Last updated: Aug 22, 2008
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Ever wonder if your shrink really understands what's going on with you?
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Psychotherapy is a multibillion-dollar industry—Americans spent nearly $9 billion on it in 2004—whose product is difficult to quantify. So its only natural for us to wonder what we're getting for our money.


Does psychotherapy work? The short answer is yes. “Psychotherapy is remarkably effective,” says Bruce Wampold, PhD, a professor of counseling psychology at the University of Wisconsin-Madison. “For almost all mental disorders, its as effective as medication—and its longer lasting. People become resistant to medication, but they dont get resistant to psychotherapy.”

Beyond that, the questions get trickier. There are hundreds of variations of psychotherapy—are some better than others? Which treatment is best for depression? Which is best for anxiety disorder? Which is best if you are depressed and anxious? Patients and therapists—not to mention insurance companies—increasingly want to know the results they can expect when they match a treatment to a condition, but the answers to such questions are hard to pin down.

In the mid-1990s, the American Psychological Association (APA) took a step toward answering them when it issued a list, which it has continued to update, of treatments supported by empirical evidence. To make the cut, a treatment has to have been proven beneficial (that is, better than no treatment at all) in at least two scientific studies, and it must also have a written manual that enables other therapists to apply it consistently to clients with similar conditions.

These guidelines have helped fuel a trend in recent years toward “evidence-based” psychotherapy. The growing body of research evaluating the effectiveness of the various therapeutic techniques is more influential than ever. The U.S. Department of Health and Human Services has created a registry for evidence-based treatments that rates the quality of research supporting the treatment on a 0–4 scale, and some insurance companies and state health-care systems (such as the one in Oregon) have altered their reimbursement policies to favor evidence-based therapies.


Psychoanalysts vs. cognitive therapists
The new emphasis on evidence in assessing psychotherapy has led to a deep rift among therapists, partly because some types of therapies have benefited from this trend more than others.

Cognitive-behavioral therapy (CBT), for instance, is the king of the evidence-based therapies. A brief, focused treatment geared toward relieving a patients immediate symptoms, CBT has been studied more than 300 times; its success in these trials largely accounts for its skyrocketing popularity.

Several studies have suggested that CBT is at least as effective as antidepressants for patients with major depression, and researchers have reported promising results for anxiety disorders as well. CBT also appears to be especially effective in the long term: A 1998 review of several CBT studies found that patients who are successfully treated with cognitive therapy are about half as likely as patients taking antidepressants to relapse after the end of treatment.

Now CBT is looking to expand its reach. Nearly 150 clinical trials are currently under way to determine CBTs effectiveness for conditions ranging from gambling addiction to chronic pain.

Psychodynamic psychotherapy, a more traditional school of therapy derived from psychoanalysis, has not fared as well under the new evidence-based paradigm. Though it is among the most common types of therapy, there is less evidence for its efficacy than there is for CBT. Studies showing that psychodynamic therapy is effective at relieving symptoms of mood disorders in both the short and long term do exist, but there are far fewer of them and they tend to be on the small side. In one study comparing a group of patients who underwent long-term psychodynamic therapy with a group that received no therapy at all, three-quarters of the therapy patients showed a significant improvement in their symptoms, while there was no significant improvement in the control group. But the study included just 55 patients.

Psychodynamic treatments are at something of an unfair disadvantage in this respect, according to Prudence Gourguechon, MD, president of the American Psychoanalytic Association. "Something that is ‘evidence-based is much more amenable to large-scale data collection, large-scale payment programs—anything that is large," says Dr. Gourguechon. "And psychoanalysis is a very individualistic thing. It is the smallest enterprise: one analyst and one patient trying to understand what has caused the patients suffering and how it can get better."


Can you even measure mental health success?
One of the weaknesses of the evidence-based approach is that psychotherapy is by nature very challenging to study in a trial. Psychotherapy, unlike handing pills out to patients, is difficult to standardize, since the skill of the therapist and whats actually covered in the sessions varies from case to case.

Some experts feel that CBT has earned its reputation as a highly successful evidence-based therapy mainly because it is particularly well-suited to the randomized controlled trial (RCT), which is considered the gold standard for scientific study and is used to test new drugs.

Unlike psychodynamic therapies and psychoanalysis, which can go on for months or even years, the average length of a CBT treatment is about four months of weekly sessions—a perfect amount of time for a controlled trial. CBT, moreover, is a highly structured therapy with specific "lesson plans" for each session, which makes it easy to write manuals and ensure that each patient receives approximately the same treatment. (The limited number of sessions and standardized treatment has also made CBT attractive to insurance companies, incidentally.)

Even CBT therapists concede that this is a factor. "We certainly have many scientific studies that show effectiveness," says Aldo Pucci, PsyD, president of the National Association of Cognitive-Behavioral Therapists. "The reason we do is because cognitive-behavioral therapies are much more conducive to being researched. Im not in a position to say that we have a great deal of evidence that cognitive-behavioral therapy is more effective than other approaches, such as psychoanalysis."

Dr. Gourguechon believes that the definition of evidence should be expanded to reflect the aspects of psychoanalysis and other treatments that are difficult to capture in a scientific study. “I dont know if doing a full RCT of psychoanalysis is impossible, but it seems almost impossible to me,” says Dr. Gourguechon. “There are certain kinds of treatments that just dont lend themselves to that kind of study. So are you willing to accept a different kind of evidence, like anecdotal studies or case studies?” She adds, “There are some medical-economic interests that prefer to limit evidence to randomized controlled trials.”

Trust your gut when it comes to therapy
If youre shopping around for a therapy or wondering whether the therapy youre in now is a good fit, dont ignore the research—but dont follow it blindly either. Most therapists agree that, regardless of your symptoms or what the research shows, its far more important to find a skilled and experienced therapist with whom you connect.

Its important to remember that talk therapy, no matter how structured and studied it may be, is not a pill.

“The idea that psychotherapy is like medicine, that theres one treatment thats better for a particular disorder because it focuses on the particular deficit—like antibiotics for a gastric ulcer—is a myth,” says Wampold. “Thats not true in psychotherapy. Whats really important is the therapist.”