by Morton Hunt
Couples therapy: Couples therapy was originally known as marriage counseling but today often proceeds at a deeper level than old-time counseling and is offered not only to married couples but to premarital, extramarital, and homosexual couples, all of whom have somewhat similar relationship problems.
The therapist’s role in couples therapy is a tightrope act: If he or she is perceived by either member of the couple as siding with the other member, the therapy may be abruptly broken off. The therapist therefore seeks to avoid transferences that would generate strong feelings by either client; acts as interpreter, adviser, and teacher; and stresses that the troubled relationship, not either individual, is the client.
The therapist solicits information and makes interpretations; teaches communications skills and problem solving; plays back to the couple how they sound and look in their interaction (“Are you aware that you sat as far apart as possible?”); brings up sensitive issues that they avoid discussing with each other but can safely fight about in the relative safety of the therapist’s office; and assigns homework to teach them new and more satisfying patterns of behavior. Couples therapy is usually conducted on a weekly basis, and most problems can be resolved in a year or less. In some cases, the partners in couples therapy recognize that what one or both really want is the end of the relationship. In that case, the therapist sometimes is able to help them separate cooperatively rather than combatively and minimize the damage to themselves and to the children, if there are any.108
Family therapy: Family therapy was developed almost simultaneously in several different places in the United States in the 1950s, most notably in Palo Alto and New York. Its basic assumption is that psychological symptoms and difficulties of all sorts stem from faulty relationships within the family rather than from individual intrapsychic mechanisms (although these are not ruled out).
Even though the family may come in with an “identified patient”—a scapegoat or supposedly sick member on whom the family blames its troubles—the therapist regards the family as the patient, or, to be more precise, the family’s interactions, rules, roles, relationships, and organization. All these make up the “family system”; family therapy draws heavily on systems theory, which was borrowed and adapted from biology. In systems theory terms, the family members may be either overly or insufficiently involved with one another; cut off from outside influences by rigid family boundaries; conversely, lacking in a sense of familial belonging because of vague family boundaries; and so on.109
The therapist diagnoses the family’s problems in systems theory terms by means of genograms (diagrams of family patterns over three generations), by determining what the alliances are within the family, and by using other methods special to family therapy. There are several schools of family therapy, each of which has developed its own intervention techniques. Family therapy is offered not only privately but in clinics and community mental health centers.
The American Association for Marriage and Family Therapy now has more than 23,000 members, who come from various disciplines and have met the association’s requirement of training and supervised postgraduate experience as marriage and family therapists. Many other thousands of psychotherapists, who may or may not have had extensive training in marital and family therapy, call themselves marital and family therapists—the term is not controlled by law in most states—to indicate that they deal with couples and family problems as well as individual ones.110
Odds and ends: In addition to all the above, a large selection of other brands of therapy is available, at least in America’s major cities and particularly in California. Some are strange but based on sound psychology; others are even stranger and based on pseudo-scientific or mystical ideas. All told, they are essentially trifling in their contribution to mental health treatment. A random sample:
Primal theory requires the client to engage in prolonged screaming in order to release infantile rage. The client is taught to do this at home when necessary.
Morita therapy, developed in Japan, is based on Zen principles and begins with four to seven days of total bed rest, isolation, and sensory deprivation. Thereafter, the patient is taught to accept his feelings and symptoms and to live actively in the present, directing his thinking away from himself and toward the world around him.
Ordeal therapy assigns the patient to a task or situation worse than the presenting problem, such as getting up in the middle of the night, every night, to exercise.
Paradoxical prescription, employed to break down powerful resistances, consists of telling the patient to keep on with his problem behavior or even to step it up. The permission to do the impermissible is supposed to defuse it, rob it of its perverse value, and lead to a breakthrough.
Positive psychology, discussed in an earlier chapter, is an umbrella term for a therapeutic regimen that, while not ignoring what is known about human suffering and disorders, stresses positive emotions, positive character traits, peak experiences, and an understanding of happiness. It has been widely publicized by its originator, Martin Seligman, but accounts for only a minuscule percentage of psychotherapy patients.
Hypnosis or, more precisely, post-hypnotic suggestion, sometimes helps people control their smoking or overeating, overcome stage fright, and deal temporarily with other undesirable traits.
EMDR (Eye Movement Desensitization and Reprocessing): After several initial stages of preparation, the client focuses on the image of the cause of the disorder and moves his/her eyes back and forth following the therapist’s fingers as they move across his/her field of vision for twenty to thirty seconds or more. This is repeated a number of times during the session. It is supposed to eliminate the influence of the source of the image.
est (Erhard Seminars Training), popular in the 1970s, consisted of two weekends spent in a ballroom (at a cost of $250). Bathroom privileges were denied except at official breaks, and the audience was subjected to a day-long barrage of abuse by the leaders (“You are all assholes… You’re nothing but a goddamn machine”). When the clients were sufficiently exhausted and humiliated, the secret of life was revealed: You are a machine, cannot be anything but, and can be happy only by being what you are. Werner Erhard stopped holding sessions in 1991, but a firm called Landmark Forum continues to run est-type meetings.
