Psychotherapy-An Active Agent: Assessing the Effectiveness of Psychotherapy and Its Curative Factors
Bachar, Eytan, The Israel Journal of Psychiatry and Related Sciences
Abstract: In the last two decades there has been a remarkable expansion in research on psychotherapy in two areas: (a) assessing the effectiveness of psychotherapy compared to wait-list, no-treatment patient groups and groups treated with pharmacotherapy; (b) investigating curative factors in the therapeutic process: the extent of the psychotherapist 's experience and kinds of interventions and errors in handling techniques. The first section of the review deals with the first of these areas and the second with the other. The following are the main research findings: 1. The effectiveness of psychotherapy compared to wait-list and non-treatment groups has been proven by so many research papers that there is hardly any need to do so again; 2. Psychotherapy was found to be effective in treating focused psychiatric disorders such as OCD, depression and anxiety disorders (with preference to cognitive-behavioral approaches over psychodynamic approaches, and in some instances in preference to pharmacotherapy). Psychotherapy was also effective in less focused disorders, such as personality disorders and mixed neurotics (with preference to psychodynamic approaches over cognitive-behavioral approaches); 3. The advantages of patients receiving psychotherapy over those who did not receive it persisted in follow-up studies of one year's duration or more; 4. Psychotherapy was more effective than "psychotherapeutic placebo" (the encounter between therapist and patient where systematic psychotherapeutic work using one out of the three main psychotherapeutic approaches is experimentally prevented), which in turn was more effective than wait-list or non-treatment groups; 5. Psychotherapeutic maintenance of one session a month was effective in preventing relapse; 6. Experienced psychotherapists are more effective than beginners; 7. Empathy, the ability to identify the central thread of the session, and encouragement of the patient to reflect were found to be the key factors in techniques most associated with therapeutic success.
At a time when changes in the financial structure of health services all over the world are taking place, it is important to review the effectiveness of psychotherapy, the durability of its outcome and its advantages in relapse prevention. The research literature provides clear, definite and positive answers to the question of whether psychotherapy is effective. It also leads to the conclusion that psychotherapy works as an active, defined and predictable agent rather than a vague non-specific placebo like condition.
Meta-analytic studies (a kind of research that reviews papers by analyzing and quantifying them in a sophisticated manner, sometimes encompassing more than 500 research reports and reaching a measure across all these studies) found that, at the end of psychotherapy, the average patient was in better mental health than 80% of the people in wait-list and non-treatment groups (1, 2, 3).
Meta-analytic studies (1, 3, 4 and 5) and literature review (6) consistently show that psychotherapeutic treatments produce effect size (magnitude of therapeutic change expressed in terms of standard deviations) of 0.8 to 1.0 equivalent, for example to antidepressant medication. Surprisingly, it seems that psychotherapy is one of the best documented medical interventions in history (7).
Specificity of a Certain Technique to a Certain Condition
Results in treating depression with psychotherapy appeared consistent. In all metaanalytic reviews, patients undergoing psychotherapy surpassed no-treatment and wait-list control patients. For example, Dobson (7) reports that the average patient treated with Beck's cognitive therapy surpassed 98% of the control patients. Similar, but less dramatic results, are reported by Robinson et al. (8), who found that behavioral, cognitive-behavioral and, to a lesser extent, "general verbal therapies" all had positive outcomes compared with non-treatment or wait-list control groups. Of even more interest to practising clinicians was the finding that the effect of psychotherapies were equal to, or surpassed, the effects of a variety of anti-depressant medication (7, 8, 9). Dobson (7), in meta-analytic studies equating Beck's cognitive therapy with pharmacotherapy in treating depression, found that the average patient treated with the former technique had results that surpassed 70% of patients treated with pharmacotherapy.
A review of the psychotherapeutic treatment of agoraphobia and panic disorders has produced results similar to those of depression. Psychotherapies (mainly cognitivebehavioral) have been shown to be equal to or more effective than pharmacotherapeutic interventions, especially where follow-up data are concerned, because relapse rates are typically higher after treatments using medication only. (10, 11).
