Does Psychotherapy work?
The short answer is: yes. We know from scientific research that psychotherapy works. Years of careful scientific investigations have clearly demonstrated its effectiveness. Both qualitative and quantitative reviews of thousands of scientific studies have shown that about 75 to 80% of patients who enter psychotherapy benefit from it. This finding generalizes across a wide range of disorders and different therapy formats, including individual, couple, family, and group therapies.
The factors that make it work, however, are harder to explain. A review of the scientific research shows that the key factors for the success of psychotherapy are the relationship between therapist and client, and the customization of the treatment for the individual client. (Cuijpers, et al., 2008, Lambert, 2004; Karver, et al., 2006; Norcross, 2011; Shirk & Karver, 2003; Wampold, 2007 ).
The American Psychological Association (APA) created a task force to examine the factors that are causing the success of psychotherapy. (Norcross, 2011: Psychotherapy Relationships That Work: Evidence-Based Responsiveness (2nd edition.). Oxford University Press, USA). They examined the association between elements of the therapy relationship and treatment effectiveness through several meta-analyses. (A meta-analysis is a study of studies, a research method that aggregates the results of multiple studies on the same topic.) The effectiveness of therapy in these studies is measured by clients’ improved functioning, reduced suffering, physiological indicators, treatment retention, richer interactions with other people, work performance, and other indexes of recovery. The results of about 20+ meta-analyses converge into a series of research-supported conclusions with important consequences for psychotherapists and clients alike. Here are the findings they published: (In Norcross, J. C. 2011)
The therapy relationship makes substantial and consistent contributions to patient success in all types of psychotherapy studied (for example, psychodynamic, humanistic, cognitive, behavioral, systemic).
The therapy relationship accounts for why clients improve (or fail to improve) as much as the particular treatment method.
Practice and treatment guidelines should address therapist qualities and behaviors that promote the therapy relationship.
Practitioners should routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, improve the relationship, modify technical strategies, and avoid premature termination (Lambert, 2010).
Efforts to promulgate best practices or evidence-based practices without including the relationship are incomplete and potentially misleading.
The relationship acts in concert with treatment methods, patient characteristics, and practitioner qualities in determining effectiveness.
A comprehensive understanding of effective (and ineffective) psychotherapy will consider all these determinants and their optimal combinations.
Adapting or tailoring the relationship to several patient characteristics (in addition to diagnosis) enhances effectiveness (as summarized in chapter 13).
Virtual Psychotherapy in the Days of Covid-19
Since March 17, 2020, the day our local shelter-in-place order was implemented, this office has been closed to in-person visits. All psychotherapy has been taking place virtually; mostly over Zoom, sometimes through Skype, and in several cases, via the telephone. This practice will continue for an indeterminate period of time. You will have the option to continue virtual therapy appointments once the shelter-in-place order is lifted.
Psychotherapy via the Internet?
A study found that online psychotherapy is just as efficient as conventional therapy. Researchers at the University of Zurich have conducted a study in order to compare online psychotherapy with conventional face-to-face therapy. Six therapists treated 62 patients, the majority of whom were suffering from moderate depression. The patients were divided into two equal groups and randomly assigned to one of the therapeutic forms. The treatment consisted of eight sessions with different established techniques that stem from cognitive behavior therapy and could be carried out both orally and in writing. Patients treated online had to perform one predetermined written task per therapy unit — such as querying their own negative self-image.
Three months after the end of the therapy, patients with online treatment displayed fewer symptoms than patients treated face-to-face.
“In both groups, the depression values fell significantly,” says Professor Andreas Maercker, one of the investigators. At the end of the treatment, no more depression could be diagnosed in 53 percent of the patients who underwent online therapy — compared to 50 percent for face-to-face therapy.
Three months after completing the treatment, the depression in patients treated online even decreased whereas those treated conventionally only displayed a minimal decline: no more depression could be detected in 57 percent of patients from online therapy compared to 42 percent with conventional therapy.
