Effectiveness of Psychological Treatment Research Paper

2. The Definition Of Psychotherapy

In general, psychological treatment is a method designed to change a person’s thoughts, feelings, or behaviors with the intention of facilitating increased functioning and life adjustment. Approaches to psychotherapy are numerous and diverse including such orientations as cognitive, behavioral, client centered, gestalt, and existential therapies. All of the various approaches involve a confiding relationship with a trained therapist focused on a patient in need of assistance.

3. The Effectiveness Of Psychotherapy

As mentioned above, the conclusion made by Eysenck stimulated both the frequency and quality of studies designed to evaluate the outcome of therapy. Researchers pursuing evidence to refute Eysenck’s claim have investigated a number of domains that are considered relevant to distinguishing the effects of psychotherapy. Assessments of the benefits of psychotherapy have focused on such domains as an increase in problem-solving skills, reduction in symptoms, improvements in interpersonal and social functioning, and health. The changes noted in patients treated with psychotherapy have been compared to groups of individuals who have not been exposed to therapy. Reviews of this literature have confirmed the beneficial effects of therapy, concluding that treated patients consistently fare better than untreated patients (Lambert and Bergin 1992, 1994).

An often used statistical technique, meta-analysis, has enabled researchers to summarize individual collections of empirical data, comparing the effect sizes of treatment, placebo, and control groups. For example, using meta-analysis, Smith et al. (1980) reported that the average person in treatment is better off at the end of treatment than 80 percent of the untreated persons. A graphic representation of the effect sizes (treatment, placebo, and control) found in a number of meta-analytic reviews is presented in Fig. 1.

4. Treatment Duration And Lasting Effects

In contrast to the length of treatment associated with early theories of psychoanalytic psychotherapy, the extant literature suggests that substantial benefits from treatment occur in relatively short durations, and equally important, these gains are maintained. Doseeffect designs, derived from the dosage model introduced by Howard et al. (1986), have confirmed a positive rate of effect as the dose (i.e., number of sessions) increases, with diminishing returns at higher dosage levels. Studies from the dose-effect literature suggest that, for many clinical disorders, a range of 10 to 20 sessions is sufficient for 50 percent of patients to return to normal functioning. Moreover, promising results occur as the dosage level is increased to the extent that 75 percent of patients can be expected to recover substantially after 26 to 50 sessions (Lambert et al. 2001).

Although a majority of patients experience significant benefits from psychotherapy, there is also evidence that different clusters of psychological symptoms respond to treatment at distinct rates of improvement. It appears that symptoms of poor morale respond most quickly, followed by chronic symptoms of distress, with symptoms intrinsic to the character of the patient recovering the slowest. Observed trends in patient improvement have led some researchers to propose a phase model of recovery in which personal welfare, symptom reduction, and interpersonal and social functioning improve in sequence.

In addition to results supporting relatively short recovery periods for a majority of patients, there is evidence that beneficial gains from psychotherapy are enduring. Although adjustment from psychotherapy treatment does not prevent recurrences of psychological disturbance, it appears that many patients maintain healthy functioning for prolonged periods of time subsequent to treatment. However, exceptions to the notion of lasting treatment gains are noted in the conclusions of a review by Nicholson and Berman (1983), which included patients suffering from symptoms of substance abuse, eating, recurrent depression, and personality disorders.

5. Factors Important To Psychotherapy Outcome

In addition to the research focused on supporting the effectiveness of psychotherapy, considerable emphasis has been placed on the factors attributable to positive patient outcome. Findings from this research fall into three general categories: patient variables, common variables, and specific intervention variables.

5.1 Patient Variables

Although a number of studies have investigated the impact therapists have on psychotherapy outcome, there is surprisingly little evidence that suggests therapists or their techniques are central and essential factors affecting patient outcome. On the contrary, it is in fact the patient that is most likely to determine successful outcome. The literature focusing on the study of patient variables is too voluminous to repeat, and thus only the most important findings are reported here.

Each patient entering treatment brings a diverse array of factors when presenting to the clinician. These include a variety of psychological disorders, historical backgrounds, stresses, and the quality of their social support networks to name just a few. Patient variables found to have relationships with outcome are severity of disturbance, motivation and expectancy, capacity to relate, strength of ego, psychological mindedness, and ability to recognize relevant problems (Garfield 1994). Therefore, patients suffering from challenging symptoms as well as relative deficits in numerous patient variable categories are likely to experience negligible improvement during treatment. For example, the borderline, alcoholic patient with suicidal tendencies who is forced into treatment, believing that most marital problems are a result of an insensitive spouse, is likely to benefit less from treatment than the depressed patient who voluntarily begins treatment and is determined to make personal changes that will lead to marital harmony.

