Psychotherapy Struggles to Demonstrate Scientific Validity
Psychologist, heal thyself. That may well have been the caption to the cover story of Science News,1 illustrated with an iconic cartoon of the patient on the psychoanalyst’s couch – only this time, psychotherapy itself is the patient. “Researchers spar over how best to evaluate psychotherapy,” announced Bruce Bower, as he described the attempts of professional “talk psychology” to legitimize itself as science. What has happened? A few years ago, it was common for people to converse about their shrink and how their therapy was going. What’s driving the new scrutiny? Health insurance dollars, for one thing:
These are the times that try psychotherapists’ souls. Federal and state mental-health budget cuts have reduced the number of people who can afford one-on-one psychotherapy sessions to address their problems. Managed care companies demand to see proof that various psychological treatments work, and even then, they reimburse the cost of 2 or 3 months of psychotherapy at most….
Today, the financial survival of any medical treatment or procedure rests on published evidence for its effectiveness. In that environment, the science of psychotherapy has assumed special urgency. Psychologists with backgrounds in both research and treatment stand at ground zero of efforts to conduct psychotherapy studies and then integrate the findings into clinical practice. (Emphasis added in all quotes.)
How can this be? The scientific validity of psychotherapy has seemed as solid as that of Darwinism. Now, both are increasingly being asked to produce the evidence. The American Psychological Association (APA) recently approved a policy statement on “evidence-based practice in psychology,” Bower reports. The presumption is that such evidence has been lacking, or is being questioned. Why?
Following the money, we find that insurance companies are increasingly restricting their subsidies to about two dozen therapies deemed “empirically supported” according to an 1998 APA study. Then Bower gives a stunner: only a handful of procedures are even adequately documented, let alone demonstrated effective:
The list of science-backed psychotherapies emphasizes a handful of approaches grounded in concrete procedures that are described in training manuals. For instance, in cognitive therapy for depression, a therapist assists patients in identifying and correcting faulty beliefs, such as a tendency to regard any setback as confirmation of one’s failure as a person. Cognitive therapy includes homework assignments, for instance, a patient trying out a challenging new hobby and monitoring negative thoughts as they crop up.
It gets worse. Even the therapies deemed “empirically supported” are being viewed more and more as subjective, with cause-and-effect inferences difficult to establish. Bower says that even the definition of “evidence-based practice” is a “sticky issue.” One psychologist accuses the APA of politicking in favor of psychotherapy practitioners over researchers. Another calls “evidence-based practice” the most “consequential, incendiary topic in mental health in recent years.”
Bower spends some time with specific examples of testing therapies to see if they can be legitimized scientifically. Randomized controlled trials of cognitive therapies were studied to establish the “gold standard” of validity. But how does one do a controlled experiment on people, when each patient represents a unique combination of symptoms? Bower describes the examples only to question them: “Not everyone is brimming with optimism for psychotherapies bearing scientific seals of approval,” he says. There are plenty of insiders willing to cast doubt. Better not let the insurance companies get wind of this:
Rare comparisons of patients receiving either of two forms of genuine psychotherapy have yielded no clear winners, [Drew] Westen [Emory U] notes. In head-to-head comparisons, for example, a few months of cognitive therapy for depression works about as well as the same amount of interpersonal therapy does. The latter form of one-on-one talk therapy, which is also outlined in a training manual, focuses on helping the patient find ways to resolve conflicts with others, to adjust to new roles in life, and to foster better relationships.
Psychologist Bruce E. Wampold of the University of Wisconsin-Madison has combed through data from psychotherapy studies and concludes that a good working relationship between therapist and patient plays a larger role in sparking psychological progress than any particular treatment technique does.
But if that is true, who needs a professional? Why could not a good friend, or a clergyman, achieve results just as valid as the psychotherapist? “The methodological tail is wagging the therapeutic dog,” Westen says. This means that one cannot control for something as complex as the interpersonal relationship between a therapist and the patient.
That has not prevented psychologists from trying. Enrico E. Jones (UC Berkeley) devised a 100-item rating instrument called a Q-test in hopes of providing unbiased observers a way to rate the success of a therapy. Unfortunately, the ratings of viewers were influenced by their subjective impressions and biases. One review of Q-test data found that “cognitive therapists usually blended psychodynamic techniques into their treatment, while psychodynamic therapists often examined faulty thinking and irrational beliefs just as cognitive therapists did.”
