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, many others have joined their ranks. Clinical and counseling psychologists offer psychotherapy, and so do clinical social workers; pastoral, marital, abuse, and school counselors; and psychiatric nurses.

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Psychotherapy takes an enormous amount of time, money, and effort. A critical thinker might wonder: Is the faith that millions of people worldwide place in psychotherapy justified? The question, though simply put, is not simply answered.

Imagine that a loved one, knowing that you’re studying psychology, has asked for your help. She’s been feeling depressed, and she’s thinking about making an appointment with a therapist. She wonders: Does psychotherapy really work? You’ve promised to gather some answers. Where will you start? Who decides whether psychotherapy is effective? Clients? Therapists? Friends and family members?

Clients’ Perceptions

If clients’ glowing comments were the only measuring stick, your job would be easy. Most clients believe that psychotherapy is effective. Consider 2900 Consumer Reports readers who rated their experiences with mental health professionals (1995; Kotkin et al., 1996; Seligman, 1995). How many were at least “fairly well satisfied”? Almost 90 percent (as was Kay Redfield Jamison, as we saw at this chapter’s beginning). 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 clients’ self-reports don’t persuade everyone. Critics point out some 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 satisfied. This means that 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. Thus, the same person, suffering from the same recurring anxiety, depression, or marital difficulty, may be a “success” story in several therapists’ files.

Therapists are like the rest of us in another way. We all sometimes suffer from two obstacles to critical thinking (Lilienfeld et al., 2014). The first, confirmation bias, is the tendency to unconsciously seek evidence that confirms our beliefs and to ignore evidence that contradicts them. The second is the tendency to see illusory correlations—to perceive associations that don’t really exist.

Outcome Research

If clients’ and therapists’ most sincere ratings of their experiences can’t inform us about psychotherapy’s effectiveness, how can we know what to 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 most of the fashionable treatments (bleeding, purging) were 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 doctors 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. The study showed that bleeding was worthless (Thomas, 1992).

In the twentieth century, psychology 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 found that untreated people, such as those on waiting lists for the same treatment, had similar rates of improvement. With or without psychotherapy, roughly two-thirds improved noticeably. Time was a great healer.

Eysenck’s findings sparked an uproar. Some critics 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 such studies. The best of these studies are randomized clinical trials, in which 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.

Therapists welcomed the result when the first statistical digest combined the results of 475 of these investigations (Smith et al., 1980). The outcome for the average therapy client was better than that for 80 percent of the untreated people (FIGURE 14.3).

Dozens of such summaries have echoed 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 have sudden reductions in their symptoms. These “sudden gains” offer hope for long-term improvement (Aderka et al., 2012).

So psychotherapy is a good investment of time and money. Like prenatal care, psychotherapy reduces long-term health care costs. One digest of 91 studies showed that after seeking psychotherapy, clients’ search for other medical treatment dropped by 16 percent (Chiles et al., 1999).

It’s good to know that psychotherapy, in general at least, is somewhat effective. But distressed people—and those paying for their therapy—really want a different question answered. How effective are particular treatments for specific problems? So what can we tell these people?

The early statistical summaries and surveys did not find that any one type of psychotherapy was generally better than others (Smith & Glass, 1977; Smith et al., 1980). Later studies have similarly found little connection between clients’ outcomes and their clinicians’ experience, training, supervision, and licensing (Bickman, 1999; Luborsky et al., 2002; Wampold, 2007). A Consumer Reports survey confirmed this result. 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. One general finding emerges from the studies. The more specific the problem, the greater the hope (Singer, 1981; Westen & Morrison, 2001). Moreover, some forms of psychotherapy get prizes for particular problems. Behavioral conditioning therapies work well for specific behavior problems, such as bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions (Baker et al., 2008; Hunsley & Di Giulio, 2002; Shadish & Baldwin, 2005). Psychodynamic therapy has helped treat depression and anxiety (Driessen et al., 2010; Leichsenring & Rabung, 2008; Shedler, 2010b). Nondirective (person-centered) counseling often helps people with mild to moderate depression (Cuijpers et al., 2013). And many studies confirm cognitive and cognitive-behavioral therapies’ effectiveness (some say superiority) in helping people cope with anxiety, posttraumatic stress disorder, and depression (Baker et al., 2008; De Los Reyes & Kazdin, 2009; Stewart & Chambless, 2009; Tolin, 2010).

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But no prizes would go to certain other psychotherapies (Arkowitz & Lilienfeld, 2006). We would all be wise to avoid approaches that have little or no scientific support, such as

It is as true for psychological treatments as it is for medical treatments—some can be not only ineffective but also harmful (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 by having them visit with adult inmates) as an example of a well-intentioned program that has proven unsuccessful or even damaging.

This list of discredited therapies raises another question. Who should decide which psychotherapies get prizes and which do not? What role should science play in clinical practice, and how much should science guide health care providers and insurers in setting payment policies for psychotherapy?