Although patient variables have been conveniently categorized, the impact each has on the outcome of therapy is not equal. In general, the severity of disturbance is the patient variable that is most related to the outcome of the treatment. Patients with serious mental disorders, such as the schizophrenic, schizoaffective, and bipolar disorders are typically treated primarily with psychopharmacological management, suggesting the challenge these disturbances provide for psychotherapy alone. Personality disturbances also appear immutable to change in the short term use of psychotherapy.

5.2 Common Factors

Because outcome researchers have consistently failed to find sufficient evidence indicating superior effect sizes for particular theoretical modalities, some have concluded that psychotherapy equivalence is a result of factors common to all theories of psychotherapy. Whereas some view these beneficial ingredients as both necessary and sufficient for change, others perceive that these ingredients act in coalition with variables that are unique to particular interventions. It is important to note that regardless of the position held, factors common to all treatments are likely to account for the greatest amount of the improvement in patients undergoing psychotherapy.

In a review of the empirical research, Lambert and Bergin (1994) grouped many of the shared active ingredients of a variety of psychotherapies into three categories: support, learning, and action factors. The factors included in these categories seem to operate most actively during the in-session process of therapy, resulting in a collaborative working relationship that allows clients to confront and cope with reality more effectively. Factors that engender a collaborative relationship include a client’s increased sense of trust, security, and safety, along with a reduction in tension, threat, and anxiety that in turn promotes a client’s awareness of problems and ultimately new and more healthy perspectives on fears, appropriate risk taking, and motivations for resolving problems in interpersonal relationships.

Factors receiving the most attention in the literature are the common factors considered to be the core of therapy (empathy, warmth, and positive regard). A number of related terms such as acceptance, tolerance, therapeutic alliance, working alliance, and support are also used to describe these ingredients. In a study designed to explore which of several therapist variables distinguished most consistently between more effective and less effective therapist trainees, Lafferty et al. (1991) concluded that a client’s perception of empathy is important to outcome, because less effective therapists, those with patients experiencing more distress as a result of treatment, were found to have lower levels of empathy.

Findings from studies investigating the therapeutic relationship have suggested that a positive working alliance between the patient and therapist is a necessary condition for patient improvement. When asked for factors that were most helpful in their treatment, patients tended to endorse the personal qualities of their therapists, using adjectives such as ‘sensitive,’ ‘honest,’ and ‘gentle.’ The results of similar studies confirm the import that patients place on the characteristics of therapists (Horvath and Greenberg 1994).

Additional evidence supporting the necessity for a strong working relationship is the positive association repeatedly found between scores on measures of early treatment alliance and psychotherapy outcome. In clinical trial studies comparing multiple treatments for particular psychological disorders, patients’ positive assessment of the therapeutic alliance is one of the best predictors of psychotherapy outcome (e.g., Krupnick et al. 1996). Although a significant amount of evidence points to common factors as mediators of patient change, the notion of beneficial ingredients unique to specific therapies cannot be ruled out, as occasionally such interventions can be shown to contribute to successful outcomes in patients independent of common factors.

5.3 Specific Interventions

The drive to empirically validate the efficacy of specific interventions is due, in part, to the field of psychotherapy’s commitment to theoretically based approaches, as well as the influence of political and economic forces. Collectively, these factors have led to the use of comparative outcome studies, which generally avoid the ethical and methodological problems associated with no-treatment and placebo controls, while enabling researchers to study the effectiveness of particular techniques or theories by comparison.

5.3.1 Anxiety Disorders. Specific behavioral treatments have been found to be effective in treating patients with anxiety disorders. To date, two treatments, systematic exposure and applied relaxation techniques, have been shown to be efficacious in treating a variety of anxiety disorders. Exposure is a broad term that encompasses both interoceptive and situational exposure interventions. Interoceptive procedures attempt to reliably produce panic-type sensations, with the intent of severing or weakening the patient’s associations between certain bodily cues and their respective reactions to panic. The technique of situational exposure, also known as in vivo exposure, refers to the patient’s repeated intentional encounters with a feared stimulus. Given the focus placed on the catalyst of fear, it is not surprising that clearly identifying the stimulus that induces the patient’s reactions is crucial for the success of these procedures.

Evidence suggests that the most effective treatment strategy includes identification of feared stimuli, confrontative periods of exposure sufficient in length to reduce the patient’s level of anxiety, and a focus on thoughts providing self-efficacy or performance accomplishment. A general strategy employing the use of exposure techniques appears to be the only efficacious intervention for agoraphobia (DeRubeis and Crits-Christoph 1998). Similar techniques have been shown to be successful for social phobic, panic, and post-traumatic stress disorder patients as well.

