Psychotherapy

VI

The Process of Psychotherapy

For most people, psychotherapy involves a common sequence of events: finding a therapist, assessing the problem, exploring the problem, resolving the problem, and terminating therapy. Sometimes therapy will end prematurely, before the problem is resolved. For example, the therapist or client may move to a new city.

When someone has a personal problem and seeks help from a therapist, the individual may turn to a variety of people to get a referral—a friend, a pastor or rabbi, or a family physician. Phone books list associations of psychologists, psychiatrists, and social workers that can also provide referrals to therapists. As noted earlier, however, some health insurance plans may restrict a person’s choice of therapist.

When prospective clients call a therapist for an appointment, they may discuss several aspects of therapy. One concern is availability—is the therapist taking on new patients? Are there hours when both patient and therapist can meet? Another issue is fees. Both therapists in private practice and those in community mental health agencies have to negotiate fees depending in part on the client’s health insurance plan. Some agencies do not require health insurance and have very low fees or a sliding scale that sets fees depending on the ability of the client to pay.

During the first meeting, clients try to explain their problems to the therapist. The therapist usually asks about the nature of the problems, what may make the problems better or worse, and how long the problems have existed. For many therapists, hearing details, even small ones, helps them to assess the problems and to decide the best form of treatment. Some therapists collaborate with clients in deciding the goals of therapy and what treatment methods will be used. Assessment does not stop with the first session, but continues through therapy. Occasionally, goals of therapy change upon assessment of new issues or problems.

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During therapy, the client sits across from the therapist—except in classical psychoanalysis, in which the client lies on a couch. The specific nature of the discussions between therapist and client differs greatly depending on the therapist’s theoretical orientation. Some therapists are interested in unconscious forces and the early childhood years of the client (psychodynamic therapy), others in actions of the client (behavioral therapy), others in the client’s thinking patterns (cognitive therapy), and yet others in all or some of these aspects. Therapists often take notes during a session or make notes after the session has ended. Sessions typically last from 45 to 50 minutes, although therapists may hold longer sessions during the initial stages of treatment. Clients typically meet weekly with the therapist, although some may meet twice a week or more.

When does therapy end? Clients and therapists discuss this issue together and determine when it is best to stop. Ideally their decision depends on their judgments about the client’s degree of progress and improvement. Some clients may find that therapy does not seem to be making progress, and may decide to change therapists. However, the cost of therapy may also factor in the decision to end therapy. Managed-care companies generally limit the number of sessions they will subsidize to between 15 and 20. Some therapists, especially those in private practice, may arrange to go beyond these limits by negotiating a fee that the client will pay for services. In other cases, the therapist may refer the client to other mental health agencies that have lower fees and do not require insurance. At the end of therapy, the therapist may schedule a follow-up session several months later to check the client’s progress. Also, the therapist and client agree on what to do if the client’s problems recur.

VII

Effectiveness of Psychotherapy

Almost since the inception of psychotherapy, therapists and their clients have asked, “Does it work? Does psychotherapy help people resolve their problems, feel better, and change the way they deal with other people?” Therapists and clients are not the only ones asking these questions. In recent years, the agencies that fund mental health services—health insurance companies, health maintenance organizations, and government organizations—have increased their scrutiny of the effectiveness of various psychotherapies in an effort to contain costs.

Measuring the effectiveness of psychotherapy is an extremely complex task. Asking psychotherapists or their clients, “How helpful has therapy been?” is only a start. The answer does provide some information about how therapists and their clients perceive therapy. However, it does not answer the question of whether psychotherapy is effective because both therapists and clients have vested interests in believing that therapy succeeded. Therapists want to uphold their professional reputation and sense of competence, and clients want to feel that their investment of time and money has been worthwhile. Because of these biases, most studies of effectiveness rely on other evaluations of a client’s improvement: psychological tests given before and after treatment, reports from the client’s friends and family, and reports from impartial interviewers who do not know the client or whether the client received any therapy.

A

Overall Effectiveness

In 1952 British psychologist Hans Eysenck reviewed the results of 24 studies of psychotherapy and came to a controversial conclusion: Although two-thirds of patients who received psychotherapy showed improvement, a roughly equal proportion of patients who had been on a waiting list for therapy improved with no treatment. According to Eysenck, the patients on the waiting list showed spontaneous remission—recovery without treatment. Although researchers soon exposed flaws in his analysis and problems with the original studies, Eysenck’s findings touched off hundreds of new studies on the effectiveness of psychotherapy.

