Psychotherapy - Criticisms and Questions Regarding Effectiveness

Criticisms and Questions Regarding Effectiveness

Within the psychotherapeutic community there has been some discussion of empirically-based psychotherapy, e.g.

Virtually no comparisons of different psychotherapies with long follow-up times have been done. The Helsinki Psychotherapy Study is a randomized clinical trial, in which patients were monitored for 10 years after the onset of short-term (6 months) psychodynamic or solution-focused, or long-term (3 years) psychodynamic study treatments. The effectiveness, suitability and sufficiency of the therapies were compared also with that of psychoanalysis (5 years), within a quasi-experimental design. The assessments were completed at the baseline and 14 times thereafter during the follow-up. The results of the 3- and 5-year follow-up indicate that the length of therapy is important when predicting the outcome of therapy. Patients in the two short-term therapies improved faster, but in the long run long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies. Follow-up evaluations of this study will continue up to 2014.

There is considerable controversy about which form of psychotherapy is most effective, and more specifically, which types of therapy are optimal for treating which sorts of problems. Furthermore, it is controversial whether the form of therapy or the presence of factors common to many psychotherapies best separates effective therapy from ineffective therapy. Common factors theory asserts it is precisely the factors common to the most psychotherapies that make any psychotherapy successful: this is the quality of the therapeutic relationship.

The dropout level is quite high; one meta-analysis of 125 studies concluded that the mean dropout rate was 46.86%. The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy. For a brief review article on dropout or attrition in therapy see link attached http://www.lenus.ie/hse/bitstream/10147/121474/1/DropoutRelatedfactorsPSI.pdf. There are different drop out rates depending on how drop-out is defined. Another large meta-analysis reports drop-oute rates not larger than 20 to 25%.

Psychotherapy outcome research—in which the effectiveness of psychotherapy is measured by questionnaires given to patients before, during, and after treatment—has had difficulty distinguishing between the success or failure of the different approaches to therapy. Those who stay with their therapist for longer periods are more likely to report positively on what develops into a longer-term relationship. This suggests that some "treatment" may be open-ended with concerns associated with ongoing financial costs.

As early as 1952, in one of the earliest studies of psychotherapy treatment, Hans Eysenck reported that two thirds of therapy patients improved significantly or recovered on their own within two years, whether or not they received psychotherapy.

Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice.

In 2001, Bruce Wampold of the University of Wisconsin published the book The Great Psychotherapy Debate. In it Wampold, who has a degree in mathematics and who went on to train as a counseling psychologist, reported that

1. psychotherapy is indeed effective,
2. the type of treatment is not a factor,
3. the theoretical bases of the techniques used, and the strictness of adherence to those techniques are both not factors,
4. the therapist's strength of belief in the efficacy of the technique is a factor,
5. the personality of the therapist is a significant factor,
6. the alliance between the patient(s) and the therapist (meaning affectionate and trusting feelings toward the therapist, motivation and collaboration of the client, and empathic response of the therapist) is a key factor.

Wampold therefore concludes that "we do not know why psychotherapy works".

Although the Great Psychotherapy Debate dealt primarily with data on depressed patients, subsequent articles have made similar findings for post-traumatic stress disorder and youth disorders. There have also been studies of Panic Disorder, where treatment effectiveness is measured in the abatement of panic attacks. Psychoanalytic psychotherapy has been found to be as effective as Cognitive Behavioral Therapy for immediate relief and more effective over the long term.

Some report that by attempting to program or manualize treatment, psychotherapists may be reducing efficacy, although the unstructured approach of many psychotherapists cannot appeal to those patients motivated to solve their difficulties through the application of specific techniques different from their past "mistakes."

Critics of psychotherapy are skeptical of the healing power of a psychotherapeutic relationship. Because any intervention takes time, critics note that the passage of time alone, without therapeutic intervention, often results in psycho-social healing. Social contact with others is universally seen as beneficial for all humans and regularly scheduled visits with anyone would be likely to diminish both mild and severe emotional difficulty. Yet a large part of effectiveness studies include waiting-list control groups. This type of study design proves psychotherapy to be significantly more effective than passage of time alone.

Many resources available to a person experiencing emotional distress—the friendly support of friends, peers, family members, clergy contacts, personal reading, healthy exercise, research, and independent coping—all present considerable value. Critics note that humans have been dealing with crises, navigating severe social problems and finding solutions to life problems long before the advent of psychotherapy. Of course, it may well be something in the patient that does not develop these "natural" supports that requires therapy.

Further critiques have emerged from feminist, constructionist and discursive sources. Key to these is the issue of power. In this regard there is a concern that clients are persuaded—both inside and outside the consulting room—to understand themselves and their difficulties in ways that are consistent with therapeutic ideas. This means that alternative ideas (e.g., feminist, economic, spiritual) are sometimes implicitly undermined. Critics suggest that we idealize the situation when we think of therapy only as a helping relation, that it is fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified, and while it is seldom intended, the therapist-client relationship always participates in society's power relations and political dynamics.