The results of a form of relaxation, referred to as applied relaxation, appear to show promise in treating specific anxiety disorders. Applied relaxation entails instructing patients in the skill of progressive muscle relaxation. Patients are generally taught how to progressively relax specific muscle groups. Whereas the evidence supporting the use of applied relaxation techniques alone is mixed in the panic disorder literature, it appears there is support for treating generalized anxiety disorder with relaxation training.

Additional evidence suggests that the treatment of specific disorders is most successful when particular interventions are combined with specific theory-based therapies. For instance, panic disorder is treated most effectively when a cognitive-behavioral theory of therapy is used in tandem with behavioral techniques. Barlow et al. (1989) compared relaxation training (RT), imaginal exposure plus cognitive restructuring (E + C), and a combination of these two interventions (RT + E + C). Outcome was determined by the percentage of patients experiencing panic attacks. Results indicated that 36 percent of the WL (wait-list control) patients, 60 percent of the RT patients, 85 percent of the E C patients, and 87 percent of the RT + E + C patients were free of panic attacks at the end of treatment.

5.3.2 Depression. Like anxiety-based disorders, there is some evidence supporting the use of specific behavioral techniques in the treatment of depression; however, in the case of depression, these procedures are no more effective than cognitive, interpersonal, and psychodynamic-interpersonal therapies. For example, behavioral activation alone, which refers to a patient scheduling activities that promote mastery as well as pleasure experiences, has been found to be as effective as cognitive therapy. Whereas behavioral activation is a procedure that makes concerted efforts to involve patients in constructive and pleasurable activities, cognitive therapy emphasizes the modification of maladaptive thoughts, beliefs, attitudes, and behaviors of individuals. Although some researchers predicted the superiority of cognitive therapy’s ability to successfully treat depressive patients (Hollon and Beck 1986), the results of large well-controlled studies suggest that interpersonal and psychodynamic-interpersonal therapies are efficacious as well. In contrast to the focus that cognitive therapy places on maladaptive thoughts, beliefs, and behaviors, the interpersonal theory perceives depression as the consequence of problems in the interpersonal history of the patient.

5.3.3 Eating Disorders. As eating disorders are generally characterized by harmful cognitions surrounding weight and physical image, cognitive and behavioral interventions have been the most extensively researched treatments. In particular, cognitive behavior therapy has been the focus of much research in the treatment of bulimia nervosa, showing promising results. However, it appears that interpersonal therapy provides generally equivalent results when long term follow-up findings are considered (Fairburn et al. 1993).

5.3.4 Substance Abuse Disorders. Reviews of the treatment of substance abuse disorders suggest that various therapy modalities have been found effective in treating patients. Therapies that provide generally equivalent results are cognitive, cognitive behavior, and psychodynamic derived therapies. Whereas patients abusing alcohol have been treated, with similar success, using psychodynamic, cognitive behavior, and psychoeducational treatment modalities, opiate dependent patients have been treated with cognitive and supportive-expressive psychodynamic therapies with generally equivalent results.

Some caution should be applied when interpreting the above findings, however, as the results mentioned are typically based on randomized clinical trials. To date, there is little evidence suggesting that these findings generalize to the clinical setting. The question of whether one technique is comparatively unique and more effective than another is a consistent topic in the literature of psychotherapy. There is currently little evidence supporting superiority of particular interventions, although future research may note unique contributions. For instance, there is a growing body of evidence suggesting that the use of therapy manuals allow for the detection of discernable differences in the behavior of therapists, while at the same time enhancing the effects of specific therapy procedures. Perhaps these contributions will allow for more accurate comparisons in outcome studies. The search for specific techniques and common factors that distinguish successful treatment has proved to be difficult because of the myriad factors that likely exist in the interactions between therapists and clients.

6. The Negative Effects Of Psychotherapy

Findings from the study of the progress and outcome of patients undergoing psychotherapy have resulted in both expected and unexpected conclusions. Most patients receiving treatment improve, a minority of patients remain unchanged, and contrary to the intent of psychotherapy, some patients actually worsen as a result of treatment. Independent reviews of the literature suggest that there are patients who fail to achieve beneficial gains from treatment. Although accurate estimates of patient worsening are difficult to make because the results of such incidents are not often the focus of psychotherapy outcome studies, estimates of patient worsening vary between 0 and 15 percent (Lambert and Bergin 1992). Similar to patient improvement, it appears that the phenomenon of deterioration is equivalent across theoretical orientations. In addition, treatment failures are reported in all client populations, treatment interventions, and group and family therapies.

