1. Does psychotherapy work?
A review of the research

2. Definition
Efficacy:
A measure of the treatment’s ability to improve whatever condition it is indicated for.

3. Treatment efficacy (does it work?)
Historically, therapy efficacy was of little interest until the 1950's
Freud rejected outcome research (problems too heterogeneous -- "apples vs. oranges")
Freud and contemporaries relied on case-studies to illustrate techniques

4. Hans Eysenck’s 1952 “bombshell”
Methodology
19 peer-reviewed studies
Outcome data for over 7000 neurotic patients
5 sets of psychoanalytic groups and 14 “eclectic” groups
Findings
Spontaneous recovery rate =72%
Psychoanalytic recovery rate=44%
Eclectic recovery rate= 62%
But Eysenck's study met much criticism
“Apples and oranges”
No control groups
Outcome criteria differences (when criteria restructured and data reanalyzed:)
Spontaneous remission =30%
Psychoanalytic = 83% and eclectic = 65%

5. The ideal efficacy study
random assignment of patients to treatment and control groups
treatment group
no-treatment controls
placebo controls (see next slide)
patients meet criteria for only one psychiatric diagnosis
treatments are manualized and scripted
patients are seen for a fixed number of sessions (usually 6-12)
outcome measures are unequivocal and quantifiable
raters and diagnosticians are blind (unknowledgeable) as to which group the patient is in
includes both post-treatment and follow-up assessment after a fixed period
Manualized treatment includes videotaping of sessions in order to monitor and eliminate any spontaneous divergence from the prescribed approach

6. Placebos: A Short Detour
Effects are strongest in patients expressing pain, fatigue, depression, and nausea
The placebo effect is getting stronger, making it increasingly harder for both new meds and new psychotherapies to outperform placebos (left)
Placebo effect relatively LESS pronounced when symptoms are more severe (middle)
Meds and PT still outperform placebos over longer time (right)
Ironically, placebos don’t work without a prescription
Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med, 5(2), e45. (middle)
DeRubeis, R. J., Siegle, G. J., & Hollon, S. D. (2008). Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nature Reviews Neuroscience, 9(10), (right)

7. Smith & Glass (1980)
Methodology: meta-analysis of  475 psychotherapy outcome studies
Findings: People in treatment function better than 75-80% of patients w/ no treatment (on waiting list)
Conclusions:
Psychotherapy works
There are negligible differences between different types of therapy

8. Other meta analyses:
Effectiveness of psychotherapy with children and adolescents: a meta-analysis for clinicians. Journal of consulting and clinical psychology
Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psychological, educational, and behavioral treatment: confirmation from meta-analysis. American psychologist, 48(12), 1181.

9. Some more findings
Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L. (1987). Effectiveness of psychotherapy with children and adolescents: a meta-analysis for clinicians. Journal of consulting and clinical psychology, 55(4), 542.

10. Therapy vs Medication (Depression)
DeRubeis, R. J., Siegle, G. J., & Hollon, S. D. (2008). Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nature Reviews Neuroscience, 9(10),

11. Efficacy vs. effectiveness
Efficacy: a measure of the treatment’s ability to improve whatever condition it is indicated for.
Treatment carefully standardized
Therapists highly trained
Patients/clients carefully selected and randomly assigned to treatment vs control group
Effectiveness: a measure of the how well the treatment works in the real world with all of its limitations.
Patients may have multiple problems (comorbidity)
Patients may receive multiple treatments at same time
Treatments may vary as function of therapist of patient characteristics, as well as insurance, time, etc.

12. Seligman’s 1995 Consumer Reports survey
Methodology
180,000 readers received issue w/survey
7,000 filled out survey, of which 3,000 saw mental health professionals
Respondents
educated
middle class
50% female
median age=46
Three outcome measures
Specific Improvement
Satisfaction
Global Improvement

13. Seligman’s 1995 Consumer Reports survey
Findings
Psychotherapy resulted in improvement for majority (90%) of respondents
Psychiatrists, psychologists, and social workers all equally effective but better than marriage counselors (after controlling for severity and type of problem)

14. Consumer Reports Findings (cont.)
Longer treatment (i.e., more sessions) was related to more improvement
The 300-point scale is derived from point sub-scales measuring specific improvement, satisfaction with therapist, and global improvement

15. Consumer Reports Findings (cont.)
Limitations on insurance coverage was associated with less improvement

16. Consumer Reports Findings (cont.)
People who reported feeling the worst prior to treatment, reported the most improvement
No difference between different types of therapies
No difference between psychotherapy alone and psychotherapy with meds
Active shoppers and active clients did better
Conclusion: Psychotherapy works!

17. Seligman’s 1995 Consumer Reports survey: A critique
Non-random, potentially biased sample
Cognitive dissonance may lead to positive bias in self reports
Improvement may be due to spontaneous remission or “regression to the mean”

18. 10 major achievements of psychotherapy outcome research (Lambert & Bergin, 1992)
Psychotherapy generally has positive effects
Many therapies > placebo
Research now looks at specific types
Behavior therapies effective for many disorders
Cognitive therapy effective for depression
Different types often equally effective
Therapies have many factors in common
Therapy may have negative effects 
Brief therapy works for many (50%)
Effects are relatively lasting

19. Is the Dodo bird extinct?
"Everybody has won, and all must have prizes."
Chapter 3 of Lewis Carroll's Alice's Adventures in Wonderland

20. Dodo bird effect (graphical form) (Wampold, 2001)
(NO significant differences among psychotherapies)
(significant differences among psychotherapies)

21. Revisiting Smith and Glass:
Is the Dodo real or extinct?