treasure compliments from clients saying good-bye or later expressing their gratitude. The problem is that clients justify entering psychotherapy by emphasizing their unhappiness. They justify leaving by emphasizing their well-being. And they stay in touch only if they are satisfied. Thus, therapists are most aware of the failures of other therapists—those whose clients, having experienced only temporary relief, are now seeking a new therapist for their recurring problems. The same person, with the same recurring anxieties, depression, or marital difficulty, may be a “success” story in several therapists’ files. Moreover, therapists, like the rest of us, are vulnerable to cognitive errors, such as confirmation bias and illusory correlation (Lilienfeld et al., 2014).

OUTCOME RESEARCH How, then, can we objectively assess psychotherapy’s effectiveness? What outcomes can we expect—what types of people and problems are helped, and by what type of psychotherapy?

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In search of answers, psychologists have turned to controlled research. This is a well-traveled path. In the 1800s, skeptical medical doctors began to realize that many patients got better on their own and that many fashionable treatments (bleeding, purging) might be doing no good. Sorting fact from superstition required following patients and recording outcomes with and without a particular treatment. Typhoid fever patients, for example, often improved after being bled, convincing most physicians that the treatment worked. Then came the shock. A control group was given mere bed rest, and after five weeks of fever, 70 percent improved, showing that the bleeding was worthless (Thomas, 1992).

In the twentieth century, psychology, with its many different therapy options, faced a similar challenge. British psychologist Hans Eysenck (1952) launched a spirited debate when he summarized 24 studies of psychotherapy outcomes. He found that two-thirds of those receiving psychotherapy for disorders not involving hallucinations or delusions improved markedly. To this day, no one disputes that optimistic estimate.

Why, then, are we still debating psychotherapy’s effectiveness? Because Eysenck also reported similar improvement among untreated persons, such as those who were on waiting lists for treatment. With or without psychotherapy, he said, roughly two-thirds improved noticeably. Time was a great healer.

An avalanche of criticism greeted Eysenck’s conclusions. Some pointed out errors in his analyses. Others noted that he based his ideas on only 24 studies. Now, more than a half-century later, there are hundreds of studies. The best of these are randomized clinical trials: Researchers randomly assign people on a waiting list to therapy or to no therapy. Later, they evaluate everyone and compare the outcomes, with assessments by others who don’t know whether therapy was given. Statistical digests of the results of many studies, or meta-analyses, give us the bottom-line result.

Therapists welcomed the first meta-analysis of some 475 psychotherapy outcome studies (Smith et al., 1980). It showed that the average therapy client ends up better off than 80 percent of the untreated individuals on waiting lists (FIGURE 44.3). The claim is modest—by definition, about 50 percent of untreated people also are better off than the average untreated person.

Dozens of subsequent summaries have now examined psychotherapy’s effectiveness. Their verdict echoes the results of the earlier outcome studies: Those not undergoing therapy often improve, but those undergoing therapy are more likely to improve, and to improve more quickly and with less risk of relapse. Moreover, between the treatment sessions for depression and anxiety, many people experience sudden symptom reductions. Those “sudden gains” bode well for long-term improvement (Aderka et al., 2012).

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Is psychotherapy also cost-effective? Again, the answer is Yes. Studies show that when people seek psychological treatment, their search for other medical treatment drops—by 16 percent in one digest of 91 studies (Chiles et al., 1999). Given the staggering annual cost of psychological disorders and substance abuse—including crime, accidents, lost work, and treatment—psychotherapy is a good investment, much like money spent on prenatal and well-baby care. Both reduce long-term costs. Boosting employees’ psychological well-being can lower medical costs, improve work efficiency, and diminish absenteeism.

But note that the claim—that psychotherapy, on average, is somewhat effective—refers to no one therapy in particular. It is like reassuring lung-cancer patients that medical treatment of health problems is, “on average,” somewhat effective. What people want to know is whether a particular treatment is effective for their specific problem.

44-9 Are some psychotherapies more effective than others for specific disorders?

The early statistical summaries and surveys did not find that any one type of psychotherapy is generally better than others (Smith et al., 1977, 1980). Later studies have similarly found little connection between clients’ outcomes and their clinicians’ experience, training, supervision, and licensing (Luborsky et al., 2002; Wampold, 2007). A Consumer Reports survey illustrated this point by asking: Were clients treated by a psychiatrist, psychologist, or social worker? Were they seen in a group or individual context? Did the therapist have extensive or relatively limited training and experience? It didn’t matter. Clients seemed equally satisfied (Seligman, 1995).