Despite what appears to be an equitable distribution of treatment failures, specific factors have been associated with deterioration. Consistent with the influence that patient variables often have in treatment success, patient characteristics appear closely linked to treatment failure. Severity of mental illness alone is predictive of unsuccessful outcome, and severe levels of mental illness in combination with specific interventions designed to breach, challenge, and undermine entrenched coping strategies and defense mechanisms are more likely to result in treatment failure. Consequently, psychotic, borderline, schizophrenic, and bipolar patients are those patients most frequently experiencing deterioration during the course of treatment. Similar findings have been reported in the psychoanalytic literature, as patients lacking quality interpersonal relationships, low anxiety tolerance at the inception of treatment, and low motivation were more likely to worsen when treated with psychoanalysis and purely supportive therapies, whereas patients treated with supportive-expressive psychotherapy enjoyed better outcomes. Deterioration is not unique to individual therapy, however. Reviews of group psychotherapy outcome have reported a positive correlation between treatment failure and patient variables such as low participation, poor self-esteem, poor self-concept, and more significant needs for fulfillment. Additional personal characteristics associated with patient deterioration include hostility, interpersonal dysfunction, and negative expectations of treatment.

The above findings suggest that it is important to consider the type of intervention most appropriate for a particular client; however, harm is not the fault of patient and intervention alone. The results of studies investigating therapists’ contributions to the phenomenon of deterioration have suggested that specific therapists’ behaviors can lead to treatment failure. For instance, the results of a study investigating the relationship between therapist’s emotional adjustment, empathy, directiveness, support, and credibility, and patient outcome found that a therapist’s empathic abilities were the most predictive of patient outcome (Lafferty et al. 1991). Additional findings of the study suggested that effective therapists were also likely to provide more direction and support than ineffective therapists. These researchers were also interested in the similarity in values held by the therapists and patients, and found that less-effective therapists emphasized values, such as the importance placed on a life of comfort and excitement, whereas effective therapists considered intellectual values, such as reflection, as more important.

Another study suggested that patient deterioration is related to therapist countertransference reflecting disappointment, hostility, or irritation (Mohr 1995). In addition, there was some indication that client deterioration is more prevalent when clinicians underestimate their client’s illness or overestimate their client’s progress in treatment. Research exploring the importance of leadership styles in group therapists suggests that confrontational and aggressive group therapists tended to have more treatment failures in their groups. These therapists were observed to be more likely to insist upon immediate client disclosure, emotional expression, and change in attitude.

7. Conclusion

Years of clinical research have produced compelling evidence for the value of psychotherapy. Contrary to Eysenck’s controversial publication regarding the efficacy of psychotherapy, outcome studies have confirmed that patients benefit in a variety of domains from treatment. According to the dose-effect literature, benefits derived from therapy transpire in relatively brief periods of time. For many clinical disorders, generally one-half of all patients return to normal functioning in 10 to 20 sessions. An additional 25 percent of patients experience substantial improvement when dosage levels are increased to 30 to 50 sessions. The benefits from treatment appear to be durable, as the results of follow-up studies suggest that the effects of treatment endure for at least one to two years subsequent to treatment.

Not all patients experience the beneficial effects of treatment, and this finding has inspired the investigation of factors facilitating both positive and negative change. The results of such studies have indicated that a patient’s level of disturbance is most predictive of outcome; however, desire to change, interpersonal skills, ego strength, psychological mindedness, and awareness of relevant problems have all been found to be related to outcome. In addition to patient variables predictive of successful outcome, there are characteristics of a therapeutic relationship that facilitate a patient’s sense of trust, safety, and security. According to patients’ reports, therapist empathy and a strong therapeutic alliance are most predictive of treatment outcomes.

Although the use of specific interventions has showed promising results in the case of particular disorders, in general the search for superior treatment strategies has been disappointing, and according to some researchers unnecessary, given the complexity of potential interactions between therapists, clients, and modes of therapy. Regretfully, not all patients improve from treatment, indeed, some actually worsen. Knowledge of this phenomenon is somewhat limited; however, there is evidence that suggests that treatment failure is best predicted by severity of mental illness. Furthermore, factors inhibiting the development of a strong therapeutic alliance also predict negative outcome.

Although researchers have contributed empirical evidence supporting the effectiveness of psychotherapy, they are just learning to understand why patients tend to improve. In time, it is likely that focused and determined research will eventually lead to greater insights into this important question.

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