Special-purpose workshops last half a day or all day, and sometimes for a whole weekend, with time out only for food, toilet use, and sleep. Lectures, group therapy, sensitivity training, and other activities are all used to deal with feelings and emotional symptoms stemming from a problem the attenders share: child abuse, incest, spousal abuse, fear of revealing oneself, and many others.
And all those others: What shall we call them? Well, let’s not call them anything but merely mention a few in passing: orgone therapy (in which the patient sits in a special box that supposedly collects a curative energy pervading the universe), dance therapy, past lives therapy, miracles therapy, healing through visionary experience, aromatherapy, mindfulness, therapeutic touch… but it is time to call a halt. We have gone beyond the bounds of science, even though many people think of these fringe activities as psychotherapies based on psychology.
But Does It Really Work?
In his autobiography, the late H. J. Eysenck proudly termed himself “rebel with a cause.” Indeed, many causes. After leaving Germany for England in his youth, he enthusiastically laid about him in sundry educational, political, and scientific battles, even while making solid contributions in several areas of psychology. Long a professor and researcher at the Institute of Psychiatry, University of London, and with an impressive list of published and widely cited contributions on intelligence, testing, and personality, he, like Ellis (but on a serious plane), was always a resolutely cheerful bad boy of psychology.
None of his imbroglios was more heated than the one brought about by his historic assault on psychotherapy in 1952. Eysenck had always been contemptuous of psychotherapy, which he felt was unsupported by any scientific evidence.
To prove the point he reviewed the data of nineteen studies reporting the results of psychotherapy and came to some shocking conclusions. The different studies claimed “improvement” in as few as 39 percent and as many as 77 percent of the cases, a range so broad as to justify suspicion, he said, that something was amiss. Far worse, Eysenck added up the findings and calculated that, on average, 66 percent of the patients had improved—and then cited other studies reporting that of neurotic patients who had custodial care but no psychotherapy, 66 to 72 percent had improved. His conclusion: There was no evidence that psychotherapy was responsible for its supposed effects. His radical corollary to that conclusion: All training in psychotherapy should be abandoned forthwith.111
“The sky fell in,” he later commented. “I immediately made enemies of Freudians, of psychotherapists, and of the great majority of clinical psychologists and their students.”112 As was to be expected, many of his newly made enemies—including prestigious names in British and American psychology—wrote angry replies. Anger aside, they had good grounds for discrediting his findings, and published rebuttals in a number of leading British and American psychology journals. Their most telling criticisms were that Eysenck had lumped together data derived from different forms of therapy, different kinds of patients, and different definitions of improvement; moreover, the untreated group was not truly comparable to the treated groups.113 Still, he had thrown down the gauntlet; it was now up to those who believed in psychotherapy to prove that it was effective, a task they had never seriously undertaken.
Ever since, there has been a steady flow of psychotherapy outcome studies—many hundreds, in fact—differing greatly in scientific quality, in the size of the samples studied, in the criteria of improvement, and in the use or lack of use of control groups. Their findings, accordingly, have shown great variation.
But meta-analyses that rate the studies by scientific quality, adjust for differences in method, and only then sum up the results, have repeatedly found that the weight of evidence is clearly in favor of psychotherapy. In 1975, a painstaking meta-analysis of nearly a hundred controlled studies, by Lester Luborsky of the University of Pennsylvania, concluded that most of them found a high proportion of patients benefiting from psychotherapy. And, contrary to Eysenck’s claim, two thirds of the studies showed that significantly more treated than untreated patients improved.114 (If studies involving minimal treatment had been excluded from the Luborsky review, the superiority of therapy over no therapy would have appeared still greater.)
A comprehensive review of outcome studies made in 1978 by a team at the National Institute of Mental Health came to a similar conclusion.115 In 1980 a still more comprehensive meta-analysis by another team of psychologists reviewed and evaluated the findings of 475 studies, using a wide range of outcome measures to compare the experience of patients who received psychotherapy with untreated members of control groups. Its conclusions were unequivocal: Therapy yields benefits in most, though not all, cases.
Psychotherapy benefits people of all ages as reliably as schooling educates them, medicine cures them, or business turns a profit …The average person who receives therapy is better off at the end of it than 80% of the persons who do not. This does not, however, mean that everyone who receives psychotherapy improves. The evidence suggests that some people do not improve, and a small number get worse.116
But one aspect of the findings of these meta-analyses seemed baffling: All forms of therapy appeared to benefit about two thirds of the patients. Yet if each kind of therapy works for particular reasons—as spelled out by the theory it is based on—how could all work equally well? Luborsky’s team wondered whether it was really true that, as in the dodo bird race in Alice in Wonderland, “everyone has won and all must have prizes,” and concluded that it did seem to be true. Their explanation was that there are common components among the psychotherapies, most notably the helping relationship between therapist and patient. Other researchers pointed to other common factors, especially the chance to test reality in a protected environment, and the hope of relief, generated by therapy, that motivates the patient to change.