Henry et al. (12) studied psychodynamic psychoanalytically-oriented psychotherapies and replicated the finding that these therapies also were more effective than wait-list and non-treatment control groups. With regard to comparisons with other psychotherapeutic approaches, Henry et al. (12) and Willliams (13) found that behavioral and cognitive therapies were more effective in cases of depression and anxiety disorders, whereas the psychoanalytic psychodynamic approaches were more effective for groups of patients with personality disorders or mixed neurotics.
To this latter conclusion one may add Stevenson and Meares (14) and Higget and Fonagy's (15) findings which have shown that dynamic psychotherapies are effective in treating borderline personality disorders. Stevenson and Meares ( 14) found in a group of 30 borderline (according to DSM-III-R) patients who were treated by psychodynamic psychotherapy ("psychology of the self in its broader sense"), twice weekly for a year, significant improvement in all outcome measures used: number of violent episodes and self harm, time away from work, number of hospital admissions, score on self report index of symptoms and number of DSM-III-R criteria (weighted for frequency severity and duration) fulfilled. Thirty percent of the patients no longer fulfilled the diagnostic criteria of the personality disorder. Improvement in all outcome measures persisted for a year of follow-up.
Henry et al. (12) maintains that there is research bias against the psychoanalytic psychodynamic approaches in outcome studies. This is because these studies, in general, do not include measures that investigate change in personality elements which theoretically are supposed to be improved by psychoanalytic psychodynamic approaches.
A rare example of unproblematic criteria of outcome with regard to psychodynamic approaches is to be found in marital therapy, where the outcome criteria are divorce rates. Snyder et al. ( 16) found that marital therapy that was insight-oriented had a better longterm outcome than behavioral therapy for couples, as measured by their rate of divorce. After four years, the rate of divorce of couples receiving the insight-oriented method was 3% as compared to 38% divorce rate after use of the behavioral method.
The area of short-term dynamic psychotherapy provides another opportunity to test psychodynamic psychotherapies. The fixed time-table and the focality of the method enables standardized investigation. Recently Chrits-Christoph (17) and Shefler et al. (18) found effect size around 1.0 s.d. of therapeutic change following short-term dynamic psychotherapy.
Psychotherapy of eating disorders presents an interesting field of comparing psychotherapies and assessing their specificity. These disorders present, on the one hand, defined and focused symptomatology and, on the other hand, they involve a disturbed personality organization. Until recently, these disorders were mainly the target of cognitive-behavioral research. In the last decade, some studies began to compare the efficacy of cognitive behavioral therapies (CBT) with dynamic ones. Fairburn et al. (19) compared CBT with interpersonal therapy (IPT) and Garner (20) compared CBT with expressive supportive psychotherapy. Somewhat to the surprise of these researchers, the psychodynamic therapies did not fall behind CBT with regard to symptom reduction, but CBT was superior in changing attitudes towards food, and in improving psychosocial skills. Yet, as Henry et al. ( 12) argue, these studies did not include measures which tap characteristics theoretically predicted to be changed following psychodynamic psychotherapy. Bachar et al. (21) compared psychodynamic technique, self-psychology to a cognitive one. (cognitive orientation therapy) in the treatment of bulimia and anorexia. They included a measurement relevent to self-psychology theory - a questionnaire which studies the cohesion of the self. They found that self psychology treatment was superior to cognitive orientation therapy and to control group (nutritional counseling only) both in symptom reduction (effect size of 1.5) and achieving better self cohesion (effect size 1.1).
Psychotherapy in Comparison with Psychotherapeutic Placebo
The concept of psychotherapeutic placebo is interesting. This concept refers to an encounter between psychotherapist and patient which was designed to be placebo, i.e., it included intimacy and warmth but systematic therapeutic work (according to one of the three main methods - dynamic, cognitive or behavioral) was experimentally prevented. The groups which received psychotherapeutic placebo were compared with non-treatment groups and with groups which received systematic therapeutic work using one of the three above-mentioned techniques. Lambert and Bergin (22) summarized studies according to this design. In most of the studies dealing with symptom relief (mainly in depression) they found a fascinating order of improvement: Groups which received real psychotherapy were the most improved. In second place came the psychotherapeutic placebo group, and in the last place was the non-treatment group. This research design proves, on the one hand, the unique contribution of certain psychotherapeutic techniques and, on the other hand, it proves the importance of common, non-specific factors such as relationship, acceptance and warmth.
Durability of Therapeutic Gains Psychotherapy was found effective in follow-up studies over a time span of one week to one year following termination of therapy. These studies point to a high correlation between therapy outcomes and follow-up. (22)
Once a month Psychotherapeutic Maintenance and Prevention of Relapse: Frank et al. (23) studied maintenance strategies for the prevention of relapse in 128 unipolar depressed patients. The inclusion criteria were: at least three recurrent episodes of unipolar depression and complete remission from the acute episode due to pharmacotherapy or psychotherapy. Patients were distributed randomly into five groups:
(1) psychotherapeutic maintenance alone, once a month. The psychotherapy was the interpersonal type (IPT), a kind of humanistic dynamic psychotherapy; (2) psychotherapeutic maintenance plus full daily dosage of imipramine (200 mg a day); (3) psychotherapeutic maintenance plus pharmaco-placebo; (4) imipramine alone; (5) pharmaco-placebo only.
After three years of follow-up, it was found that among the patients who received only placebo, only 20% did not relapse. Among patients who received medication, 80% did not relapse. These two findings are well-known in the literature, but the surprising and interesting finding was that of the patients who received psychotherapeutic maintenance alone, i.e., one session a month, 50% did not relapse.
Another psychotherapeutic approach, the cognitive, was also found effective in preventing relapse after remission from depression (24, 25) Patients treated with cognitive therapy with or without pharmacotherapy were less likely to relapse than patients who were treated with pharmacotherapy alone (26, 24)
Dush et al. (27), in a meta-analytic review, studied the effectiveness of therapists from the viewpoint of patient outcome. They compared therapists from the two possible extremes of experience, i.e., therapists with doctorates and undergraduate therapists. The former achieved results that were seven times more effective than the latter. Such findings have special significance since, conceptually, they resemble studies that compare psychotherapy with psychotherapeutic placebo or wait-list or non-treatment groups.
Orlinsky and Howard (28) carried out retrospective studies on files of 143 patients who were treated by 23 psychodynamicallyoriented therapists. They wanted to study whether clinical success was equally distributed among the therapists. The researchers had set certain criteria: Therapists who had achieved improvement in 70% of their patients with not a single case becoming worse were placed in the "successful therapists" group. At the other extreme were placed therapists with no more than 50% of their patients showing improvement and at least 10% getting worse. The six therapists who had surpassed the criteria for success were the most experienced practitioners. The average rate of their success was 84%. All the "failed therapists" (five in number) were the least experienced and had even poorer results than the criteria set by the researchers for inclusion in the "failed therapists" category. Orlinsky and Howard (28) concluded their study with the thought that if less-experienced therapists had been excluded from outcome studies on psychotherapy, those studies would have yielded much better results. Weisz et al. (29), in a meta-analytic study of children and adolescents, found that among the less experienced therapists or paraprofessionals, better results were achieved when treating younger children, while among the more experienced therapists, there was no such interaction due to the age of the patient. Weisz et al. (29) suggest that the concept of paraprofessional should be modified as they get some supervision even by proxy while they are working within a framework where they listen and study from professionals, and may apply techniques which were designed and instituted by professionals.
Dose Response Relationship
Ricks (30) compared long-term outcomes of two psychodynamically-oriented psychotherapists who worked in an adolescent out-patient clinic. The clinic's population included both less-severely disturbed patients and patients who already, at adolescence, were close to the diagnosis of schizophrenia or were diagnosed as very severe borderline cases. The case load of the two therapists was identical. While there were no differences between therapists in the long run with regard to outcomes of the less severely disturbed patients, there was found to be a very significant difference with regard to the adolescent patients who were at the brink of schizophrenia. Only 27% of therapist A's patients had deteriorated to schizophrenia vs. 88% of the patients of therapist B. When the working habits of A and B were studied, it was found that A had devoted much more time to the most disturbed patients, while B had done the reverse. B seemed terrified by the severe pathology and withdrew emotionally from the severe cases.
It ensues from Rick's observation (30) that devoting more time, attention and dedication in the psychodynamically oriented psychotherapy of disturbed adolescents yielded better response.
Mitchell et al. (31 ) similarly showed that in cognitive behavioral treatment of bulimic patients two weekly sessions of CBT yielded better response (in symptom reduction of binging and purging) then one weekly session of the same technique.
Errors in Technique, Therapists' Characteristics and Therapy Outcomes
Sach (32) found that the factor most associated with negative therapeutic outcome was error in technique. Such errors are assessed by a special scale. The error which was most associated with negative therapeutic outcomes was the therapist's inability to find the central guiding thread of the session. In second place was the therapist's failure to meet patients' negative attitudes towards the therapist and the therapy. The third error was "harmful interventions," which included interpretations with poor timing and/or inadequate interpretations. Luborsky et al. (33), studying nine therapists, listed the therapist variables which were associated with better outcomes in adults who were opiate-dependents. They compared three categories of patients; those who received only drug consultation, those who received psychodynamically-oriented psychotherapy and those receiving therapy using the cognitive technique. The two groups who received the psychotherapeutic addition showed better outcomes than drug consultation alone. Three therapist variables were most associated with success: (1) therapists' readiness to be involved and to help even difficult patients; (2) the purity of the psychotherapeutic technique which the therapist offers (this finding is of special interest, considering modern views that call for combining techniques); (3) the quality of patient-therapist relationships.
Lafferty et al. (34) studied the relationship skills of the therapist via the Bert Leonard Relationship Inventory. Therapist effectiveness was defined according to the extent of symptomatic improvement of his patient on the SCL-90 questionnaire. The psychotherapeutic technique of all therapists in this research was dynamic Rogerian client centered therapy. The researchers had divided 30 therapists according to the degree of improvement or worsening of their patients. Therapists whose patients' condition had worsened in at least one standard deviation were grouped among the ineffective therapists. Therapists whose patients had improved in at least one standard deviation were grouped among the successful ones. Discriminant factor analysis discovered three features associated with therapist effectiveness that would be listed according to their magnitude: (1) ability for empathic listening; (2) therapist attitude, which requires the patient to show great involvement with his therapy; (3) emphasizing reflection in the patient.
Such research strategies reviewed in this paper's previous section which connect errors in technique and therapists' characteristics, on the one hand, and therapy outcome as it is assessed by symptomatic change, on the other, are of special importance. They point out those factors in the therapeutic process which have significance in achieving good outcome, and in this way can further the improvement of therapy. At the same time, they provide another proof of the effectiveness of psychotherapy.
The state of knowledge to date leads to the conclusion that psychotherapy works as an active, defined and predictable agent. The following summary of findings which have been reviewed in the above manuscript support this conclusion.
A. 1. Psychotherapy was more effective than non-treatment or waiting-list groups. 2. A descending order of improvement was found: (a) real, active psychotherapy (psychodynamic, cognitive or behavioral); (b) psychotherapeutic placebo; (c) non-treatment waiting-list groups.
B. Specificity: 1. Certain psychotherapeutic techniques were found to be more helpful in specific disorders; 2. Psychotherapy had a specific advantage over psycho-medication in preventing relapse, particularly when interventions are stopped.
C. Similar effect size to that obtained in other active therapies such as psychotropic medications.
D. Delineation of therapist factors and of factors in the therapy process which were found to be related to therapy outcomes, for example: error in technique, experience of therapist and the kind of involvement of the patient.
E. Dose-response relationship - A positive relationship was found between the amount and intensity of therapy and therapy outcome.
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Department of Psychiatry, Hadassah University Medical Center and Israel Society for Psychoanalytic Psychotherapy, Jerusalem, Israel
Address for correspondence: Eytan Bachar, PhD, Dept. of Psychiatry, Hadassah University Medical Center, POB 12000, Ein Karem, Jerusalem 91120, Israel…
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Publication information: Article title: Psychotherapy-An Active Agent: Assessing the Effectiveness of Psychotherapy and Its Curative Factors. Contributors: Bachar, Eytan - Author. Journal title: The Israel Journal of Psychiatry and Related Sciences. Volume: 35. Issue: 2 Publication date: January 1, 1998. Page number: 128+. © Gefen Publishing House Ltd. 2008. Provided by ProQuest LLC. All Rights Reserved.