In a 2002 paper that Ablon calls “a shocker,” clinicians and psychology graduate students rated videotaped sessions of therapists practicing what they considered either cognitive or interpersonal therapy. The researchers found that, at least in the sessions with depressed patients, both treatments fit the definition of cognitive therapy, suggesting that a single therapy had been compared with itself. The two sets of therapists were similarly effective….
Many proponents of randomized controlled trials regard Q-set studies as a swamp of correlations that can’t establish what actually helps a patient. Moreover, many psychoanalysts frown on what they consider to be superficial attempts to measure what they do.
Anything so far to help an insurer determine how to spend the money? It gets even worser:
Brent D. Slife stood before an audience at the annual APA meeting held in Washington, D.C., in August, and filed the equivalent of a philosophical antitrust suit against psychotherapy researchers. Slife, a psychologist at Brigham Young University in Provo, Utah, bemoaned what he called “the almost dogmatic status” of the philosophy of empiricism in guiding examinations of psychotherapy.
Slife thinks that psychotherapy should be evaluated qualitatively instead. This might help therapies that get slighted by the “evidence-based” craze, like humanistic and existential psychotherapy. But then, how can it get the coveted label of science? “If we took Slife’s approach,” a critical colleague said, “we’d quickly get booted out of the health care system.” Bower ends on that thought:
In the quarrelsome world of psychotherapy studies, there’s one issue that everyone agrees on: Psychotherapists are fighting an uphill battle to procure more than minimal health insurance coverage for their services. Norcross remarks, “The sad reality is that insurance companies largely respond to financial considerations, not psychotherapy research.”
Update 11/23/2005: A similar story appeared in New Scientist about psychiatry. Psychiatrists earn an M.D. and are licensed to dispense drugs, but this article by Liz Else says they face similar credibility breakdowns:
In psychiatry, the cost of erroneous scientific theories can be incalculable. Get things wrong (or even only half right) and once adopted by the profession it can take years to weed them out. The result can be millions of shattered lives.
Some of the world’s leading psychiatrists believe that this is just what has happened in their craft today. Poor diagnosis, shaky science and drugs with costly side effects all point to the same conclusion: psychiatry is badly in need of a radical overhaul.
1Bruce Bower, “Researchers spar over how best to evaluate psychotherapy,” Science News, Week of Nov. 5, 2005; Vol. 168, No. 19 , p. 299.
For those who didn’t already know that psychotherapy is a sickman fraud, this should be a real eye-opener. Put up or shut up, the insurance companies rightfully ask: let’s see some evidence that psychotherapy actually works before we dole out millions of dollars for it. What do they reply? “Well, it’s just too complicated to measure. You can’t treat it like uniform circular motion or gravity; but trust us, it’s scientific, and we know what we are doing.” Anybody who trusts a psychotherapist should get his head examined. You’d be better off seeing a real head-shrinker. You could save a lot of money by employing the Lucy in Peanuts fame, at her “Psychological Help: 5 Cents” booth. It appears her standard reply, “Snap out of it!” would prove as successful as anything the psychological charlatans come up with. It might even be less harmful. How many psychotherapists have irreparably damaged patients by “helping” them with their sex problems? If the truth were told, they would, in fact, be booted out of the health care system.
It’s no secret that Sigmund Freud was a worshiper of Darwin. Psychology has always followed the tradition of building on the Darwinist foundation, treating the human mind as a concourse of molecules molded by natural selection. Psychotherapy is a secular religion masquerading as science, intended to replace the pastor of the local church. Here we see that after all these years the Charlietans have nothing to show for it. Don’t waste your time; they are wells without water, clouds without rain.*
Need healing? There is hope for those who hurt. The secret is to follow the Manufacturer’s Manual. No one could ever figure out the complexities of the human mind but the one who made it. Need evidence-based healing? “Come unto me, all you who are weak and heavy laden,” said the Good Shepherd, “and I will give you rest. Take my yoke upon you, and learn of me, for I am meek and lowly of heart, and you will find rest for your souls” (Matthew 11:28-30). There are millions who will vouch for that. When God’s spirit takes control of a mind, a host of therapeutic agents are included: faith, hope, love, confidence, unselfishness, forgiveness, peace, thanksgiving, joy, and self-control. See our list of Bible verses on the subject. For some “evidence-based” illustrations of the power of God to change lives and heal sorrows, watch this film.