Defining Psychotherapy: The Last 25 Years Have Taught Us That It's Neither Art nor Science

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face=+Bold; Defining Psychotherapyface=-Bold; face=+Italic; The last 25 years have taught us that it's neither art nor scienceface=-Italic;

face=+Italic; by face=-Italic; Jay Efran face=+Italic; with face=-Italic; Michael Lukensface=+Italic; and face=-Italic; Mitchell Greene

With managed care looking over our shoulders and an increasingly sophisticated client base forcing us to make sharper distinctions between what we do and the banalities of pop psychology, it's the rare practitioner who hasn't felt the pressure to achieve better, more reliable therapeutic results. In fact, the last 25 years of the history of psychotherapy, commemorated in this special anniversary issue of the face=+Italic; Psychotherapy Networker,face=-Italic; might well be dubbed the field's Age of Accountability. Even the remnants of Freud's adherents have felt the pinch. In his new book, face=+Italic; Practical Psychoanalysis for Therapists and Patients,face=-Italic; renowned analyst Owen Renik argues that the only way to stop his profession's downward spiral is to prove that analysts, too, can produce measurable symptom relief. Recently, the clinical psychology faculty at a nearby university felt obligated to drop the two therapy courses in their program that didn't teach cognitive-behavioral techniques and to focus the curriculum entirely on empirically supported treatments. They told the graduate students that mastering these cutting-edge techniques would put them ahead of the curve, and that they should consider themselves fortunate to be witnessing the end of psychotherapy's "anything goes" era.

Back in 1993, prompted in part by pressure from managed care, Division 12 of the American Psychological Association (APA) created a task force to develop a list of "empirically supported" treatments (ESTs). The attempt to distinguish hype and clinical zealotry from reliable science was aided by legions of aspiring graduate students and their research-savvy professors, who conducted hundreds of psychotherapy outcome studies. Nevertheless, despite all this scientific hoopla, there's still no compelling evidence that therapists are achieving better outcomes today than they did 25 years ago. With rare exceptions, virtually all treatments produce about the same (modest) level of results. For example, in face=+Italic; The Great Psychotherapy Debate,face=-Italic; metanalyst Bruce Wampold reports that meaningful differences between approaches are nonexistent, particularly when the investigators' allegiances are taken into account. Similarly, therapy critics Barry Duncan and Scott Miller report that the equivalence of methods continues to be the "most replicated finding in the psychological literature, encompassing a broad array of research designs, problems, and clinical settings." To this finding, social scientist Robyn Dawes adds that therapist credentials--Ph.D., M.D., M.S.W., or no degree at all--make no real difference in outcome. Evidently, whatever works in therapy has little to do with the specialized knowledge people bring to the enterprise. The hope that therapy manuals would increase treatment effectiveness hasn't been fulfilled either. In fact, according to Duncan and Miller, therapists working from manuals sometimes perform more poorly, perhaps because they've developed "better relationships with their manuals than with [their] clients."

So why, despite all the seeming therapeutic advances and the enormous energy that's gone into establishing therapy as a legitimate science, do we have so little empirically to show for it? In the past quarter-century, we've seen truly stunning advances in medicine, including the completion of the Human Genome Project, the invention of imaging technologies such as the fMRI and the PET scan, the development of drugs to lower cholesterol, the improvement in minimally invasive surgery techniques, the discovery of more specific immunosuppressant drugs for organ transplants, and so on. But, aside from lots of hype and the overheated claims of advocates of the various new methods in the therapy field, what comparable successes can therapists point to? …


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