Introduction
Although the roots of psychotherapy can be traced back to ancient times, the birth of modern psychotherapy is frequently targeted with the famous case of Anna O. in 1882. Physician Josef Breuer, who was a colleague of Sigmund Freud, described Anna O. as a twenty-one-year-old patient with multiple symptoms, including paralysis and loss of sensitivity in her limbs, lapses in awareness, problems in vision and speech, headaches, and dual personality. During treatment, Breuer found that if Anna discussed every occurrence of a symptom until she described its origin and vividly recalled its first appearance, the symptom would disappear. Hypnosis was also employed to help Anna O. eliminate the symptoms more rapidly. (Eventually, Breuer stopped working with this patient because of numerous difficulties, including his jealous wife and his patient’s tendency to become hysterical.) Anna O., whose real name was Bertha Pappenheim, later became well known throughout Germany for her work with children, prostitutes, and Jewish relief organizations.
The case of Anna O. is not only important as perhaps representing the birth of modern psychotherapy but also characteristic of a method of investigation referred to as the case study or case report. A case report attempts to highlight descriptions of a specific patient and treatment approach, typically as reported by the therapist. Given the fact that most patients treated in psychotherapy are seen individually by a single therapist, it is not surprising that some of the most influential literature in the history of psychotherapy is based on case reports. Unfortunately, the majority of case reports are inherently problematic in terms of scientific merit and methodological rigor. Moreover, it is difficult to determine which factors are most effective in the treatment of any particular patient. Thus, whereas case reports are common in the history of psychotherapy research, their value is generally limited.
Early Studies
The earliest psychotherapy outcome studies were conducted from the 1930s to the 1960s. These initial investigations were concerned with one primary question: Does psychotherapy demonstrate positive effects? Unfortunately, the research methodology employed in these studies was typically flawed, and interpretations proved ambiguous. The most common area of disagreement in the early investigations was the concept of spontaneous remission. Psychotherapy was evaluated in comparison to the rates of improvement seen among patients who were not currently receiving treatment.
For example, British psychologist Hans Eysenck
created a furor in the early 1950s, one that continued to trouble psychologists and mental health workers for several decades. Eysenck concluded, on the basis of his review of twenty-four studies, that psychotherapy produced no greater changes in individuals than did naturally occurring life events. Specifically, he argued that two-thirds of people with neurotic disorders improve over a two-year period with or without psychotherapy. Two particular problems with his review warrant comment, however. First, the studies that were included in his review rarely employed randomization, which raises significant concerns about subsequent interpretations. Second, later analyses of the same data set demonstrated that Eysenck’s original estimates of improvements in the absence of treatment were inflated.
The manner in which research investigations were conducted (the research methodology) became more sophisticated in the 1970s. In particular, research designs included appropriate control groups to account for spontaneous improvements, randomly assigned experimental conditions, well-specified treatment protocols administered by well-trained therapists, and improved instruments and procedures to measure effectiveness. As a result, it became increasingly clear that many psychotherapies demonstrate statistically significant and clinically meaningful effects on patients. Not all patients reveal improvement, however, and many patients relapse following successful treatment.
In 1977, researchers Mary Smith and Gene Glass presented a review of 375 psychotherapy outcome studies carried out by means of a newly devised methodology called “meta-analysis.” Meta-analysis literally means “analysis of analyses” and represents a statistical procedure used to summarize collections of research data. Meta-analysis is frequently regarded as more objective and more sophisticated than traditional review procedures such as those employed by Eysenck. Smith and Glass revealed that most patients who entered outpatient psychotherapy showed noticeable improvement. In addition, the average therapy patient improved more than did 75 percent of comparable control patients.
The results reported by Smith and Glass were controversial, and they stimulated much productive debate. In particular, the authors were criticized for certain procedural steps (for example, excluding particular studies and including others). In response to such criticism, many researchers conducted additional meta-analytic investigations to examine the empirical effectiveness of psychotherapy. Of particular importance is the large follow-up investigation that was conducted by Smith, Glass, and Thomas Miller in 1980. The authors presented many detailed analyses of their results and expanded the data set from 375 studies to 475 studies involving approximately twenty-five thousand patients treated by seventy-eight therapies over an average of sixteen sessions. Smith, Glass, and Miller revealed that the average therapy patient was better off than 80 percent of the control group.
