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Does Therapy Work?

     The decision to go to a therapist is a difficult one. Besides the practical considerations of time and money, and the emotional consideration of whether you are ready to face the challenge of revealing yourself to a stranger, you may (and should) be asking: Does therapy work? Hundreds of studies about this question have been published in academic journals in the last 60 years. An overwhelming preponderance of those investigations indicates that therapy is usually quite helpful. We thought we would tell you about a particularly unique study, expertly conducted, that emphasizes the effectiveness of the therapy experience in real world circumstances.

     In 1994, Consumer Reports magazine decided to use its annual reader survey to investigate the effectiveness of therapy. Along with the usual questions they ask about appliance reliability, car repair histories, etc., they included a number of questions about therapy. Specifically, they asked whether the respondents had, during the previous three years, sought help for an emotional problem. If they had, they were asked what kind of therapist they had seen and what kind of therapy he/she conducted (insight-oriented, cognitive-behavioral, etc.), how long they attended, for what kind of problems, how they felt then and now, how much they thought therapy had helped, how satisfied they were with the therapy, how competent they thought the therapist was, and their reasons for stopping treatment if they were no longer attending.

     The survey questions relating to therapy were designed and analyzed in consultation with academic researchers, including one whose name may be familiar to you: Martin Seligman. Seligman, a past-president of the American Psychological Association, is one of the progenitors of the field of "Positive Psychology" and is an old-school, highly published psychotherapy researcher. The Consumer Reports study was and is the largest survey about therapy ever conducted. Twenty-two thousand people responded to the survey. Seven thousand answered the mental health questions.

     The results very clearly indicated that therapy is beneficial: almost half of the people felt "a lot better" after therapy and another 40% felt "somewhat better." This was true even for those people who felt the worst ("very poor" or "fairly poor") at the onset of therapy.

Some of the other main results:

* The longer the therapy lasted, the greater the improvements. Staying in therapy for one year produced 11% more improvement compared to staying for a few months and staying in treatment for 2 years produced an additional 10% improvement. This finding of continued improvement over time was not true for therapy with family doctors, only for treatment conducted by mental health professionals.
* The advantage of long-term therapy with mental health professionals held up for nearly all specific complaints that led people to seek therapy, as well as for a variety of other more general improvements in functioning (e.g., 'ability to relate to others', 'enjoying life more', 'coping with stress', 'improved self-confidence').
* All mental health professionals effected improvements in their patients. Psychologists, social workers and psychiatrists did equally well and significantly better than marriage counselors.
* Active therapy shoppers and active patients in therapy had better improvements than passive patients. This was determined from answers to such questions as "When choosing this therapist did you check out other therapists?", "Did you discuss the qualifications and approach of the therapist?", "During therapy did you discuss negative feelings toward your therapist with him or her?"
* No specific type of therapy (i.e., psychodynamic, cognitive-behavioral, feminist, etc.) was found to be superior to the others for any type of presenting problem.
* Respondents with insurance coverage that limited their choice of therapist, the duration of their therapy, or the frequency of their sessions reported significantly less improvement than their counterparts without such restrictions.
* Therapy combined with medication was not superior in benefit to psychotherapy alone. The study was unable to make conclusions regarding the efficacy of treatment by medication alone because not enough of the respondents reported this.

     As Seligman points out in his paper in American Psychologist (which was a companion to the Consumer Reports article), there is a serious shortage of studies in the literature looking at therapy as it is conducted in the real world. Almost all studies about therapy are done in a somewhat artificial way: they limit the number of sessions offered, they do not allow people to self-select into the type of therapy they think would help them the most, they do not allow patients to pick a specific therapist, they do not allow the therapist to change treatment tactics if the situation suggests it, they exclude patients with multiple presenting problems, and they typically only measure symptom relief and not the kinds improvement in general functioning that people often say is very important to them. The Consumer Reports study imposed none of those limitations and thus really was able to answer the question: Are people with all types of issues helped when they seek help from all types of therapists. The answer to that question was quite positive.

     A noteworthy finding from the survey is that no therapy approach was found to be superior to any other. Most lay people, and many professionals, however, think that the research literature indicates that Cognitive-Behavioral therapy (CBT) is generally superior. How should we understand this apparent contradiction? In a nutshell, CBT, by its nature, is easier to study using the above-described 'laboratory' method and because of this there are many studies showing that CBT works and that it works for many types of symptoms: depression, obsessive-compulsive disorder, panic, phobias, agoraphobia, bulimia. Other types of therapy are much less amenable to laboratory study. Thus, there are many fewer studies indicating the usefulness of those approaches and many problems and symptoms for which there is no evidence of their utility simply because no studies have been conducted. Logically, though, the absence of studies should not be interpreted to mean that the non-CBT approaches are inferior. What has been lacking is research that can include psychodynamic, interpersonal, humanistic, and family-systems approaches in real-world settings. The Consumer Reports study did this and indicated the relative equivalence of all approaches.

     A reasonable inference from this study is that patients will probably benefit best if treatment and therapist characteristics are matched to them specifically. Experienced therapists do this naturally, and patients should be active participants in this matching process by insisting on feeling well-matched with their therapist and his or her approach to treatment.