So, was the dodo bird in Alice in Wonderland right: “Everyone has won and all must have prizes”? Not quite. Some forms of therapy get prizes for effectively treating particular problems. Behavioral conditioning therapies have had especially good results with specific behavior problems, such as bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions (Baker et al., 2008; Hunsley & DiGiulio, 2002; Shadish & Baldwin, 2005). Psychodynamic therapy has helped treat depression and anxiety (Driessen et al., 2010; Leichsenring & Rabung, 2008; Shedler, 2010). With mild to moderate depression, nondirective (client-centered) counseling often helps (Cuijpers et al., 2013). And many studies confirm cognitive and cognitive-behavioral therapy’s effectiveness (some say superiority) in coping with anxiety, posttraumatic stress disorder, and depression (Baker et al., 2008; De Los Reyes & Kazdin, 2009; Stewart & Chambliss, 2009; Tolin, 2010).

Moreover, we can say that therapy is most effective when the problem is clear-cut (Singer, 1981; Westen & Morrison, 2001). Those who experience phobias or panic, who are unassertive, or who are frustrated by sexual performance problems can hope for improvement. Those with less-focused problems, such as depression and anxiety, usually benefit in the short term but often relapse later. The more specific the problem, the greater the hope.

But no prizes—and little or no scientific support—go to certain other therapies (Arkowitz & Lilienfeld, 2006). We would all therefore be wise to avoid energy therapies that propose to manipulate people’s invisible energy fields, recovered-memory therapies that aim to unearth “repressed memories” of early child abuse, and rebirthing therapies that engage people in reenacting the supposed trauma of their birth.

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As with some medical treatments, it’s possible for psychological treatments to be not only ineffective but also harmful—by making people worse or preventing their getting better (Barlow, 2010; Castonguay et al., 2010; Dimidjian & Hollon, 2010). The National Science and Technology Council cites the Scared Straight program (seeking to deter children and youth from crime) as an example of well-intentioned programs that have proved ineffective or even harmful.

The evaluation question—which therapies get prizes and which do not?—lies at the heart of what some call psychology’s civil war. To what extent should science guide both clinical practice and the willingness of health care providers and insurers to pay for psychotherapy? On one side are research psychologists using scientific methods to extend the list of well-defined and validated therapies for various disorders. They decry clinicians who “give more weight to their personal experiences” (Baker et al., 2008). On the other side are nonscientist therapists who view their practice as more art than science, something that cannot be described in a manual or tested in an experiment. People are too complex and psychotherapy is too intuitive for such an approach, many therapists say.

Between these two factions stand the science-oriented clinicians calling for evidence-based practice, which has been endorsed by the American Psychological Association and others (2006; Lilienfeld et al., 2013). Therapists using this approach integrate the best available research with clinical expertise and with patient preferences and characteristics (FIGURE 44.4). After rigorous evaluation, clinicians apply therapies suited to their own skills and their patients’ unique situations. Increasingly, insurer and government support for mental health services requires evidence-based practice.

44-10 How do alternative therapies fare under scientific scrutiny?

The tendency of many abnormal states of mind to return to normal, combined with the placebo effect (the healing power of mere belief in a treatment), creates fertile soil for pseudotherapies. Bolstered by anecdotes, boosted by the media, and broadcast on the Internet, alternative therapies—newer, nontraditional therapies, which often claim healing powers for various ailments—can spread like wildfire. In one national survey, 57 percent of those with a history of anxiety attacks and 54 percent of those with a history of depression had used alternative treatments, such as herbal medicine, massage, and spiritual healing (Kessler et al., 2001).

Proponents of alternative therapies often feel that their personal testimonials are evidence enough. But how well do these therapies stand up to scientific scrutiny? There is little evidence for or against most of them. Some, however, have been the subject of controlled research. Let’s consider two. As we do, remember that sifting sense from nonsense requires the scientific attitude: being skeptical but not cynical, open to surprises but not gullible.

EYE MOVEMENT DESENSITIZATION AND REPROCESSING EMDR (eye movement desensitization and reprocessing) is a therapy adored by thousands and dismissed by thousands more as a sham—“an excellent vehicle for illustrating the differences between scientific and pseudoscientific therapy techniques,” suggested James Herbert and six others (2000).

