KEY THEME

Decades of research demonstrate that psychotherapy is effective in helping people with psychological disorders.

KEY QUESTIONS

Let’s start with a simple fact: Most people with psychological symptoms do not seek help from mental health professionals (Jagdeo & others, 2009; Kessler & others, 2004). Some people may be reluctant to seek treatment because of the stigma that is still associated with psychological problems (Pescosolido & others, 2013; Wahl, 2012). And, of course, not everyone has access to professional treatment (Kazdin & Blase, 2011). But many people eventually weather their psychological problems without professional intervention, sometimes seeking help and support from friends and family. And some people eventually improve simply with the passage of time, a phenomenon called spontaneous remission. Does psychotherapy offer significant benefits over just waiting for the possible “spontaneous remission” of symptoms?

The basic strategy for investigating this issue is to compare people who enter psychotherapy with a carefully selected, matched control group of people who do not receive psychotherapy (Freeman & Power, 2007; Nezu & Nezu, 2008). During the past half-century, hundreds of such studies have investigated the effectiveness of the major forms of psychotherapy (Cooper, 2008; Nathan & Gorman, 2007). To combine and interpret the results of such large numbers of studies, researchers have used a statistical technique called meta-analysis. Meta-analysis involves pooling the results of several studies into a single analysis, essentially creating one large study that can reveal overall trends in the data.

When meta-analysis is used to summarize studies that compare people who receive psychotherapy treatment to no-treatment controls, researchers consistently arrive at the same conclusion: Psychotherapy is significantly more effective than no treatment. On average, the person who completes psychotherapy treatment is better off than about 80 percent of those in the untreated control group (Cooper, 2008; Lambert & Ogles, 2004).

The benefits of psychotherapy usually become apparent in a relatively short time. As shown in FIGURE 15.4, approximately 50 percent of people show significant improvement by the eighth weekly session of psychotherapy. By the end of six months of weekly psychotherapy sessions, about 75 percent are significantly improved (Baldwin & others, 2009; Lambert & others, 2001).

The gains that people make as a result of psychotherapy also tend to endure long after the therapy has ended, sometimes for years (Lambert & Ogles, 2004; Shedler, 2010). Even brief forms of psychotherapy tend to produce beneficial and long-lasting changes (Beck, 2011; Shapiro & others, 2003). And, multiple meta-analyses have found that individual and group therapy are equally effective in producing significant gains in psychological functioning (Burlingame & others, 2004; Cuijpers & others, 2008).

Brain imaging technologies are providing another line of evidence demonstrating the power of psychotherapy to bring about change for people with many psychological disorders (Barsaglini & others, 2014; Karlsson, 2011). In one study, PET scans were used to measure brain activity before and after 10 weeks of therapy for obsessive–compulsive disorder (Schwartz & others, 1996; Schwartz & Begley, 2002). The psychotherapy patients who improved showed the same changes in brain function that are associated with effective drug therapy for this disorder.

Similarly, PET scans of patients with major depressive disorder show changes in brain functioning toward more normal levels after 12 weeks of interpersonal therapy (Martin & others, 2001). In other words, psychotherapy alone produces distinct physiological changes in the brain—changes that are associated with a reduction in symptoms (Arden & Linford, 2009; Karlsson, 2011).

Nevertheless, it’s important to note that psychotherapy is not a miracle cure. While most people experience significant benefits from psychotherapy, not everyone benefits to the same degree. Some people who enter psychotherapy improve only slightly or not at all. Others drop out early, presumably because therapy wasn’t working as they had hoped (Barrett & others, 2008). And in some cases, people get worse despite therapeutic intervention (Boisvert & Faust, 2003; Linden, 2013).

Given that the major types of psychotherapy use different assumptions and techniques, does one type of psychotherapy stand out as more effective than the others? In some cases, one type of psychotherapy is more effective than another in treating a particular problem (Barlow & others, 2013; Budd & Hughes, 2009). For example, cognitive therapy and interpersonal therapy are effective in treating major depressive disorders (Craighead & others, 2007). Cognitive, cognitive-behavioral, and behavior therapies tend to be more successful than insight-oriented therapies in helping people who are experiencing panic disorder, obsessive–compulsive disorder, phobias, and post-traumatic stress disorder (Clark & others, 2003; Craske & Barlow, 2008; Foa & others, 2013). And, insight-oriented therapies are also less effective than other therapies in the treatment of disorders characterized by severe psychotic symptoms, such as schizophrenia (Mueser & Glynn, 1993).

However, when meta-analysis techniques are used to assess the collective results of treatment outcome studies, a surprising but consistent finding emerges: In general, there is little or no difference in the effectiveness of different psychotherapies. Despite sometimes dramatic differences in psychotherapy techniques, all of the standard psychotherapies have very similar success rates (Cooper, 2008; Luborsky & others, 2002; Wampold, 2001). For example, one meta-analysis examined seven different types of psychotherapy for depression (Barth & others, 2013). All seven were more effective than a control group in which patients received no therapy, and the seven were fairly similar in their effectiveness in reducing symptoms of depression.