For both patient groups, the satisfaction with the treatment and the therapists was very high. 96 percent of the patients given online therapy and 91 percent of the recipients of conventional treatment rated the contact with their therapist as “personal.”
In the case of online therapy, the patients tended to use the therapy contacts and subsequent homework very intensively to progress personally. For instance, they indicated that they had re-read the correspondence with their therapist from time to time.
“In the medium term, online psychotherapy even yields better results. Our study is evidence that psychotherapeutic services on the Internet are an effective supplement to therapeutic care,” concludes the study.
The study is probably based on a sample that is too small. It would also be important to know how these patients were selected and instructed about the study. Did they have other therapy before or after the study was conducted, and how did the therapy methods compare between the online group and the in-person group? It’s the same problem with all psychotherapy research – questionnaires are not enough.
Nevertheless, the findings are a good starting point for a broader discussion. As the second article under “References” shows, web-based psychiatry (Telepsychiatry) is taking off, but it consist mainly in online consultations with a psychiatrist for medication decisions. Online psychotherapy is more difficult, but in principle just as good as in-person meetings. The advantage is that we can reach remote populations, and extent badly needed mental health services everywhere. The obstacle is the licensing process: as a therapist licensed in California, I am currently not allowed to treat a patient in New York via online technology. if it were allowed, it would greatly increase competition among therapists and licensing bodies. What would happen to New York therapists who charge $250 an hour? I hope the laws that regulate these new avenues for psychotherapy will soon get created.
Birgit Wagner, Andrea B. Horn, Andreas Maercker, Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial, Journal of Affective Disorders, 2013. DOI: 10.1016/j.jad.2013.06.032
Getting the most out of Therapy
Psychotherapy may not cure your condition or make an unpleasant situation go away. But it can give you the power to cope in a healthy way and to feel better about yourself and your life.
Here are a few tips to get the most out of the process:
You should feel comfortable with your therapist. If you don’t, look for another therapist with whom you feel more at ease.
Approach therapy as a partnership. Therapy is most effective when you’re an active participant and share in decision making. Make sure you and your therapist agree about the major issues and how to tackle them. Together, you can set goals and measure progress over time.
Be open and honest. Success with psychotherapy depends on your willingness to share your thoughts, feelings and experiences. It also depends on your willingness to consider new insights, ideas and ways of doing things. If you’re reluctant to talk about certain things because of painful emotions, embarrassment or fears about your therapist’s reaction, let your therapist know.
Stick to your treatment goals. If you feel down or lack motivation, it may be tempting to skip psychotherapy sessions. Doing so can disrupt your progress. Try to attend all sessions and to give some thought to what you want to discuss.
Don’t expect instant results. Working on emotional issues can be painful and may require hard work. It’s not uncommon to feel worse during the initial part of therapy as you begin to confront past and current conflicts. You may need several sessions before you begin to see improvement.
Continue to work between sessions. If your therapist asks you to document your thoughts in a journal or do other activities outside of your therapy sessions, follow through. These homework assignments can help you apply what you’ve learned in the therapy sessions to your life.
If psychotherapy isn’t helping, talk to your therapist. If you don’t feel that you’re benefiting from therapy after several sessions, talk to your therapist about it. You and your therapist may decide to make some changes or try a different approach that may be more effective.
What makes a good therapist?
We know that psychotherapy works across all modalities for about 75 to 80% of all clients. The therapeutic relationship itself is key to the success of the process. Therefore, the next question is: What makes a good therapist? A review of the existing research was summarized by Bruce Wampold into the following traits of a good psychotherapist: Wampold, B. E. (2013). The Great Psychotherapy Debate: Models, Methods, and Findings (Counseling and Psychotherapy: Investigating Practice from Scientific, Historical, and Cultural Perspectives) (1 edition.). Routledge.
Has a sophisticated set of interpersonal skills.
Builds trust, understanding and belief from the client.
Has an alliance with client.
Has an acceptable and adaptive explanation of the client’s condition.
