Image: MARIO WAGNER
As a prospective client searches for a psychotherapist, numerous questions may spring to mind. How experienced is the therapist? Has he helped people with problems like mine? Is she someone I can relate to? Yet it may not occur to clients to ask another one: What type of therapy does the clinician deliver? People often assume that the brand of therapy offered is irrelevant to the effectiveness of treatment. Is this assumption correct?
Psychologists do not agree on whether the “school” of therapy predicts its effectiveness. In a survey in 2006 by psychologists Charles Boisvert of Rhode Island College and David Faust of the University of Rhode Island, psychotherapy researchers responded to the statement that “in general, therapies achieve similar outcomes” with an average score of 6 on a 7-point scale, indicating strong agreement. In contrast, psychologists in practice averaged a rating of 4.5, signifying that they agreed only moderately with that position.
As we will discover, both camps can justify their point of view. Although a number of commonly used psychotherapies are broadly comparable in their effects, some options are less well suited to certain conditions, and a few may even be harmful. In addition, the differences among therapies in their effectiveness may depend partly on the kinds of psychological problems that clients are experiencing.
Tale of the Dodo Bird
At least 500 different types of psychotherapy exist, according to one estimate by University of Scranton psychologist John Norcross. Given that researchers cannot investigate all of them, they have generally concentrated on the most frequently used approaches. These include behavior therapy (altering unhealthy behaviors), cognitive-behavior therapy (altering maladaptive ways of thinking), psychodynamic therapy (resolving unconscious conflicts and adverse childhood experiences), interpersonal therapy (remedying unhealthy ways of interacting with others), and person-centered therapy (helping clients to find their own solutions to life problems).
As early as 1936, Washington University psychologist Saul Rosenzweig concluded after perusing the literature that one therapy works about as well as any other. At the time, many of the principal treatments fell roughly into the psychodynamic and behavioral categories, which are still widely used today. Rosenzweig introduced the metaphor of the Dodo Bird, after the feathered creature in Lewis Carroll's Alice in Wonderland, who declared following a race that “everyone has won, and all must have prizes.” The “Dodo Bird verdict” has since come to refer to the claim that all therapies are equivalent in their effects.
This verdict gained traction in 1975, when University of Pennsylvania psychologist Lester Luborsky and his colleagues published a review of relevant research suggesting that all therapies work equally well. It gathered more momentum in 1997, when University of Wisconsin–Madison psychologist Bruce E. Wampold and his co-authors published a meta-analysis (quantitative review) of more than 200 scientific studies in which “bona fide” therapies were compared with no treatment. By bona fide, they meant treatments delivered by trained therapists, based on sound psychological principles and described in publications. Wampold's team found the differences in the treatments' effectiveness to be minimal (and they were all better than no treatment).
One explanation for the Dodo Bird effect is that virtually all types of psychotherapy share certain core features. In a classic 1961 book the late psychiatrist Jerome Frank of the Johns Hopkins University argued that all effective therapies consist of clearly prescribed roles for healer and client. They present clients with a plausible theoretical rationale and provide them with specific therapeutic rituals, he wrote. They also take place in a setting, usually a comfortable office, associated with the alleviation of distress. Later writers elaborated on Frank's thinking, contending that effective therapies require empathy on the part of the clinician, close rapport between practitioner and client, and shared therapeutic goals.
Rights & Permissions
See what we're tweeting about
7 Comments
Add CommentThe million dollar question, completely undiscussed in this article, is, what is the definition of successful therapy? Asking practitioners if a methodology is effective is akin to asking politicians to assure they are not influenced by donations. On the other hand, asking patients is hardly the answer. Until a good method for defining and measuring therapy effectiveness is developed, this discussion will be fairly pointless. To my knowledge, only psychoanalysts ponder the truly long term effects of any treatment, perhaps because they generally treat for long periods.
Reply | Report Abuse | Link to thisHuh!: it seems it was said that the basic mechanism in all psychotherapies is what Sigmund Freud described and named "Transfer", in an automatic way the therapist occupies in the person he/she has in front the place and the functions of a parental or authority figure, thus putting the person attending the therapists' office in dependence, susceptible of an induced regression to early stages of psyche development, and able to accept commands, mainly of a super-ego nature, as parental figures are mainly a source of constraints, if they acted in a different way, destruction of mature ego defenses and attitudes may result, even to a point close to a psychopathic personality. Even if the psychotherapy type pretends being non-dynamic or non-psychoanalytic, just entering somebody's office, be it a doctor or a head of state or a CEO puts the transfer mechanisms working in the passive part of meeting. Beware of the dog!
Reply | Report Abuse | Link to thisArkowitz and Lilienfeld present a remarkably balanced, even reasonable, discussion of this never ending debate. Sometimes when I hear clinicians argue about the effectiveness of their brand of therapy vs someone else's I think they sound like they are selling McDonalds as better than Burger King.
