Psychotherapy works

Does Psychotherapy Work?  The answer, supported by a large body of research, is YES.

(Thanks to Andrew Kronk, Ph.D. for an earlier version of the first part of this article)

Psychotherapy is effective.  Research finds that psychotherapy helps, consistently and significantly. Depending upon which goals are established, some of the ways, according to clinical research, in which psychotherapy can be effective are:

  1. Promoting symptom relief and personality change.
  2. Reducing future episodes of symptoms.
  3. Enhancing quality of life.
  4. Promoting healthy adaptation to work, school, or relationships.
  5. Increasing the likelihood of making healthy life choices.
  6. Psychotherapy reduces medical costs.

All psychotherapy is based on a therapeutic alliance between the therapist and patient, and is enhanced by agreement about the goals and tasks of treatment.   The quality of this therapeutic alliance has been found to have a significant impact on the patient’s progress.

Some further findings from scientific research on psychotherapy are as follows:

  • The benefits of psychotherapy “tend to last longer and be less likely to require additional treatment courses than psychopharmacological [medication] treatments.  For example, in the treatment of depression and anxiety disorders, psychotherapy clients / patients acquire a variety of skills that are used after the treatment termination and generally may continue to improve after termination of treatment.”
  • Children, adults and older adults can be helped by a variety of psychotherapies.
  • People who receive psychotherapy, according to the research, show benefits not seen in people who receive no treatment.
  • The benefits of psychotherapy last after completion of treatment, and clients often report that they continue to improve over time.
  • Two common problems—DEPRESSION and ANXIETY—are effectively treated “after a relatively short course of treatment.”  This means clients can return to a level of functioning “that is typical of most well-functioning individuals…”

People who consult a psychologist can be helped by different forms of psychotherapy.  Psychologists explain their approach at the start of treatment.

Psychotherapy and Medical Care

  • Medication helps many clients.  However, many individuals express a preference not to use medication.
  • Research indicates that the effects of psychotherapy are comparable to, or exceed the effects of many psychopharmacological treatments for the same condition.
  • Psychotherapy, when necessary, reduces medical costs:  Clients who have participated in psychotherapy experience, on average, experience a lower risk of medical difficulties and lower medical costs.
  • “Patients diagnosed with a mental health disorder and who received treatment had their overall medical costs reduced by 17 percent compared to a 12.3 percent increase for those with no treatment for their mental disorder.”
  • Psychotherapy is cost-effective because, according to research, its effects may:
    • Reduce disability.
    • Improve work functioning.
    • Decrease use of psychiatric hospitalization.
    • Sometimes result in reduction of unnecessary use of medical and surgical services.
  • Scientific evidence supports a link between mental and physical health. Psychologists are increasingly linking their services with those of primary care physicians, finding that early mental health treatment (including psychotherapy) reduces overall medical expenses for patients with physical conditions (including cancer and heart disease).
  • Many people prefer psychotherapy to medication because of side effects of medication.  In psychotherapy, clients typically learn skills and develop insights into themselves that help maintain improvement.
  • Psychotherapy has been found to improve mood and reduce depression in persons with acute and chronic health conditions (e.g. arthritis, cancer, HIV / AIDS).

Psychotherapy Across the Life Span

  • “The best research evidence conclusively shows that individual, group and couple / family psychotherapy are effective for a broad range of disorders, symptoms and problems with children, adolescents, and older adults.”
  • Psychotherapy has been found to be helpful to older adults, who “can benefit from psychological interventions to a degree comparable with younger adults.”
  • “Furthermore, many older adults prefer psychotherapy to antidepressants, and psychotherapy is an important treatment option for older adults who are on multiple medications for management of chronic conditions and are more prone to the adverse effects of psychiatric medications than younger adults.”

For a full list of research references, and to see the full text from which this summary was taken, please see www.apa.org/about/policy/resolution-psychotherapy.aspx

A Classic Large-Scale Study of the Effectiveness of Psychotherapy

In November 1995 Consumer Reports published the article:  DOES THERAPY HELP?, based on the results of a survey of 7,000 Consumer Reports subscribers.  Of these, 4,100 went to some combination of mental health professionals, family doctors, and support groups, and of these 2,900 saw a mental health professional. This is a very large sample for a study of psychological treatment. Nowhere else are such large sample sizes available in the (large and growing) literature on the effectiveness of psychotherapy.

In December, 1995 The American Psychologist, a journal of the American Psychological Association, published an article by Martin Seligman, Ph.D. an eminent psychologist who was a consultant to Consumer Reports for their study.  This article expanded on the findings and issues raised by the Consumer Reports Study:

Findings of the Consumer Reports Study

The Consumer Reports study concluded that therapy works.  The vast majority of patients benefited very substantially from psychotherapy. 87 percent of patients who felt “very poor” or & “fairly poor” at the beginning of therapy improved.  Outcome measures included:

  • Improvement in the specific problem that led the respondent to therapy;
  • Overall satisfaction with the therapist’s treatment of the respondent’s problems; and
  • Global improvement in the respondents’ “overall emotional state

The longer patients stayed in treatment, the better the outcomes of the treatment in terms of satisfaction and outcomes. The longer the treatment, the greater the more positive the outcome.  This connection between the duration of appropriate treatment and its outcome has been repeatedly demonstrated in controlled studies. It is known as the Dose Effect.  It is important to remember that the vast majority of people, even when unlimited therapy is available, end therapy before six months have passed (90% before 20 visits; according to actuarial data).