In 1980 American researchers statistically combined the results of 475 studies on psychotherapy outcomes using a technique known as meta-analysis. Their study found that the average psychotherapy recipient showed more improvement than 80 percent of untreated individuals. Later studies have confirmed that overall, psychotherapy is better than no therapy at all. Furthermore, it appears at least as effective as drug treatment for most psychological problems. However, psychotherapy is not effective for everyone. About 10 percent of people who receive psychotherapy show no improvement or actually get worse.

Researchers have also studied how quickly people improve with psychotherapy. One analysis, which reviewed data from more than 2400 psychotherapy patients, found that 50 percent of people receiving once-a-week psychotherapy showed significant improvement after eight sessions, or two months. After six months, or 26 sessions, about 75 percent of people show improvement. However, most people required about a year of psychotherapy for relief from severe symptoms, such as feelings of worthlessness.

B

Comparing Different Psychotherapies

Are some types of psychotherapy more effective than others? This question has been hotly debated for decades, and research on this issue presents many difficulties. In conducting studies that compare different therapies, researchers seek to make sure that each treatment group is as similar as possible. For example, researchers may limit the groups to people with the same severity of depression. In addition, within each treatment group, researchers try to make sure that therapists are using the same techniques and are trained similarly. However, patients do not come to therapy with simple problems that fit easily into studies. Furthermore, therapists of the same theoretical orientation may vary in their techniques and in the skillfulness with which they apply them.

Because of these problems, there is no conclusive answer about which type of therapy is best. Most studies have failed to demonstrate that any one approach is superior to another. The meta-analysis of 475 studies mentioned earlier, for example, found that psychodynamic, humanistic, behavioral, and cognitive approaches were all about equally effective. In the 1990s a major study by the National Institute of Mental Health compared the effectiveness of cognitive-behavioral therapy, interpersonal psychotherapy (a form of short-term psychodynamic therapy that focuses on social relations), and drug therapy for people with depression. The study found that all three types of treatment helped individuals become less depressed. Furthermore, no one method was significantly more effective than the others.

Some researchers suggest that all therapies share certain qualities, and that these qualities account for the similar effectiveness of therapies despite quite different techniques. For instance, all therapies offer people hope for recovery. People who begin therapy often expect that therapy will help them, and this expectation alone may lead to some improvement (a phenomenon known as the placebo effect). Also, people in psychotherapy may find that simply being able to talk freely and openly about their problems helps them to feel better. Finally, the support, encouragement, and warmth that clients feel from their therapist lets them know they are cared about and respected, which may positively affect their mental health.

Although different therapeutic approaches may be equally effective on average, mental health researchers agree that some types of therapy are best for particular problems. For panic disorder and phobias, behavioral and cognitive-behavioral therapies seem most effective. Behavioral techniques, often in combination with medication, are also an effective treatment for obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and sexual dysfunction. Cognitive-behavioral, psychodynamic, and humanistic approaches all provide moderate relief from depression.

C

The Therapist-Client Relationship

Mental health professionals agree that the effectiveness of therapy depends to a large extent on the quality of the relationship between the client and therapist. In general, the better the rapport is between therapist and client, the better the outcome of therapy. If a person does not trust a therapist enough to describe deeply personal problems, the therapist will have trouble helping the person change and improve. For clients, trusting that the therapist can provide help for their problems is essential for making progress.

The founder of person-centered therapy, Carl Rogers, believed that the most important qualities in a therapist are being genuine, accepting, and empathic. Almost all therapists today would agree that these qualities are important. Being genuine means that therapists care for the client and behave toward the client as they really feel. Being accepting means that therapists should appreciate clients for who they are, despite the things that they may have done. Therapists do not have to agree with clients, but they must accept them. Being empathic means that therapists understand the client’s feelings and experiences and convey this understanding back to the client.

In helping their clients, all therapists follow a code of ethics. First, all therapy is confidential. Therapists notify others of a client’s disclosures only in exceptional cases, such as when children disclose abuse by parents, parents disclose abuse of children, or clients disclose an intention to harm themselves or others. Also, therapists avoid dual relationships with clients—that is, being friends outside of therapy or maintaining a business relationship. Such relationships may reduce the therapist’s objectivity and ability to work with the client. Ethical therapists also do not engage in sexual relationships with clients, and do not accept as clients people with whom they have been sexually intimate.

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