This question lies at the heart of a controversy—some call it psychology’s civil war. On one side are research psychologists who use scientific methods to extend the list of well-defined therapies with proven results in aiding people with various disorders. They worry that many clinicians “give more weight to their personal experience than to science” (Baker et al., 2008).

On the other side are the nonscientist therapists who view their practices as more art than science. They view psychotherapy as something that cannot be described in a manual or tested in an experiment. People are too complex and psychotherapy is too intuitive for a one-size-fits-all approach, many therapists say.

Between these two camps stand the science-oriented clinicians calling for evidence-based practice (FIGURE 14.4), which has been endorsed by the American Psychological Association and others (2006; Lilienfeld et al., 2013). Therapists using this approach make informed decisions based on research evidence, clinical expertise, and their knowledge of the patient. Increasingly, insurer and government support for mental health services requires evidence-based practice.

Why do therapists’ training and experience have so little influence on clients’ outcomes? The answer seems to be that all psychotherapies offer three basic benefits (Frank, 1982; Goldfried & Padawer, 1982; Strupp, 1986; Wampold, 2001, 2007). They all offer hope for demoralized people; a new perspective on oneself and the world; and an empathic, trusting, caring relationship.

HOPE FOR DEMORALIZED PEOPLE Many people seek therapy because they feel anxious, depressed, self-disapproving, and unable to turn things around. What any psychotherapy offers is hope—an expectation that, with commitment from the therapy seeker, things can and will get better. By harnessing the person’s own healing powers, this belief, apart from any therapy technique, can improve morale, create feelings of inner strength, and reduce symptoms (Corrigan, 2014; Frank, 1982; Prioleau et al., 1983).

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A NEW PERSPECTIVE Every psychotherapy also offers people an explanation of their symptoms. Psychotherapy is a new experience that can help people change their behavior and their view of themselves. Armed with a believable fresh perspective, people may approach life with new energy to make needed changes.

AN EMPATHIC, TRUSTING, CARING RELATIONSHIP No matter what technique they use, effective psychotherapists are empathic. They seek to understand people’s experiences. 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, at key moments during the most significant parts of their sessions, they were strikingly similar. They helped clients evaluate themselves, connect different aspects of their life, and gain insight into their interactions with others. At these points, an emotional bond—called a therapeutic alliance—forms between psychotherapist and client. This bond is a key aspect of effective psychotherapy (Klein et al., 2003; Wampold, 2001). In one U.S. National Institute of Mental Health depression-treatment study, the most effective therapists were those who formed the closest therapeutic bonds with their clients by showing empathy and care (Blatt et al., 1996).

These three basic benefits—hope, a fresh perspective, and an empathic, caring relationship—help us understand why paraprofessionals (briefly trained caregivers) can assist so many troubled people so effectively (Christensen & Jacobson, 1994). They are an important part of what self-help and support groups offer their members. And they also 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 they have empathized, reassured, advised, consoled, interpreted, and explained (Torrey, 1986). These three elements of effective psychotherapy may also explain another finding. 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 psychotherapy 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.

All psychotherapies offer hope. Nearly all psychotherapists try to enhance their clients’ sensitivity, openness, personal responsibility, and sense of purpose (Jensen & Bergin, 1988). But in matters of culture and values, psychotherapists 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 psychotherapists reflect the majority culture’s individualism, which often gives priority to personal desires and identity. Clients with a collectivist perspective, as found in many Asian cultures, may assume people will be more mindful of social and family responsibilities, harmony, and group goals. These clients may have trouble relating to therapies that require them to think only of their individual well-being (Markus & Kitayama, 1991).

Cultural differences help explain some groups’ reluctance to use mental health services. People living in “cultures of honor” prize being strong and tough. They may feel that seeking mental health care is an admission of weakness (Brown et al., 2014b). And some minority groups tend to be both reluctant to seek therapy and quick to leave it (Broman, 1996; 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 more alliance with the counselor (Kim et al., 2005).

Client-psychotherapist mismatches may also stem from religious values. Highly religious people may prefer and benefit from therapists who share their values and beliefs (Masters, 2010; Smith et al., 2007; Wade et al., 2006). They may have trouble establishing an emotional bond with a therapist who views the world differently.

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Life for everyone is marked by a mix of calm and stress, blessings and losses, good moods and bad. So when should we seek a mental health professional’s help? APA offers these common trouble signals:

In looking for a psychotherapist, you may want to have a preliminary meeting with two or three. College health centers are generally good starting points, and they offer some free services. In your meeting, you can describe your problem and learn each therapist’s treatment approach. You can ask questions about the therapist’s values, credentials (TABLE 14.2), and fees. And you can assess your own feelings about each therapist. The emotional bond between therapist and client is perhaps the most important factor in effective therapy.

The American Psychological Association recognizes the importance of a strong therapeutic alliance and it welcomes diverse therapists who can relate well to diverse clients. It accredits programs that provide training in cultural sensitivity (for example, to differing values, communication styles, and language) and that recruit underrepresented cultural groups.