Despite the solidity of Christensen and Jacobson's findings, a long
line of scientists take issue with their conclusions. Psychotherapy
researcher Kenneth Howard, professor of psychology at Northwestern
University, argues that "it is not possible to test treatment in a lab
model." In other words, you can't study psychotherapy in controlled
clinical trials the way medical research does. "You or I would never
volunteer for a study involving nonprofessionals, so why would anyone
else?" Better are naturalistic studies of cases from everyday
practice--like one of his own. It shows, he says, that experienced
therapists progress more than inexperienced therapists in the first three
sessions. But the inexperienced ones catch up by about the sixth
session.
Naturalistic research does not necessarily support Howard's
optimism for psychotherapy. In a review of child psychotherapy research,
John Weisz, professor of psychology at UCLA, found that child
psychotherapy actually works only in lab settings. When child
psychotherapy is studied in "real life" it shows no benefits.
Whether professionals do better than paraprofessionals is
irrelevant, Howard insists. He worries that Americans' overall health
will be affected by the Clinton health care reform plan, which may limit
access to psychotherapy by limiting coverage.
States Christensen, "If you are concerned about access to care,
then a crucial question is who can provide the care. If only a small
group of people can, then access is going to be limited automatically.
But if a much larger group can provide care, then the benefits are much
greater."
Wait a minute, says Larry E. Beutler, Ph.D., editor of the journal
of Consulting and Clinical Psychology, the leading journal of
psychotherapy research. Most psychotherapy research, including the
studies cited by Christensen and Jacobson, look at only half the
question.
The full answer will come only from asking who is getting the
psychotherapy and just what kind of therapy are they getting, Beutler
argues. What's needed are "matching" studies that figure out which
treatments work for which clients. Then services can be tailored to
people based on the characteristics of clients, not of experts.
Jacobson's concern goes beyond any difference training or matching
makes. As a practicing therapist (as is Christensen), he asks whether
behavior changes even temporarily. The National Mental Health
Association, a mental health lobby, recently reported that mental health
professionals have an 80 percent success rate in treating
depression.
Jacobson points out that some studies declaring "success" measure
how many patients return to a healthy state--that's called clinical
significance. Other studies measure only whether improvement has
occurred--called statistical significance. At the end of treatment a
severely anxious person maybe improved--a statistical difference--but
still a long way from a functional state--clinical significance.
When he applies the clinical-significance standard, psychotherapy
shows disappointingly low success rates--and so does drug therapy--for
treating marital distress, agoraphobia, and children's disorders, among
others. "All the treatments are pretty weak. Some patients get better
without treatment," he explains.
A new study of depression treatment by the National Institute of
Mental Health puts the success rate--for drugs or psychotherapy--at 19 to
30 percent. "My mother wonders what I get paid for if this is the best I
can do," quips Jacobson.
So how can 40 million Americans get effective help without breaking
the public or private bank? The answer lies in examining what makes
people get better--not what psychotherapy can do to help. it is
indisputable that solving mental health problems--with psychotherapy,
computer programs, or help cleaning your house--offers many benefits. It
saves employers money by reducing sick days, improves physical health,
reduces doctor visits, and reduces violence and abuse.
Sometimes psychotherapy does the trick; sometimes less costly
approaches work. It depends on the person and the problem.
However psychotherapy works--whether it heals, or even treats, what
ails you--people want it and like it. (There's research that says so.) On
the average, psychotherapy offers more benefits than no therapy--it just
may be that much simpler interventions yield similar results.
CARTOON
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