One important qualification must be made at this point. In this chapter, we’ve devoted considerable time to explaining four major approaches to therapy: psychoanalytic and psychodynamic therapy; humanistic therapy; behavior therapy; and cognitive and cognitive-behavioral therapies. While distinct, all of these psychotherapy approaches have in common the fact that they are empirically supported treatments. In other words, they are based on known psychological principles, have been subjected to controlled scientific trials, and have demonstrated their effectiveness in helping people with psychological problems (David & Montgomery, 2011).

In contrast, one ongoing issue in contemporary psychotherapy is the proliferation of untested psychotherapies (Barlow & others, 2013). The fact that there is little difference in outcome among the empirically supported therapies does not mean that any and every form of psychotherapy is equally effective (Dimidjian & Hollon, 2010; Herbert & others, 2000). Too often, untested therapy techniques are heavily marketed and promoted, promising miraculous cures with little or no empirical research to back up their claims (Lazarus, 2000; Lilienfeld, 2007).

Psychologist James D. Herbert and his colleagues (2000) argue that before being put into widespread use, new therapies should provide empirically based answers to the following questions:

Often, “revolutionary” new therapies are developed, advertised, and marketed directly to the public—and to therapists—before controlled scientific studies of their effectiveness have been conducted (Lazarus, 2000). Many of the untested therapies are ineffective or, as in the case of EMDR discussed on pages 628–629, are no more effective than established therapies (Lilienfeld, 2011; Lohr & others, 2003).

How can we explain the fact that different forms of psychotherapy are basically equivalent in producing positive results? One possible explanation is that the factors that are crucial to producing improvement are present in all effective therapies. Researchers have identified a number of common factors that are related to a positive therapy outcome (Bjornsson, 2011; Laska & others, 2013; Sparks & others, 2008).

First and most important is the quality of the therapeutic relationship (Cooper, 2008; Norcross & Lambert, 2011; Norcross & Wampold, 2011a). When psychotherapy is helpful, the therapist–client relationship is characterized by mutual respect, trust, and hope. Working in a cooperative alliance, both people are actively trying to achieve the same goals.

Second, certain therapist characteristics are associated with successful therapy. Helpful therapists have a caring attitude and the ability to listen empathically. They are genuinely committed to their clients’ welfare (Aveline, 2005). Regardless of approach, they tend to be warm, sensitive, and responsive people, and they are perceived as sincere and genuine (Beutler & others, 2004). Interestingly, however, years of experience as a therapist is not associated with successful therapy (Tracey & others, 2014). Researchers speculate that experience does not lead clinicians to perform better because there is no structure to provide them with ongoing feedback about their patients’ improvement.

Third, client characteristics are important (Clarkin & Levy, 2004; Knerr & others, 2011). If the client is motivated, committed to therapy, and actively involved in the process, a successful outcome is much more likely (Tallman & Bohart, 1999). Emotional and social maturity and the ability to express thoughts and feelings are important. Clients who are optimistic, who expect psychotherapy to help them with their problems, and who don’t have a previous history of psychological disorders are more likely to benefit from therapy (Leon & others, 1999). Finally, external circumstances, such as a stable living situation and supportive family members, can enhance the effectiveness of therapy.

Effective therapists are also sensitive to the cultural differences that may exist between themselves and their clients (Smith & others, 2011; Sue & Sue, 2008b). As described in the Culture and Human Behavior box below, cultural differences can be a barrier to effective psychotherapy. Increasingly, training in cultural sensitivity and multicultural issues is being incorporated into psychological training programs in the United States (Sammons & Speight, 2008).

Notice that none of these factors are specific to any particular brand of psychotherapy. However, this does not mean that differences between psychotherapy techniques are completely irrelevant. Rather, it’s important that there be a good “match” between the person seeking help and the specific psychotherapy techniques used (Norcross & Wampold, 2011b). One person may be very comfortable with psychodynamic techniques, such as exploring childhood memories and free association. Another person might be more open to behavioral techniques, like systematic desensitization. For therapy to be optimally effective, the individual should feel comfortable with both the therapist and the therapist’s approach to therapy.

Increasingly, such a personalized approach to therapy is being facilitated by the movement of mental health professionals toward eclecticism—the pragmatic and integrated use of diverse psychotherapy techniques (Hollanders, 2007; Lambert & others, 2004). Today, therapists identify themselves as eclectic more often than any other approach (Norcross & others, 2005; Lambert & Ogles, 2004). Eclectic psychotherapists carefully tailor the therapy approach to the problems and characteristics of the person seeking help. For example, an eclectic therapist might integrate insight-oriented techniques with specific behavioral techniques to help someone suffering from extreme shyness. A related approach is integrative psychotherapy. Integrative psychotherapists also use multiple approaches to therapy, but they tend to blend them together rather than choosing different approaches for different clients (Lazarus, 2008; Stricker & Gold, 2008).