Reply | Report Abuse | Link to thisAs the authors point out, what type of therapy is to some extent, dependent upon the particular problems a client is dealing with. Yes, there are "empirically supported treatments (EST)" but they are always for a specific disorder. Many people (maybe even most) come to see us without a bona fide "disorder" --they simply want to do a better job handling their ordinary problems in living. So to use an EST for X or Y or Z won't necessarily make sense. At this point, having been a clinician and researcher for several decades, I've come to the conclusion that 1) Case specificity is always needed (i.e., each person is different); and 2) We should all know the empirically supported techniques (not as treatments necessarily, but as methods we can suggest if we think they might be helpful). So if I see someone who has no specific disorder but gets anxious when something anxiety producing is happening, I know specific techniques used in CBT/Behavioral "treatments," I have an arsenal of methods and it seems reasonable that every clinician should be able to use methods from different "treatments." Perhaps a problem is that it is difficult for clinicians to admit that clients come to them with no real disorder --how will they get 3rd party payments for no disorder? I don't have an answer, other than to repeat that we clinicians should all learn how to use multiple techniques when it seems they might be helpful, without leaning on a rigid manualized, by-the-books "treatment" for a disorder a client doesn't have. Sometimes passing on books or journal articles is helpful, sometimes suggesting a self-help group in addition to our meetings is in order, sometimes a medication consult is a good idea. We need to be fluid in our ability to help people, according to their needs.
I really like the reasoned, balanced perspective the authors take in this commentary.
Lynn O'Connor
Probably not. I tend to agree with Lynn O'Connor that the kind of therapy used should be tailored to the needs of the individual patient.
Reply | Report Abuse | Link to thisWhat isn't mentioned is that the different types of psychotherapies also correlate to the many different "models" of human spirit, mind, congnition, intellect, reaction, whatever the "psychologists" want to call it. From Alder to Skinner to Jung to Freud. The very fact that there are so many differing "theories", with no resolution even after more than a century of "study", suggests that "psychology" does not deserve to be classed as a "science", and, although this may cause this to be removed, therefore, any "science" venue that discusses "psychology" as a validated field cannot be trusted.
Reply | Report Abuse | Link to thisThere is another ugly little secret about "psychology" that absolutely no one in "psychology" or "science" wants to admit. All of "psychology" comes solely from case histories! They make involved and potentially destructive pronouncements about the presumed nature of all humans, but the "analysis" comes from only a few who exhibited uncontrollable even criminal deviate tendencies! Every human judged by the behavior of a few sociopaths! Never did any "psychological" "school of thought" actually set out to examine the actual thinking and motivation of, frankly, normal people! They simply issued pronouncements on the basis of what unhinged individuals did, "concluding" that everyone thought the same!
That "schools" as different as the simplistically mechanistic Skinner to the sexually obsessed Freud to the archetypes of Jung to "gestalt" and so on can all supposedly have the same effectiveness can suggest a number of things. It could say, among other things, that no "psychoanalyst" can tell when a patient is cured. It suggests that every "psychoanqa;yst" claims a pateint is cured, even if they set a city afire, and the "medicaql" community won't turn against one of their own. Or it can be that the one thing every form of "psychoanalysis" has in common is the one thing that cures! What was known from the beginning as "the talking cure". Giving someone the chance to express what they're thinking, feel they have a friend to confide to, feel validated, be comforted, maybe even embarass themselves into reconsidering!
Study findings depend on the questions asked, the variables defined, and the perspective of the researcher who interprets and presents them, among many other factors. These are not trivial to address. For example, how does one measure an unmeasurable quantity or quality, such as love, insight, or sadness? Often researchers do so through observable behaviors or self-report, each of which provide only partial information. One consequence of this is that the more easily measured pyschotherapies more easily gather evidence, and become promoted -- such as behavioral and cognitive behavioral. On the other end, narrative therapy is considered unmanualizable by many of its practitioners, making it impossible to quantify - yet its respectful approach and powerful effects have made it very attractive to both clinicians and clients. In another sense, strategic family therapy is often done with complete unawareness by the client(s) that the therapist is doing something strategic with them, and it would often be meaningless to ask them whether a particular session was helpful (for example). All of these components play a role in why research into what kinds of treatments are most effective is not as meaningful and compelling as we wish it were. Much of what is measured in each case is simply what is measurable -- and that is often the thing that varies so little, from theory to theory, while there are so many unmeasured and critical intangibles. Even so, there is indeed a growing body of evidence debunking the dodo bird theory. Relational, systemic therapies that address not just an individual but their context and relationships is far more effective than individualistic therapies. The former is the focus of MFT - Marriage & Family Therapy (my own field), while the latter has historically been the focus of psychology and psychiatry, although I continually hear of psychological approaches that are sounding more and more like MFT thinking. Certainly CERTAINLY, there is insufficient evidence to conclude that all therapies are created equal -- implying that a kind listening ear is just as effective as anything else (or at least that's how I interpret the dodo bird theory).
Reply | Report Abuse | Link to thisI appreciate RuthHoustonBarret's insight on this article, especially the inclusion of some of the more post-modern therapies (Narrative included). Part of the difficulty that this (and julianpenrod's comment) points to is the attempt to measure and evaluate a process that is both science AND art. The application of traditional research and evaluation techniques to psythotherapy can bear fruit in the same way that an art class can be taught, or art techniques standardized and understood. As with art, however, there is a place beyond the objective understanding and evaluation where the experience is largely subjective. Where the experience between therapist and client is as mysterious as between art and the observer. Obviously, with a push for evidence-based practices, and their ties to funding for many therapy organizations, evaluation into what "works" in therapy is a worthwhile venture. However, inasmuch as our schools are worse off for veering away from music and the arts toward science and math, the continued pursuit and inclusion of therapuetic modalities (even those that don't "work" for all clients) makes the world of psychotherapy a brighter, more balanced, place, where science and art can coexist, rather than the emphasis of the empirically provable over the subjectively valuable.
Reply | Report Abuse | Link to this