In the majority of cases, psychotherapy worked better than medication:.  Psychotherapy alone was as effective as psychotherapy combined with medications such as Prozac or Xanax.  There was no difference between psychotherapy alone and psychotherapy plus medication for any kind of disorder.  This is consistent with controlled studies showing that psychotherapy leads to superior results over medication for depression and panic disorder.

  • 60 percent of patients who took medications said they were helpful. This was considerably less than the 90 percent of patients who found psychotherapy helpful.
  • And half of the respondents who took medication complained of problems with their medications, the most frequent being drowsiness or a feeling of disorientation.

This is not to say that psychiatric medications are not helpful, when appropriately prescribed.

People who saw a mental health counselor for more than six months did much better than those who saw their family doctor for psychological problems. Family doctors failed to refer patients to mental health specialists.  Almost half of respondents who saw their family doctors received medication alone, without the benefit of contact with a mental health professional.  In the Consumer Reports Study only one quarter of patients seen first by their family physician were referred to a mental health professional.  Only half of those with severe distress were referred on.  Sixty percent of patients with panic disorder or phobias were not referred on, in spite of considerable evidence that specfic psychological therapies are the most effective treatments for these disorders.

Other research cited by Consumer Reports has shown that family doctors often fail to diagnose mental health problems (50 to 80 percent of these problems are not diagnosed). When family doctors prescribe psychiatric medications, they sometimes prescribe them at too low a dose or for too short a time.  These findings are likely to explain why, in the Consumer Reports study, only half of the respondents were highly satisfied with treatment by their family doctors.

No specific modality of psychotherapy did any better than any other for any problem. Psychologists, psychiatrists and social workers did equally well, and were significantly superior in outcome to marriage counselors.

Managed care intrusions into psychotherapy treatment interfered with its outcome:  Respondents whose choice of therapist or duration of care was limited by their insurance coverage did worse.

The Consumer Reports study can certainly be improved upon. See Seligman’s American Psychologist article for a detailed discussion of the flaws and merits of this survey, plus suggestions for followup.

Results of controlled studies

The Consumer Reports study’s results are consistent with the findings of hundreds of studies which follow strict methodological principles such as random assignment, control groups, etc. This study had the advantage of studying people in real-life conditions .

A review of 58 studies of the effectiveness of psychotherapy for depression found that depressed patients who received psychotherapy functioned better after treatment than patients with no treatment, this was true 77 percent of the time. On the average, treatment was completed in only 9 sessions.  A survey of 56 other studies found that 89% of depressed psychotherapy patients improved more than controls.  One study found that patients undergoing cognitive therapy for depression had better outcomes than 98% of control subjects (no treatment). The average cognitive-therapy patient scored better on post-treatment measures than 70% of patients treated with medication.

Similar findings are demonstrated for panic disorder (80% success rate), anxiety/stress (70-90%), and obsessive-compulsive disorder</B> (60%). These success rates are higher than for two very commonly used medical procedures: atherectomy (removal of plaque from blood vessel; 52% success rate) and angioplasty (surgical repair of blood vessel; 41%).

The results of 81 controlled trials of psychotherapy for neurosis, phobias and psychosomatic complaints were integrated in one meta-analytic study. The condition of the typical patient was better than 77% of untreated controls, and the rate of relapse in one or two years was small.

Another meta-analytic study combined 375 controlled evaluatioins of psychotherapy and counseling. The typical therapy patient was better off than 75% of untreated controls. Very few important differences were found among many different types of psychotherapy studied.

Drug therapy, while combining well with psychotherapy, was not more effective than <B>psychotherapy alone,  in 112 studies of the comparative effects of psychotherapy and psychoactive drugs.

Similar effects were found in 75 studies of the effectiveness of psychotherapy with children.

Among adolescents, the median rate of positive outcome of psychotherapy was 75%.

Comments about Family Doctors’ Treatment of Mental Health Problems

Family doctors have long been the object of a concerted marketing effort by certain pharmaceutical manufacturers. These manufacturers have been encouraging primary care physicians to keep patients in their practice and treat them with psychotropic drugs rather than referring the patient to a mental health professional.

The problems with these drugs are their expense (e.g., Paxil $1.90 wholesale per pill; Prozac, $2.24 per pill; Zoloft, $2.02 per pill), overprescription, side effects, the doctor’s failure to regularly monitor the patient while taking these drugs and failure to modify the prescription based on symptoms or side effects. Other problems are prescription when psychotherapy is the most beneficial, least restrictive and least risky option, and the failure to combine medication with psychotherapy when appropriate.

If the root causes of a patient’s anxiety, depression or other symptoms are stress, family, work or other emotional conflicts, even if medication is helpful in alleviating symptoms, it does not address the problems which need to be resolved. It is the purpose of psychotherapy to help the patient address and master such problems. And psychotherapy helps the majority of individuals who enter into it.

It was apparent in the Consumer Reports study that 40 percent of patients taking anti-anxiety medications (e.g., Valium and Xanax) were prescribed these for more than a year, and 25 percent for more than two years. This was described as “disturbing” by Consumer Reports, for the following reasons: a) research has shown a habituation effect, so that larger doses of these medications are needed over time; b) these medications produce a psychological dependency, becoming harder to kick as time goes on; and c) these medications have not been shown to be effective for problems which do not subside within a short period of time (in contrast to psychotherapy).