Which Psychotherapies Work Best?
The early statistical summaries and surveys did not find that any one type of psychotherapy is generally superior (Smith & Glass, 1977, Smith et al., 1980). Later studies have similarly found little connection between clients’ outcomes and their clinicians’ experience, training, supervision, and licensing (Barth et al., 2013; Cuijpers, 2017; Kivlighan et al., 2015). A Consumer Reports survey confirmed this result. Were clients treated by a psychiatrist, psychologist, or social worker? Were they seen in a group or individual context? Did the therapist have extensive or relatively limited training and experience? It didn’t matter. Clients seemed equally satisfied (Seligman, 1995).
“ Different sores have different salves.”
English proverb
So, was the dodo bird in Alice in Wonderland right: “Everyone has won and all must have prizes”? Not quite. One general finding emerges from the studies: The more specific the problem, the greater the hope that psychotherapy might solve it (Singer, 1981; Westen & Morrison, 2001). Those who experience phobias or panic, who are unassertive, or who are frustrated by sexual performance problems can hope for improvement. Those with less-focused problems, such as depression and anxiety, usually benefit in the short term but often relapse later. There often is also an overlapping or comorbidity of disorders.
Nevertheless, some forms of therapy do get prizes for effectively treating particular problems:
- Cognitive and cognitive-behavioral therapies—anxiety, posttraumatic stress disorder, insomnia, and depression (Qaseem et al., 2016; Scaini et al., 2016; Tolin, 2010).
- Behavioral conditioning therapies—specific behavior problems, such as bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions (Baker et al., 2008; Hunsley & DiGiulio, 2002; Shadish & Baldwin, 2005).
- Psychodynamic therapy—depression and anxiety (Driessen et al., 2010; Leichsenring & Rabung, 2008; Shedler, 2010b).
- Nondirective (client-centered) counseling—mild to moderate depression (Cuijpers et al., 2012).
The evaluation question—which therapies get prizes and which do not?—lies at the heart of what some call psychology’s civil war. To what extent should science guide both clinical practice and the willingness of health care providers and insurers to pay for psychotherapy? On one side are research psychologists using scientific methods to extend the list of well-defined and validated therapies for various disorders. They decry clinicians who “give more weight to their personal experience than to science” (Baker et al., 2008). On the other side are nonscientist therapists who view their practice as more art than science: People are too complex and psychotherapy is too intuitive to describe in a manual or test in an experiment. Between these two factions stand the science-oriented clinicians calling for evidence-based practice, which has been endorsed by the American Psychological Association and others (2006; Lilienfeld et al., 2013). Therapists using this approach integrate the best available research with clinical expertise and with patient preferences and characteristics (Figure 72.2). After rigorous evaluation, clinicians apply therapies suited to their own skills and their patients’ unique situations. Increasingly, insurer and government support for mental health services requires evidence-based practice.
Figure 72.2 Evidence-based clinical decision making
The ideal clinical decision making can be visualized as a three-legged stool, upheld by research evidence, clinical expertise, and knowledge of the patient.