The Story of Psychology (118 page)

“The sky fell in,” he later commented. “I immediately made enemies of Freudians, of psychotherapists, and of the great majority of clinical psychologists and their students.”
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As was to be expected, many of his newly made enemies—including prestigious names in British and American psychology—wrote angry replies. Anger aside, they had good grounds for discrediting his findings, and published rebuttals in a number of leading British and American psychology journals. Their most telling criticisms were that Eysenck had lumped together data derived from different forms of therapy, different kinds of patients, and different definitions of improvement; moreover, the untreated group was not truly comparable to the treated groups.
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Still, he had thrown down the gauntlet; it was now up to those who believed in psychotherapy to prove that it was effective, a task they had never seriously undertaken.

Ever since, there has been a steady flow of psychotherapy outcome studies—many hundreds, in fact—differing greatly in scientific quality, in the size of the samples studied, in the criteria of improvement, and in the use or lack of use of control groups. Their findings, accordingly, have shown great variation.

But meta-analyses that rate the studies by scientific quality, adjust for differences in method, and only then sum up the results, have repeatedly found that the weight of evidence is clearly in favor of psychotherapy. In 1975, a painstaking meta-analysis of nearly a hundred controlled studies, by Lester Luborsky of the University of Pennsylvania, concluded that most of them found a high proportion of patients benefiting from psychotherapy. And, contrary to Eysenck’s claim, two thirds of the studies showed that significantly more treated than untreated patients improved.
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(If studies involving minimal treatment had been excluded from the Luborsky review, the superiority of therapy over no therapy would have appeared still greater.)

A comprehensive review of outcome studies made in 1978 by a team at the National Institute of Mental Health came to a similar conclusion.
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In 1980 a still more comprehensive meta-analysis by another team of psychologists reviewed and evaluated the findings of 475 studies, using a wide range of outcome measures to compare the experience of patients who received psychotherapy with untreated members of control groups. Its conclusions were unequivocal: Therapy yields benefits in most, though not all, cases.

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.
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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.
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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.
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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 guidelines based on treatments of mental disorders that have been empirically proven effective. Paul Crits-Christoph calls this movement “the biggest change in therapy of the last ten years.”

That’s a change? Haven’t psychotherapists always been guided by the evidence of outcomes of various forms of treatment? Yes, by the outcomes of their own practices. But no, not by empirical research studies. The editors of
A Guide to Treatments That Work
, a massive 2002 review of empirical studies of psychotherapies and psychotropic medications, acerbically note the “lamentably low value psychotherapists and other mental health professionals more generally continue to attach to psychotherapy research… The clinical activities of most psychotherapists remain largely untouched by findings from empirical research. Many clinicians continue to utilize methods and procedures that lack empirical support.”
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One reason for this is the well-documented phenomenon known as the “expectancy effect.” Therapists (like physicians and scientists) tend to see the results, in their own work, that they expect to see. The results reported by any therapist based on his or her own practice fall far short of the guidelines of scientific rigor. To be genuinely empirical, evidence must be produced by impartial researchers, and by comparing the outcome in a treated group with that in a control group (a strictly similar but untreated group), which enables the researchers to subtract the expectancy effect, the placebo effect, and other distortions from the apparent effect of treatment.

When the APA’s Division of Psychotherapy raised the issue of evidence-based therapy a decade ago, there was a fierce backlash from therapists who feared they would be controlled by managed care officers who would refuse to reimburse them if empirical evidence did not back up the therapy they preferred to use. A heated debate—a “major controversy,” according to an APA Web page offering a course in evidence-based psychotherapy—has continued ever since.

Yet the concept of empirical evidence as a guide to treatment is not new; in medicine it goes back a century or more, and it has been part of the world of psychotherapy for decades. “What’s different today,” says Crits-Christoph, “is that the label ‘evidence-based therapy’ now has political clout. From the early sixties through the nineties there was no process for turning research into practice. No one was pressuring anyone to sign on the dotted line that you would translate empirical research findings into practice.” In England, under socialized medicine, evidence-based therapy is enforced; here, it is beginning to be enforced by managed care providers—and by moral suasion.

For despite the resistance to the evidence-based movement, says Crits-Christoph, “It has raised consciousness of the importance of empirical evidence. The concept of evidence-based therapy has become a fundamental guiding principle. It’s getting very hard to disagree with the idea that empirical evidence should shape practice.”
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Very hard to disagree with the idea—and with the evidence assembled in
A Guide to Treatments That Work
(and other more recent compilations). The
Guide
presents the results, primarily of rigorous studies plus some less than rigorous, of dozens of pharmacological and psychotherapeutic treatments of over two dozen major disorders. We heard above of some of the treatments that work; here are a few others:

All of which is as convincing an answer to the question “But does it really work?” as anyone could ask for.

The new forms of outcome research and the moral (and financial) pressure of the evidence-based ethos are making psychotherapy, in alliance with psychopharmacology, increasingly scientific and increasingly effective. Perhaps even the specter of Wundt, were he presented with the data, might relax his dark scowl and grudgingly nod approval.

W
hatever the phantom of Wilhelm Wundt might think of present-day clinical psychology, the flesh-and-blood Wundt was incensed at the sight of his science put to other disgracefully practical uses—and by some of his favorite students.

One of them, Ernst Meumann, committed what Wundt saw as apostasy, abandoning pure research in order to apply psychological principles to education. Even worse, two others hawked their knowledge to business and the public. In 1903 Walter Dill Scott, a professor at Northwestern University, published a book on the psychology of salesmanship and advertising, and in 1908 a prize pupil of Wundt’s, Hugo Münsterberg, whom William James brought over to be director of the psychology laboratory at Harvard, published a book on the psychology of courtroom testimony and in 1915 another on applications of psychology to everyday problems.