For Psychotherapy's Claims, Skeptics Demand Proof
August 10, 2004
By Benedict Carey, New York Times
Good therapists usually work to resolve conflicts, not inflame them. But there is a civil war going on in psychology, and not everyone is in the mood for healing.
On one side are experts who argue that what therapists do in their consulting rooms should be backed by scientific studies proving its worth.
On the other are those who say that the push for this evidence threatens the very things that make psychotherapy work in the first place.
Which side prevails may shape not only how young therapists are trained and what techniques practitioners use in the future, but also how tightly health insurers restrict the therapies they are willing to pay for, and thus how much the estimated 20 million Americans who enter psychotherapy each year have to pay out of their own pockets. Ultimately, some experts say, the survival of one-on-one counseling, or talk therapy, as an accepted mode of treatment for mental disorders may hang in the balance.
The issue of which therapies are based on science and which are not has recently become so divisive that the incoming president of the American Psychological Association, Dr. Ronald Levant of Nova Southeastern University in Fort Lauderdale, Fla., said in a telephone interview that he had already assembled a task force to address the controversy, and to find some common ground on which to anchor future practice.
The topic was debated before a raucous, packed hall at the annual meetings of the American Psychological Association in Honolulu, held July 28 to Aug. 1. The association, with more than 150,000 members, is the largest professional association of psychologists. "The split in the field is bigger than it ever has ever been," said Dr. Drew Westen, a professor of psychology, psychiatry and behavioral sciences at Emory University. "The intensity of the acrimony, the distaste, has never been so high."
At bottom, the dispute is over the nature of psychotherapy: Is it an intuitive process, more art than science? Or is it more a matter of a therapist following specific procedures that reliably help people get better?
Over the last decade, a group of academic researchers has argued for the instruction-manual approach, compiling a list of short-term therapies that studies show work for a variety of mental disorders.
The techniques are standardized, easily described in manuals for therapists, and can quickly help people with phobias, panic attacks and other problems. They include cognitive therapy, in which people learn to refute pessimistic or degrading thoughts, and exposure therapy, in which they overcome anxieties by gradually learning to face the situations they fear.
This evidence-based approach already has had a significant impact in the marketplace. Some managed care companies, including Magellan Health Services, the country's largest managed mental health insurer, base their coverage for psychotherapy on what the research says and expect their therapists to practice techniques that are backed by studies. Some companies also limit the number of sessions they will authorize for a given diagnosis based on the findings of research.
And many insurers now require therapists, patients or both to document therapeutic progress, providing evidence that what is taking place in the consulting room is working.
Dr. Jerome V. Vaccaro, a psychiatrist and the president of PacifiCare Behavioral Health, a large mental health insurer based in California, said his firm closely monitored how well each patient being seen by therapists in PacifiCare's system is doing. Patients fill out questionnaires at their first therapy session, and then after their fourth or fifth, he said.
"If things are going well, there's improvement, fine, that's what we want to see," Dr. Vaccaro said. "If things aren't going well, or the person's getting worse after a few sessions, then we'll be calling the therapist to ask what they're doing."
The idea, he said, "is to make you, the therapist, accountable for outcomes."
Some of the country's top clinical psychology programs, like those at Indiana University and the University of Maryland, have a strong emphasis on evidence-based therapies. But in a field where practitioners are used to following their own instincts, this "show me" approach has stirred outrage.
Some therapists say that the healing they offer in their offices every day is too complex to be captured in standard studies, and that having to justify it to a third party is a breach of patient privacy. They argue that to insist on proof that a therapy works denies many people adequate treatment, or the forms of treatment that they most need.
One middle-aged woman, who entered therapy after her father died, was distraught when her insurer recently stopped coverage after 10 sessions, citing lack of evidence for more, said Dr. Patricia Dowds, the woman's therapist.
No one tracks how many people have been dropped from therapy based on such arguments. But "every colleague I know has stories," Dr. Dowds said.
Some therapists even worry they might be sued for not practicing techniques on the hard-evidence list, though experts say they know of no such cases so far. An article in the March 2002 newsletter of the California State Board of Psychology warned that therapists working with families "who use any procedures not validated by empirical research would do well to fear examination by an attorney knowledgeable of the research."
Dr. Glen O. Gabbard, a psychiatrist and psychoanalyst who teaches therapeutic technique at the Baylor College of Medicine in Houston, said, "The move to worship at the altar of these scientific treatments has been destructive to patients in practice, because the methods tell you very little about how to treat the real and complex people who actually come in for therapy."
For more than a century, the practice of psychotherapy rode on the shoulders of charismatic figures, from Freud and Jung to Fritz Perls, Carl Rogers and other luminaries of the so-called human potential movement. Primal scream and rebirthing therapies vied with more traditional approaches. The effectiveness of these methods was established not by studies but by the force of the therapist's personality, and testimonials of recovered patients.