Yet the dodo bird hypothesis is exceedingly counterintuitive; common sense and lifetime experience tell us it is most unlikely that despite the great differences in therapeutic methods, they all work equally well for all conditions. The meta-analyses assure us that psychotherapy does work, but the overall figures they give do not link particular techniques to the outcomes of particular disorders. Moreover, they average out the results achieved by different therapists in each study.
Luborsky and colleagues, seeking to demystify their own findings, did a later study of therapists who used three different approaches in treating drug-dependent patients and found that the choice of therapy was less important than the personality of the therapist.117 More important has been the development, in recent years, of a genre of outcome studies that test the results of specific techniques in the treatment of specific disorders. Such research has furnished ample evidence that certain forms of therapy are anywhere from somewhat to much more effective than others in the treatment of particular conditions.
We have already heard of some of these results; among others, a technique known as “cognitive-behavioral treatment with response prevention” is markedly superior to other methods of treating OCD (obsessive-compulsive disorder); CT with exposure to a feared object or situation yields better results with anxiety disorders than other methods; psychodynamic therapy is effective in the treatment of depression if the therapist is a warm and supportive person (but, overall, CT and interpersonal therapy do as well); both CT and CBT are more effective than medication in the treatment of anxiety symptoms; CBT is more effective than medication for treating insomnia; and similar findings show other techniques to be especially effective with other disorders.118 Some of these results have been further substantiated by cognitive neuroscience: Brain scans have shown, for instance, that CBT produces changes in the brain of a depressed patient quite different from those of medication. Both methods relieve symptoms, but medication produces a bottom-up change while psychotherapy produces a top-down and hence more lasting change.119
The new outcome studies are, moreover, part of a movement within medicine and psychotherapy known as “evidence-based treatment.” In recent years the American Psychological Association, the American Psychiatric Association, the U.S. Agency for Health Care Policy and Research, and several managed care companies all have proposed psychotherapy practice guidelines based on treatments of mental disorders that have been empirically proven effective. Paul Crits-Christoph calls this movement “the biggest change in therapy of the last ten years.”
That’s a change? Haven’t psychotherapists always been guided by the evidence of outcomes of various forms of treatment? Yes, by the outcomes of their own practices. But no, not by empirical research studies. The editors of A Guide to Treatments That Work, a massive 2002 review of empirical studies of psychotherapies and psychotropic medications, acerbically note the “lamentably low value psychotherapists and other mental health professionals more generally continue to attach to psychotherapy research… The clinical activities of most psychotherapists remain largely untouched by findings from empirical research. Many clinicians continue to utilize methods and procedures that lack empirical support.”120
One reason for this is the well-documented phenomenon known as the “expectancy effect.” Therapists (like physicians and scientists) tend to see the results, in their own work, that they expect to see. The results reported by any therapist based on his or her own practice fall far short of the guidelines of scientific rigor. To be genuinely empirical, evidence must be produced by impartial researchers, and by comparing the outcome in a treated group with that in a control group (a strictly similar but untreated group), which enables the researchers to subtract the expectancy effect, the placebo effect, and other distortions from the apparent effect of treatment.
When the APA’s Division of Psychotherap
y raised the issue of evidence-based therapy a decade ago, there was a fierce backlash from therapists who feared they would be controlled by managed care officers who would refuse to reimburse them if empirical evidence did not back up the therapy they preferred to use. A heated debate—a “major controversy,” according to an APA Web page offering a course in evidence-based psychotherapy—has continued ever since.
Yet the concept of empirical evidence as a guide to treatment is not new; in medicine it goes back a century or more, and it has been part of the world of psychotherapy for decades. “What’s different today,” says Crits-Christoph, “is that the label ‘evidence-based therapy’ now has political clout. From the early sixties through the nineties there was no process for turning research into practice. No one was pressuring anyone to sign on the dotted line that you would translate empirical research findings into practice.” In England, under socialized medicine, evidence-based therapy is enforced; here, it is beginning to be enforced by managed care providers—and by moral suasion.
For despite the resistance to the evidence-based movement, says Crits-Christoph, “It has raised consciousness of the importance of empirical evidence. The concept of evidence-based therapy has become a fundamental guiding principle. It’s getting very hard to disagree with the idea that empirical evidence should shape practice.”121
Very hard to disagree with the idea—and with the evidence assembled in A Guide to Treatments That Work (and other more recent compilations). The Guide presents the results, primarily of rigorous studies plus some less than rigorous, of dozens of pharmacological and psychotherapeutic treatments of over two dozen major disorders. We heard above of some of the treatments that work; here are a few others:
