Questions on the Couch: Researchers Spar over How Best to Evaluate Psychotherapy

Article excerpt

These are the times that try psychotherapists' souls. Federal and state mental-health budget cuts have reduced the number of people who can afford one-on-one psychotherapy sessions to address their problems. Managed care companies demand to see proof that various psychological treatments work, and even then, they reimburse the cost of 2 or 3 months of psychotherapy at most. Meanwhile, in slick television commercials and in the pages of magazines, pharmaceutical firms tout pills for depression and other mental ailments as superior to old-fashioned talk therapy. Although psychiatrists, who are physicians, can prescribe these drugs, most psychotherapists--including psychologists, social workers, and clergy--cannot.

Today, the financial survival of any medical treatment or procedure rests on published evidence for its effectiveness. In that environment, the science of psychotherapy has assumed special urgency. Psychologists with backgrounds in both research and treatment stand at ground zero of efforts to conduct psychotherapy studies and then integrate the findings into clinical practice.

In August, the American Psychological Association (APA) in Washington, D.C., approved a policy statement on "evidence-based practice in psychology." An 18-member committee of researchers and clinicians concluded that psychotherapists should monitor scientific evidence of the effectiveness of treatments for specific mental conditions. Data could then be weighed against their own judgment on how to treat particular patients. Treatment needs to address such vital issues as a patient's personality traits, ethnic background, and religious beliefs, the committee added.

APA President Ronald F. Levant, a psychologist at the University of Akron in Ohio, sponsored the initiative as a way to broaden the definition of scientifically grounded psychotherapy. The impetus was largely economic. To the chagrin of many clinicians, various funding agencies and insurers are beginning to restrict reimbursements so that the only treatments eligible are the 2 dozen or so deemed "empirically supported" by APA's Society of Clinical Psychology in 1998.

The list of science-backed psychotherapies emphasizes a handful of approaches grounded in concrete procedures that are described in training manuals. For instance, in cognitive therapy for depression, a therapist assists patients in identifying and correcting faulty beliefs, such as a tendency to regard any setback as confirmation of one's failure as a person. Cognitive therapy includes homework assignments, for instance, a patient trying out a challenging new hobby and monitoring negative thoughts as they crop up.

In practice, clinicians usually encounter patients who display multiple problems and therefore need more than the "brand name-therapy" options on the 1998 list, remarks Carol D. Goodheart, a clinical psychologist in Princeton, N.J., who headed APA's latest evidence-based-practice committee. The new APA statement represents a step toward much-needed explorations both of what makes for effective psychotherapy "in the field" and of how much practitioners know about science-endorsed approaches, Goodheart says.

The sticky issue of how to define evidence-based practice is far from settled. Psychologist Larry E. Beutler of the Pacific Graduate School of Psychology in Palo Alto, Calif., who helped assemble the 1998 list of approved treatments, argues that APA'S new policy statement mistakenly gives clinical judgment equal status with scientific findings. He suggests that it's a "political concession" to the organization's predominant membership of psychotherapy practitioners rather than researchers. However, even members of Goodheart's committee disagree sharply about the direction psychotherapy research should take.

"Evidence-based practice is the most consequential, incendiary topic in mental health in recent years," says psychologist John C. Norcross of the University of Scranton in Pennsylvania. …