Is Psychotherapy Behind The Times, Or Just What You Need?
Making sense of the arguments about science in psychology
Posted Nov 24, 2009
Let's say that you, the average person, have an emotional problem you want help with. You decide that you need not only the opinion of an objective third party, but the expertise of a psychological professional. You look for therapists either by a personal referral or through your health insurance network. You find someone who has an opening for an appointment and you go to your first session. How do you know that this therapist can really help you?
This is the subject of a recent Washington Post article by Timothy Baker, Richard McFall and Varda Shoham. This provocative commentary claims that many doctoral programs in psychology are not training qualified practitioners who can adequately conduct psychotherapy. As a consequence of their education, few therapists are trained in clinical practices that are considered more effective than conventional therapy, for example, exposure therapy for post-traumatic stress disorder or other behavioral modification methods. The authors go on to report that "graduate programs in psychology do not select science oriented students to begin with and do not train students to understand and use science once they are involved."
But what is the science of psychology?
For many therapists these days, science in psychology is ubiquitous with cognitive and behavioral therapy approaches. CBT is often recommended for an array of common mental disorders. However, there is no overwhelming evidence that CBT is the most effective treatment for many complex mental illnesses that we therapists see in our clients and patients. In an important article on this topic, Ronald Levant (2004) observes that "ideal" CBT patients tend not to be the ones that show up in our offices everyday, and that the theories behind CBT don't explain what it is in psychotherapy that helps people get better.
For example, Levant points out:
-Specific techniques account for about 15% of how we explain therapy outcomes.
-"Therapeutic relationship" (involving a patient's feelings about their therapist as a person, and what is shared among all therapeutic techniques) accounts for about 30% of therapy outcomes.
-Randomized Controlled Trials on which CBT studies are based, may lack external validity (meaning they don't generalize to the real world), because manuals are used in studies that often don't mirror what is said to patients in real world practice.
-The majority of patients are excluded from typical studies. Why? Because to participate in these studies, an emotional condition has to meet specific criteria. Patients recruited for these studies can only have one "Axis I disorder," such as depression, generalized anxiety disorder, panic disorder, and post-traumatic stress disorder. Yet, less than 20% of all mental health patients have only one Axis I disorder. Comorbidity excludes over 75% of patients in most studies because many individuals have more than one kind of psychological disorder; for example, many people with depression also have generalized anxiety disorder, based on our diagnostic system.
So what this all means is that although CBT is useful for some patients, most of the people who come to us for treatment have multiple and complex conditions. In my clinical practice, many of my clients are confronting demands related to aging and/or illness. These real world problems are what cause people to experience many kinds of symptoms, often those that cannot be addressed by straightforward CBT approaches. Many of my patients simply don't have the energy to do all that's required for cognitive behavioral therapies, which often requires "homework," the practice of particular skills, not to mention the stress associated with the "exposure therapy" referred to by the Washington Post authors.
The Baker, McFall and Shoham article ends by saying there are many "highly effective treatments" for mental disorders. Their critique implies that anything not "scientific" shouldn't be considered as a valid way to carry out psychotherapy. However, there is ample research supporting a variety of different approaches to psychological issues and conditions.
CBT offers great tools for changing unwanted behaviors, and when I see how some people benefit from them, I am grateful that these methods are available. But this is a small minority in my practice. And in my experience, long-term approaches, such as psychodynamic psychotherapy, are more effective for most of the people who come to therapy for real change. An In Press article in the American Psychologist by Jonathan Shedler describes how a "one size fits all" approach for psychotherapy is simply incorrect. Equally as important, longer-term approaches have scientific backing too.
Unfortunately, Baker, McFall and Shoham conflate the issue of scientifically informed psychotherapy with the differences in training between the different doctoral degrees.
As for the Psy.D./Ph.D. controversy, which I expect will be an ongoing issue, my experience as a psychotherapist, educator and writer of psychology is that these debates have a perennial nature. And now, with the precarious future of both healthcare and clinical research, it is not surprising that this issue is being debated again. In such an uncertain climate, threats to our profession can feel overwhelming. Just last week, Medicare announced potential cuts for specialist services. We are all worried about what the current healthcare bill and the economic climate will mean for the treatment of our patients. While I do not blame the authors of the Washington Post article for expressing their views, to do so by critiquing one small aspect of the vast field of psychological research and discrediting the intensive education of Psy.D. programs does a disservice for all of our friends and neighbors seeking psychological help and treatment.
For more comments and discussion of the Washington Post article, see Letters To The Editor, including a response from James Bray and Norman Anderson of the American Psychological Association.
Levant, R. (2004). The Empirically Validated Treatments Movement: A Practitioner/Educator Perspective, Clinical Psychology: Science and Practice, 1(1), 219-224.
Shedler, J. (2009) The efficacy of Psychodynamic Psychotherapy. American Psychologist, In Press.