Psychologist Francine Shapiro (1989, 2007, 2012) developed EMDR while walking in a park and observing that anxious thoughts vanished as her eyes spontaneously darted about. Back in the clinic, she had people imagine traumatic scenes while she triggered eye movements by waving her finger in front of their eyes, supposedly enabling them to unlock and reprocess previously frozen memories. Tens of thousands of mental health professionals from more than 75 countries have since undergone training (EMDR, 2011). No new therapy has attracted so many devotees so quickly since Franz Anton Mesmer introduced hypnosis (then called animal magnetism) more than two centuries ago (also after feeling inspired by an outdoor experience).

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Does EMDR work? Shapiro believes it does, and she cites four studies in which it worked for 84 to 100 percent of single-trauma victims (Shapiro, 1999, 2002). Moreover, the treatment need take no more than three 90-minute sessions. The Society of Clinical Psychology task force on empirically validated treatments has acknowledged that EMDR is “probably efficacious” for the treatment of nonmilitary posttraumatic stress disorder (Chambless et al., 1997; see also Bisson & Andrew, 2007; Rodenburg et al., 2009; Seidler & Wagner, 2006).

Why, wonder the skeptics, would rapidly moving one’s eyes while recalling traumas be therapeutic? Some argue that the eye movements relax or distract patients, thus allowing memory-associated emotions to extinguish (Gunter & Bodner, 2008). Others believe the eye movements in themselves are not the therapeutic ingredient (nor is watching high-speed Ping-Pong therapeutic). Trials in which people imagined traumatic scenes and tapped a finger, or just stared straight ahead while the therapist’s finger wagged, have also produced therapeutic results (Devilly, 2003). EMDR does work better than doing nothing, acknowledge the skeptics (Lilienfeld & Arkowitz, 2006/2007). But skeptics suspect that what is therapeutic is the combination of exposure therapy—repeatedly calling up traumatic memories and reconsolidating them in a safe and reassuring context—and perhaps some placebo effect. Had Mesmer’s pseudotherapy been compared with no treatment at all, it, too (thanks to the healing power of positive belief), might have been found “probably efficacious,” observed Richard McNally (1999).

LIGHT EXPOSURE THERAPY Have you ever found yourself oversleeping, gaining weight, and feeling lethargic during the dark mornings and overcast days of winter? Slowing down and conserving energy during the cold, barren winters likely gave our distant ancestors a survival advantage. For people today, however—especially for women and those living far from the equator—the wintertime blahs may constitute a seasonal pattern for major depressive disorder. To counteract these dark feelings, National Institute of Mental Health researchers in the early 1980s had an idea: Give people a timed daily dose of intense light. Sure enough, people reported feeling better.

Was light exposure a bright idea, or another dim-witted example of the placebo effect? Research illuminates the issue. One study exposed some people with a seasonal pattern in their depression symptoms to 90 minutes of bright light and others to a sham placebo treatment—a hissing “negative ion generator” about which the staff expressed similar enthusiasm (but which was generating nothing). After four weeks, 61 percent of those exposed to morning light had greatly improved, as had 50 percent of those exposed to evening light and 32 percent of those exposed to the placebo (Eastman et al., 1998). Other studies have found that 30 minutes of exposure to 10,000-lux white fluorescent light produced relief for more than half the people receiving morning light therapy (Flory et al., 2010; Terman et al., 1998, 2001). From 20 carefully controlled trials we have a verdict (Golden et al., 2005; Wirz-Justice, 2009): Morning bright light does dim depression symptoms for many of those suffering in a seasonal pattern. Moreover, it does so as effectively as taking antidepressant drugs or undergoing cognitive-behavioral therapy (Lam et al., 2006; Rohan et al., 2007). The effects are clear in brain scans; light therapy sparks activity in a brain region that influences the body’s arousal and hormones (Ishida et al., 2005).

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44-11 What three elements are shared by all forms of psychotherapy?

How can it be that therapists’ training and experience do not seem to influence clients’ outcomes? The answer seems to be that all psychotherapies offer three basic benefits (Frank, 1982; Goldfried & Padawer, 1982; Strupp, 1986; Wampold 2001, 2007).

HOPE FOR DEMORALIZED PEOPLE People seeking therapy typically feel anxious, depressed, self-disapproving, and incapable of turning things around. What any psychotherapy offers is the expectation that, with commitment from the therapy seeker, things can and will get better. This belief, apart from any therapy technique, may improve morale, create feelings of self-efficacy, and reduce symptoms (Corrigan, 2014; Prioleau et al., 1983).