But in the late 1980's, the increasing use of drugs like Prozac and the arrival of managed care forced therapists to start justifying their methods with better evidence. In 1995, a group of leading psychologists published a report identifying what it called empirically validated therapies. They argued that these therapies had good track records and that clinicians should be aware of them and receive training in using them. An empirical grounding, many hoped, would also help re-establish the field's respectability and repair its image among insurers as a money sink.
"When I started in practice as an intern, these therapies were just emerging," said Dr. Dianne Chambless, a professor of psychology at the University of Pennsylvania, who led the panel. "I used them on my clients, and they worked; it was a powerful thing to see."
The champions of an empirical approach say that, despite skeptics' complaints, accountability has brought more credibility, and insurers and policy makers are gradually becoming more convinced that psychotherapy is a rigorous treatment, not indulgent and open-ended. The move to science, the empiricists assert, also has given the field a base from which to evaluate and discredit fringe therapies or those that promise instant healing.
"It deeply frosts me, these people who are against measurement and evidence," said Dr. David Burns, a psychiatrist who trains residents at Stanford University School of Medicine. "It's a kind of narcissism in our field to say, 'I'm so great, I know what I'm doing,' and it puts us back 2,000 years to a time of cults, when every snake oil salesman's got something and the parade just goes on."
Those who oppose the use of treatment manuals and lists of approved therapies respond in kind. "This entire approach to develop manuals and require practicing psychologists to use them is fundamentally insane," Dr. Levant said.
So the arguments continue, and passions on either side, experts say, are not likely to cool any time soon. Recently, however, some researchers have been trying to find some accommodation between the two camps by focusing on what it is about any therapy that makes it effective, rather than holding one method above another.
Studies suggest, for example, that factors like how motivated patients are, their readiness for change, the gifts of the therapist, and the strength of the bond between patient and therapist all make a difference in whether psychotherapy is successful.
Ken Heideman, a 45-year-old meteorologist in Boston, said that his own experience in therapy illustrated this.
Mr. Heideman has struggled with severe recurrent depression since college, he said, and over the years he has tried a variety of drugs and visited many therapists. But eventually, he found someone who helped free him from his disabling moods for the first time in his adult life.
"I've been through a whole lot and I feel I can say that what ultimately is going to move someone toward healing and resolution, the most important factor, is the chemistry between client and therapist," he said. "It can be a psychiatrist, or someone with a degree in social work, and anywhere in between. What counts is whether there's that connection between the two people."
Dr. Bruce E. Wampold, a professor in the counseling psychology department at the University of Wisconsin, has found that a therapist's competence may be the most critical variable, whatever the brand of therapy.
Analyzing data from more than 12,000 people treated with a variety of evidence-based therapies, from cognitive to interpersonal techniques, mostly for depression, he found that the treatments worked equally well, regardless of the specific techniques. More important, Dr. Wampold said, was the individual therapist: some could help their patients improve significantly in eight sessions or so, others could not.
"It's not what treatment you give that matters but how competently you give it, " he said.
But even a gifted therapist can leave a patient cold. Like the tango, psychotherapy takes two, and chemistry is hard to predict or measure.
Dr. Burns has tried to do it by conducting systematic surveys of the residents he trains at Stanford and the people these students treat. Most of the time, he said, the residents assume they are well liked.
"At first it's very upsetting when they read these evaluations because about 100 percent of the time the clients don't actually like them," Dr. Burns said. "So perceptions of what is a good relationship can be really off base."
Perhaps the only emerging consensus among experts is that research into psychotherapy should not rely solely on clinical trials, in which one group of people is given a treatment and then compared with other people who receive a placebo.
Though well suited to testing drugs, this kind of study, said Dr. Westen of Emory, tends to impose artificial limits on psychotherapy: treatments are by necessity short; techniques are often standardized in manuals; and many participants are excluded because their problems are too complicated for a single diagnosis. The chaos of real life is blocked out.
Dr. Chambless, Dr. Levant, Dr. Westen and others who have been strongly divided now argue that researchers should also follow patients treated in psychotherapy clinics out in the world, to see how well they do, and why.
"The fact is that we're still in a state where we have very little knowledge, and the question is not what theory works, but what works for whom," said Dr. Larry E. Beutler, a professor of psychology at Pacific Graduate School of Psychology in Palo Alto, Calif.
It would be nice, for example, if researchers could find a way to deconstruct why Mr. Heideman, the meteorologist, feels his therapy has been so successful. After four years in treatment, he is now able to express his anger once in a while, he says, adding that his therapist "has angered me, and challenged me and I just woke up; it was like the Big Bang for me."
Mr. Heideman's therapy includes cognitive methods, like challenging his assumption that if he showed anger, some catastrophe would come about. The therapy, in short, is a blend of a good therapist match and evidence-based technique, of intuition and science. Mr. Heideman sees his success so far as the fulfillment of an article of faith that many who have suffered mental illness share: when you're ready to change, the right therapist will turn up.