There has been extensive promotion of research models of psychotherapy, largely due to the demand from certain industries for evidence based practice. The problem with psychotherapy research is not necessarily in the research itself but in the superficial application of whatever evidence one can glean from the research. There is now a growing concern about the poor application of research models to actual practice, with calls for more naturalistic and efficacy studies that look at what really works well in the real world. In considering any research, it is also important that various research findings make sense relative to each other, and also fit well with actual clinical experience. When there is considerably discrepancy between the interpretation of research and both clinicians and patients actual experience, there is clearly a problem.
Standard research psychotherapy models basically show that almost all models work about equally well, but that they all work badly. The type of results one finds across the board with standard psychotherapy research is that one gets only a modest reduction of symptoms in most people with fairly high relapse rates. These models show themselves to be better than sham or placebo conditions that are designed to be as unhelpful as possible. Most research psychotherapy models have to be “standardized” or dumbed-down in order to have consistency in the research and to be able to ascertain what therapy attributes one is testing. Therapists are restricted from doing what expert therapists do, and have to adhere to conditions that would frustrate most expert therapists. The sham therapies often used would drive most people crazy, as, for example, if one is using a strictly supportive therapy as a placebo therapy, the therapist is only allowed to make mundane supportive comments. The good news is that this type of research shows that even under these conditions, therapy does work. It just does not work as well as one would hope.
It is also important to recognize that most psychotherapy research is not done on real life populations. Most of this research is diagnosis based. This means that subjects need to fit cleanly into one, and only one diagnosis. Anyone who may fit into more than one diagnosis is excluded. In real life most people don’t fit well into one diagnosis, and many people have long-standing issues that would be beyond the scope of study in research models. So basically what standard psychotherapy research shows is that dumbed-down models of therapy work better than conditions designed not to help people in populations that don’t necessarily reflect the problems of real life individuals.
There are additional limitations amd biases in psychotherapy research. Overall, the main feature of psychotherapy that has been shown to correlate with outcome is something called the therapeutic alliance. This basically refers to the positive working relationship between the therapist and the patient. Thre is little evidence that any particular technique correlates with outcome. One interesting field of research looks at the practices of therapists who seem to have excellent results. This research indicates that these so-called “super-shrinks” are able to form very strong therapeutic alliances largely due to their ability to understand the patient on a deeper level and being able to relate that understanding to the patient. These findings support the importance of both the relationship between the patient and the therapist ,and the importance of understanding the patient. This would seem to be obvious, yet most research models limit these aspects. In the real world one often chooses a therapist through recommendations and makes first contact directly with the therapist. Even if one is going for primarily short-term therapy, there is still usually the understanding that the therapist will be available in the future if necessary. These aspects help develop the working relationship. In public system models, these aspects may be more limited, yet there is still often some flexibility in the present and future availability of the therapist, as well as a connection to the supporting system. In research models, all this is absent. Subjects are randomly assigned to therapists, with usually no chance of ever seeing the therapist again after the research is over. Extra contact with the therapist is usually prohibited. It follows that any form of therapy that strongly uses the therapeutic alliance as a foundation of the therapy will be undervalued in the outcome of the research. This is important, as research shows that it is precisely these therapies that should work best. Most research models focus on symptoms to ascertain outcome, even though most people come to therapy with emotional issues as well as symptoms. If one imagines designing two sham therapies: one which focuses on emotional issues and one which focuses on symptom reduction. In the first one, the therapist encourages the patient to talk about deeper emotions, and give the patient positive feedback when the patient is able to express these issues. In the other one, the therapist gives the patient negative feedback when the patient talks about bad feelings. If these patients are then given a symptom rating scale to fill out at the end of these therapies, it follows that the patient that was encouraged to suppress symptoms is more likely to report lower symptoms, while the other patient might feel freer to report there feelings of sadness or anxiety. What this means is that there is a natural bias in most psychotherapy research against therapies that rely on the therapeutic alliance and that are more emotion centered. Therapies that rely on tools of symptom suppression should show better results simply based on the biases in research. In reality, this is not the case. Both emotion-relationship based therapies and symptom focused therapies show equal results, with the symptom focused therapies showing a slight advantage when symptoms are the primary issue, and the other therapies showing an advantage when emotions or relationships are the primary issues. If one understands the impact of the biases in psychotherapy research, then it is clear that symptom focused therapies do not work as well as more complex, emotionally based therapies. This understanding also aligns with clinical experience where patients show much better results with emotionally based therapies. Despite this, symptom focused therapies are being highly marketed, and supported by both the pharmaceutical and insurance industries
The importance of having a deep understanding of a person in therapy is clearly essential for therapy to work well. This is supported by naturalistic studies, qualitative studies that indicate what patients felt was helpful, and research on therapeutic alliance. There is no strong evidence supporting technique in the absence of a strong therapeutic relationship as being important. In order to understand a person, one has to have a sense of their whole life experience. This is why an understanding of the person’s early life, family environment, social network and culture are all crucial. Thousands of therapists with many years of experience would agree with this. How one uses this understanding may vary between therapists, but to not have this understanding and knowledge of a person’s life, and to think one can be helpful is absurd. It is also important in order to understand a person’s experience to have some theoretical knowledge of human emotional development. Attachment theory, developmental theories and cultural studies are all important in understanding the experience of another. The more theories one is familiar with, the more people one will be able to understand. Most good therapists, regardless of their therapeutic orientation, will have this knowledge. Even Cognitive Behavior Therapy is turning more to the understanding of people’s experience and recognizing the importance of the therapeutic alliance in developing “Schema” therapy.
The truth about good therapy, is that most therapist, regardless of the school they follow will spend a significant amount of time helping a person deal with their real life issues. This is usually done with a sense of understanding what the person’s life experience has been, and how their life experience effects their view of themselves and others. These aspects are then related to the patient in a manner that conveys understanding and empathy, and which can be useful to the patient. In discussing therapeutic issues, therapists may split hairs between what is a cognition and what is a feeling, or what is a conflict and what is trauma related. While any discussion that furthers the understanding of the human condition is important, it is mostly how we relate our understanding to patients in a helpful manner that lets therapy work.
The message that is being heavily promoted, based on simplistic research models is that a therapist does not necesarily need indepth knowledge of the patient or understanding of complex theories in order to do therapy. This is especially true of the standard Cognitive Behavoiur Therapy model that many therapists are now practicing. This type of therapy can give a perjorative message to patients that may be damaging. Any implication that a patient should be able to control their symptoms if they only follow the rules and homework, puts all the onus of improvement on the patient, and can make people feel worse when they fail at these tasks. One patient, who had experienced this type of therapy, called it Confirmation Bias Therapy, as the therpist would not let the person talk about anything that could be construed as negative, and then pronounced the person better when the person stopped talking about anything important. While most experienced therapist would not apply any technique in such a superficial manner, the promotion of CBT has led to many therapist adopting these cookbook stlye practices. It is interesting to note that one can get Cognitive Behaviour Therapy certification with a four to twelve month training program, while psychodynamic psychotherapy training programs are typically two to three years long.
Among experts, the field of psychotherapy is moving towards integrative therapies that take into account what we have learned from research and clinical practice to be able to build strong working relationships with patients using multiple modalities adapted to the needs of the individual. It is sad that due to various pressures, and the misunderstanding of empirical evidence that there has been a growing use of superficial models that have been clearly shown to be only marginally better than nothing.