A NEW PERSPECTIVE LEADING TO NEW BEHAVIORS Every psychotherapy offers people an explanation of their symptoms. Therapy is a new experience that can help people change their behaviors and their views of themselves. Armed with a believable fresh perspective, they may approach life with new energy.

AN EMPATHIC, TRUSTING, CARING RELATIONSHIP No matter what technique they use, effective psychotherapists are empathic. They seek to understand people’s experience. They communicate care and concern. And they earn trust through respectful listening, reassurance, and guidance. These qualities were clear in recorded therapy sessions from 36 recognized master therapists (Goldfried et al., 1998). Some took a cognitive-behavioral approach. Others used psychodynamic principles. Regardless, they were strikingly similar during the most significant parts of their sessions. At key moments, the empathic therapists of both types would help clients evaluate themselves, link one aspect of their life with another, and gain insight into their interactions with others. The emotional bond between psychotherapist and client—the therapeutic alliance—helps explain why some therapists are more effective than others (Klein et al., 2003; Wampold, 2001). One U.S. National Institute of Mental Health depression-treatment study confirmed that the most effective therapists were those who were perceived as most empathic and caring and who established the closest therapeutic bonds with their clients (Blatt et al., 1996).

That all psychotherapies offer hope through a fresh perspective provided by a caring person is what also enables paraprofessionals (briefly trained caregivers) to assist so many troubled people so effectively (Christensen & Jacobson, 1994). These three common elements are also part of what the growing numbers of self-help support groups offer their members. And they are part of what traditional healers have offered (Jackson, 1992). Healers everywhere—special people to whom others disclose their suffering, whether psychiatrists, witch doctors, or shamans—have listened in order to understand and to empathize, reassure, advise, console, interpret, or explain (Torrey, 1986). Such qualities may explain why people who feel supported by close relationships—who enjoy the fellowship and friendship of caring people—have been less likely to need or seek therapy (Frank, 1982; O’Connor & Brown, 1984).

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To recap, people who seek help usually improve. So do many of those who do not undergo psychotherapy, and that is a tribute to our human resourcefulness and our capacity to care for one another. Nevertheless, though the therapist’s orientation and experience appear not to matter much, people who receive some psychotherapy usually improve more than those who do not. People with clear-cut, specific problems tend to improve the most.

44-12 How do culture and values influence the therapist-client relationship?

All psychotherapies offer hope. Nearly all psychotherapists attempt to enhance their clients’ sensitivity, openness, personal responsibility, and sense of purpose (Jensen & Bergin, 1988). But therapists also differ from one another and may differ from their clients (Delaney et al., 2007; Kelly, 1990).

These differences can create a mismatch when a therapist from one culture interacts with a client from another. In North America, Europe, and Australia, for example, many therapists reflect the majority culture’s individualism, which often gives priority to personal desires and identity. Clients with a collectivist perspective, as with many from Asian cultures, may assume people will be more mindful of others’ expectations. These clients may have trouble relating to therapies that require them to think only of their own well-being.

Such differences help explain minority populations’ reluctance to use mental health services, and their tendency to prematurely terminate therapy (Chen et al., 2009; Sue, 2006). In one experiment, Asian-American clients matched with counselors who shared their cultural values (rather than mismatched with those who did not) perceived more counselor empathy and felt a stronger alliance with the counselor (Kim et al., 2005). Recognizing that therapists and clients may differ in their values, communication styles, and language, all American Psychological Association–accredited therapy-training programs provide training in cultural sensitivity and welcome members of underrepresented cultural groups.

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Therapist and client may also have differing religious perspectives. Highly religious people may prefer and benefit from religiously similar therapists (Masters, 2010; Smith et al., 2007; Wade et al., 2006). They may have trouble establishing an emotional bond with a therapist who does not share their values. People living in “cultures of honor”—which prize being strong and tough—tend to be more reluctant to seek mental health care, as it may be viewed as an admission of weakness (Brown et al., 2014).

44-13 What should a person look for when selecting a therapist?

Life for everyone is marked by a mix of serenity and stress, blessing and bereavement, good moods and bad. So, when should we seek a mental health professional’s help? The American Psychological Association offers these common trouble signals:

In looking for a therapist, you may want to have a preliminary consultation with two or three. College health centers are generally good starting points, and may offer some free services. You can describe your problem and learn each therapist’s treatment approach. You can ask questions about the therapist’s values, credentials (TABLE 44.3), and fees. And you can assess your own feelings about each of them. The emotional bond between therapist and client is perhaps the most important factor in effective therapy.