Has a treatment plan and allows it to be flexible.
Is influential, persuasive and convincing.
Monitors patient progress.
Offers hope and optimism (realistic optimism, not euphemisms).
Is aware of a client’s characteristics in context.
Relies on best research evidence.
Continually improves through professional development.
Scientific research demonstrates that psychotherapy with an effective therapist works even better in the long-term and its effects are more enduring than medication. Psychotherapy is not only more cost-effective, but it leads to fewer relapses of anxiety or mild to moderate depression than medication use alone.
We live in a world saturated by advertisement. Pharmaceutical companies promise you quick fixes, and taking a pill is faster than seeing a therapist once a week for an hour. The evidence shows is that pills don’t work as well as therapy. Based on these findings, the Norwegian Health Authorities have already issued guidelines concerning the treatment of mild to moderate depression and anxiety, and they suggest that psychological interventions, not medications, should be applied first.
Psychotherapy should be the preferred treatment for most non-psychotic conditions, but major pharmaceutical companies heavily market their medications directly to the public and to health professionals, which creates false expectations in clients, and a strong demand for chemical fixes in people affected by anxiety or other emotional problems. Therapy gets sharper, more effective, and more enduring, but it continues to lose influence in the mental health field to medication-based approaches, which are also propagated by psychiatrists.
The goal is to make psychotherapy a first-line treatment for people who seek help. Eventually, people will realize that eating pills is not a solution to their life problems. Finding a good therapist can really be a life-changing event.
The Ethics of Psychotherapy
The practice of psychotherapy is governed by many rules. It is a medical procedure, and health insurances reimburse for it, which requires a legal and bureaucratic framework. For psychotherapy to be effective, the therapist must follow particular rules of engagement, for instance not to talk about himself too much during the therapy sessions (so-called "self-disclosure.") Therapists should also avoid dual relationships with clients (don't socialize with your client, etc.)
Ethical rules for psychotherapy build upon the body of principles established over the centuries by the healthcare professions. It begins with the ancient Greek Hippocratic Oath that defines the relationship between the doctor and the patient. It commits the doctor to have utmost respect for human life and to treat the whole person, not just a symptom.
The code of professional conduct for psychotherapists goes even further. Psychotherapy is a talking cure, therefore the ethics of psychotherapy is an ethics of speech. The therapist’s adherence to ethical standards is not external to the procedures applied; it is itself a necessary condition for the success of psychotherapy. Ethical rules are the guideposts for psychotherapeutic methods and techniques.
In the actual application of psychotherapy, scientific, therapeutic, legal and ethical principles all have to work together. These rules inform all aspects of the treatment: therapeutic choices as well as practical arrangements. The basic principle behind psychotherapy is the recognition that the therapist-patient relationship is itself the vehicle for important feelings, thoughts, and beliefs, and therefore it needs to be carefully set up and protected. Guarding the patient’s confidentiality, for instance, is essential for the development of trust and for the therapeutic outcome of the treatment. These boundaries protect the process; understanding them clearly is a condition for the therapeutic relationship to evolve.
The most authoritative resource for the ethical guidelines is the Code of Conduct for Psychologists compiled by the American Psychological Association.
American Psychiatric Association - The American Psychiatric Association, founded in 1844, is the world’s largest psychiatric organization. It is a medical specialty society representing more than 33,000 psychiatric physicians from the United States and around the world.
American Psychoanalytic Association - This website contains many useful articles about psychotherapy, and gives an overview of psychoanalysis in America.
American Psychological Association - The American Psychological Association is the largest scientific and professional organization representing psychology in the United States. APA is the world's largest association of psychologists, with more than 134,000 researchers, educators, clinicians
Counseling California - Resources for Clients. - Information for Patients and people who seek psychological help. Good information resource, as well as a directory of qualified marriage and family therapists in California.
Ethical Standards for Psychologists - The official page from the American Psychological Association, APA.
The British Psychological Society - Explains scientific psychology and the field of psychotherapy.