Story of Psychology - Morton Hunt [398]
Psychotherapy benefits people of all ages as reliably as schooling educates them, medicine cures them, or business turns a profit …The average person who receives therapy is better off at the end of it than 80% of the persons who do not. This does not, however, mean that everyone who receives psychotherapy improves. The evidence suggests that some people do not improve, and a small number get worse.116
But one aspect of the findings of these meta-analyses seemed baffling: All forms of therapy appeared to benefit about two thirds of the patients. Yet if each kind of therapy works for particular reasons—as spelled out by the theory it is based on—how could all work equally well? Luborsky’s team wondered whether it was really true that, as in the dodo bird race in Alice in Wonderland, “everyone has won and all must have prizes,” and concluded that it did seem to be true. Their explanation was that there are common components among the psychotherapies, most notably the helping relationship between therapist and patient. Other researchers pointed to other common factors, especially the chance to test reality in a protected environment, and the hope of relief, generated by therapy, that motivates the patient to change.
Yet the dodo bird hypothesis is exceedingly counterintuitive; common sense and lifetime experience tell us it is most unlikely that despite the great differences in therapeutic methods, they all work equally well for all conditions. The meta-analyses assure us that psychotherapy does work, but the overall figures they give do not link particular techniques to the outcomes of particular disorders. Moreover, they average out the results achieved by different therapists in each study.
Luborsky and colleagues, seeking to demystify their own findings, did a later study of therapists who used three different approaches in treating drug-dependent patients and found that the choice of therapy was less important than the personality of the therapist.117 More important has been the development, in recent years, of a genre of outcome studies that test the results of specific techniques in the treatment of specific disorders. Such research has furnished ample evidence that certain forms of therapy are anywhere from somewhat to much more effective than others in the treatment of particular conditions.
We have already heard of some of these results; among others, a technique known as “cognitive-behavioral treatment with response prevention” is markedly superior to other methods of treating OCD (obsessive-compulsive disorder); CT with exposure to a feared object or situation yields better results with anxiety disorders than other methods; psychodynamic therapy is effective in the treatment of depression if the therapist is a warm and supportive person (but, overall, CT and interpersonal therapy do as well); both CT and CBT are more effective than medication in the treatment of anxiety symptoms; CBT is more effective than medication for treating insomnia; and similar findings show other techniques to be especially effective with other disorders.118 Some of these results have been further substantiated by cognitive neuroscience: Brain scans have shown, for instance, that CBT produces changes in the brain of a depressed patient quite different from those of medication. Both methods relieve symptoms, but medication produces a bottom-up change while psychotherapy produces a top-down and hence more lasting change.119
The new outcome studies are, moreover, part of a movement within medicine and psychotherapy known as “evidence-based treatment.” In recent years the American Psychological Association, the American Psychiatric Association, the U.S. Agency for Health Care Policy and Research, and several managed care companies all have proposed psychotherapy practice