The Effectiveness of Psychotherapy

Psychotherapy arrived in Latvia relatively recently - approximately 10 years ago. The first psychotherapists received their education with the help of foreign teachers - by organizing training in Latvia or by traveling abroad to study (Stabingis, Ratniece, 2003). Comparing the situation of psychotherapy in Latvia with that in Europe, it is evident that one of the areas where work has not yet begun is research in the field of psychotherapy. The range of potential research topics is very broad, yet critically necessary for the development of the field. Similarly, the accessibility of psychotherapeutic services differs, particularly due to financial considerations: both in Europe and in the USA, psychotherapeutic services can be paid for through health insurers and sick funds - at least in some cases. The payment procedures differ in each country - sometimes quite significantly. What therapy approaches are covered varies, as does which problems are “accepted” for resolution through psychotherapy, and specific durations are set for resolving particular problems. Specific psychotherapy manuals are even published, with strictly defined methods for working with particular problems, which generates considerable debate among psychotherapists (Addis, Waltz, 2002; Addis, 2002; Godley et al, 2001; Eliot, 2000). It can also be expected that in Latvia, over time, insurers will cover psychotherapy services as well. To decide what the payment procedures will be, insurers will be interested in the effectiveness indicators of psychotherapy available in Latvia. Furthermore, factors influencing psychotherapy effectiveness are also essential for other groups of people involved in providing psychological help: for psychotherapists - to improve the quality of services they provide; for psychotherapy educators - to improve the quality of training; for healthcare sector officials - so that their regulatory and normative acts are adequate to the existing situation; for clients - for broader information about the possibilities and limitations of psychotherapy. Theory It is believed that scientific research on psychotherapy effectiveness began in 1930 (Fenichel, 1930, cited in Fonagy et al, 2002). Since then, similar studies have been conducted practically without interruption, and methods, procedures, and theoretical foundations for measuring psychotherapy effectiveness have been developed. Summarizing nearly a century of research, Lambert (Lambert, 2002) identifies the following key findings: Psychotherapy is effective. 75% of people who have received psychotherapeutic help have experienced some improvement. This applies to practically all disorders for which psychotherapeutic help is sought, except for certain disorders of biological origin such as schizophrenia or bipolar disorders, where psychological help ranks behind pharmacological treatment in importance. In some cases, psychological help should be used before medication, as it is less dangerous and has fewer side effects, or - at least - simultaneously with medication, thereby reducing the possibility of relapse after discontinuation of medication. The effects of psychotherapy are better than placebo or informal support systems. Comparing results from multiple experimental studies, it can be stated that although in all three cases (informal support systems, placebo, or psychotherapy) patients’ conditions improved, the differences are significant. (Informal support systems: 17%, placebo: 20%, psychotherapy: 75% of cases) Psychotherapy results are substantial. Analyzing studies published over five years on psychotherapy outcomes, the measurement methods include client reports, psychological change measurements, expert evaluations, assessments by family members, friends, and colleagues, as well as work, health, and legal (e.g., incarceration) indicators. Results affect such areas of a person’s life as psychiatric symptoms (e.g., anxiety, depression, anger, stress), interpersonal functioning (e.g., family relationships, loneliness, intimacy), and fulfillment of social roles (e.g., workplace conflicts, absenteeism, career). All these factors are highly significant for the client, their family, and society as a whole. Psychotherapy results are lasting. Several studies that evaluated clients’ conditions over longer time periods (from six months to five years) consistently show that psychotherapy results are long-lasting. Psychotherapy is comparatively effective. Studies examining the rate at which clients’ conditions improve and the required duration of therapy indicate that one-third of clients normalize after 10 sessions, 50% after 20 sessions, and 75% after 55 sessions. Researchers conclude that limitations on psychotherapy volume imposed by insurance companies and government institutions create a situation where the amount of services available to some patients is insufficient. Psychotherapy both helps and makes conditions worse. Despite all the positive research results, after therapy some patients’ (5-10%) conditions have worsened, and 15-25% have shown no change. However, by conducting effectiveness measurements and providing therapists with information about current effectiveness, the number of unsuccessful cases can be significantly reduced. (Lambert, 2002) Seligman, who has conducted multiple studies on psychotherapy effectiveness, has noted: “We have strong evidence that therapy works, but comparing specific methods, finding specific effects of impact is difficult.” (Seligman, 1998). Previously, while serving as president of the American Psychological Association, Seligman commented on the 1995 Consumer Reports survey (Consumer Reports survey, 1995), pointing out the differences between psychotherapy efficacy and effectiveness studies. (Seligman, 1995) In their meta-analysis of psychotherapy efficacy, Lambert and Bergin (Lambert, Bergin, 1994) clearly note that “…there are only negligible indications that one therapy school or technique is superior to another” (p. 161). The authors offer several alternative explanations for the “general finding of no differences,” including the possibility that different therapies may achieve similar results through different processes; therapies have different outcomes, but research strategies used thus far do not reveal them separately; individual therapy approaches contain common change-promoting factors that are nevertheless not emphasized in the theoretical understanding of change within that approach. (p. 161). Unfortunately, existing data do not allow these explanations to be distinguished. Finally, the authors point to the significance of the individual therapist in achieving therapy outcomes. In individual studies and meta-analyses, it is evident that the therapist’s individuality determines a large part of the therapy effect - in other words, a particular therapist’s individual abilities are even more significant than other factors, including theoretical orientation. Although there is still no strong evidence, it is not far from being able to justifiably state that there are not more or less effective therapy schools, but rather more or less effective therapists. (Lambert, Bergin, 1994). Quite surprising results can be found in Beutler’s studies, which have correlatively confirmed that therapist characteristics - experience level and training - have practically no impact on therapy outcomes. (Beutler, 1994). Jacobson (Jacobson, 1994) shows similar results regarding experienced therapists and master’s level students working in couples therapy. Effectiveness factors. Results obtained in individual quantitative studies show that therapeutic change occurs approximately 40% of the time thanks to client and extra-therapeutic variables, 30% due to relationship factors, 15% is determined by client expectations and hopes, and 15% occurs thanks to individual approach techniques and theoretical models. (Assay, Lambert, 1999) In a research summary conducted by the American Psychological Association, it is evident that therapeutic effectiveness depends much more on everyday factors rather than on special procedures, techniques, or individual therapist approach. (Hubble, Duncan, Miller, 1999) A thorough compilation of factors influencing effectiveness was conducted by Sponsel (Sponsel, 1998), who identifies ten groups, describing the therapy result as a function of these factors: TR = f ( Ei, Pi, Si, Mi, Ti, Ui, Ci, Ji, EMi, Xi ) where: E_nvironment - environment, situation, context, as well as their impact on the client/patient, including the two most important: personal relationships and professional relationships. P_erson - the person (client/patient) who has problems, difficulties, disorders, illnesses - these can be individuals, groups, families, couples, teams, organizations with their respective specific personality traits, genetic predispositions, and personal life experience. S_ymptoms - problems, disorders, difficulties, illnesses, limitations. M_ethod - the methods applied for solving problems. T_echnique - the technical implementation of methods used (organization, presentation, application). U_ser - the user (psychotherapist, consultant) who applies the specific method in therapy. C_riteria - criteria for therapeutic change, success or failure. (For example, changes in symptom manifestation, also objective criteria - reduction in work absenteeism, improvement in academic performance). J_udges - sources of evaluation - client reports, reports from acquaintances or colleagues, therapist impressions, independent evaluator reports, etc. E_valuation M_ethod - evaluation methods. (For example, how well and appropriately the specific methods have been used (objectivity, reliability, validity, stability, fairness, applicability)). Here at least three evaluation levels can be distinguished: (1) individual cases, (2) groups formed from individual cases, (3) meta-analysis of groups. X_rest - the influence of other factors. Summarizing the interaction of all factors: Each problem (S) belongs to a specific client/patient (P) who is in a specific environment (E). The therapy method (M), used by the user (U) in a specific manner (T), produces one result or another (TR) according to criteria (C), as evaluated by evaluators (J), in accordance with the evaluation method (EM). (Sponsel, 1998) Both Sponsel and Elliott note that the American Society of Clinical Psychology (Division 12 of the American Psychological Association), which relies on randomized clinical trials, is not truly suitable for all types of psychotherapy, and limits humanistic, psychodynamic, and strategic approaches. Therefore, Elliott proposes new criteria to find experimental confirmation for humanistic and other psychotherapies as well (Elliott, 2000).