To date, numerous studies have provided evidence for the general effectiveness of psychotherapy to produce positive changes in targeted problem areas; however, psychotherapy is not a unitary procedure applied to a unitary problem. Moreover, many of the nearly four hundred psychotherapeutic approaches have yet to be systematically evaluated. Thus, it is important to understand the empirical evidence for specific treatment approaches with specific patient populations. It is similarly important to note that each therapist is a unique individual who provides his or her own unique perspective and experience to the psychotherapeutic process. Fortunately, positive effects are generally common among psychotherapy patients, and negative (deterioration) effects, which are also observed regularly, often appear related to a poor match of therapist, technique, and patient factors.
Patient Improvement and Treatment Evaluation
Recent research has focused on some of the factors associated with patient improvement, and several specific methods have been used to evaluate different treatments. Common research designs include contrasting an established treatment with a new treatment approach (for example, systematic desensitization versus eye movement desensitization for anxiety) or therapeutic format (group depression treatment versus individual depression treatment), separating the components of an effective treatment package (such as cognitive behavioral treatment of anxiety) to examine the relative effectiveness of the modules, and analyzing the interactions between therapist and patient during psychotherapy (process research).
The results from studies employing these designs are generally mixed and reveal limited differences between specific therapeutic approaches. For example, in the largest meta-analytic studies, some analyses revealed that behavioral and cognitive therapies were found to have larger positive changes when compared to other types of psychotherapy (psychodynamic and humanistic), while other analyses did not. Similarly, several large comparative studies revealed considerable patient improvement regardless of treatment approach. Such results must be carefully evaluated, however, because there are numerous reasons for failing to find differences between treatments.
All psychotherapy research is flawed; there are no perfect studies. Thus, studies should be evaluated along several dimensions, including rigor of methodology and adequacy of statistical procedures. Psychotherapy is both an art and a science, and it involves the complex interaction between a socially sanctioned helper (a therapist) and a distressed patient or client. The complexity of this interaction raises some significant obstacles to designing psychotherapy research. Thus, methodological problems can be diverse and extensive, and they may account for the failure to find significant differences among alternative psychotherapeutic approaches. Some researchers have argued that the combination of methodological problems and statistical limitations (such as research samples that are too small to detect differences between groups or inconsistency with regard to patient characteristics) plagued many of the studies completed in the 1980s.
Still, the search for effective components of psychotherapy remains a primary research question focused on several key areas, including patient characteristics, therapist characteristics, treatment techniques, common factors across different psychotherapies, and the various interactions among these variables. As highlighted in Sol Garfield and Allen Bergin’s edited book entitled Handbook of Psychotherapy and Behavior Change (1986), some evidence reveals that patient characteristics (such as amount of self-exploration and ability to solve problems and express emotions constructively) are of primary importance in positive outcomes. Therapist characteristics such as empathy, interpersonal warmth, acceptance toward patients, and genuineness also appear to play a major role in successful therapy. Treatment techniques seem generally less important than the ability of the therapist and patient to form a therapeutic relationship.
Additional studies have asked patients at the conclusion of psychotherapy to identify the most important factors in their successful treatment. Patients have generally described such factors as gradually facing their problems in a supportive setting, talking to an understanding person, and the personality of their therapist as helpful factors. Moreover, patients frequently conclude that their success in treatment is related to their therapist’s support, encouragement, sensitivity, honesty, sense of humor, and ability to share insights. In contrast, other research has examined negative outcomes of psychotherapy to illuminate factors predictive of poor outcomes. These factors include the failure of the therapist to structure sessions and address primary concerns presented by the patient, poorly timed interventions, and negative therapist attitudes toward the patient.
Common Factors
Taken as a whole, psychotherapy research reveals some consistent results about many patient and therapist characteristics associated with positive and negative outcomes. Yet remarkably few differences have been found among the different types of treatment. This pattern of evidence has led many researchers to conclude that factors that are common across different forms of psychotherapy may account for the apparent equality among many treatment approaches. At the forefront of this position is psychiatrist and psychologist Jerome D. Frank.
In various books and journal articles, Frank has argued that all psychotherapeutic approaches share common ingredients that are simply variations of age-old procedures of psychological healing, such as confession, encouragement, modeling, positive reinforcement, and punishment. Because patients seeking treatment are typically demoralized, distressed, and feeling helpless, all psychotherapies aim to restore morale by offering support, reassurance, feedback, guidance, hope, and mutual understanding of the problems and proposed solutions. Among the common factors most frequently studied since the 1960s, the key ingredients outlined by the person-centered school are most widely regarded as central to the development of a successful therapeutic relationship. These ingredients are empathy, positive regard, warmth, and genuineness.
Various factors should be considered when one chooses a therapist. To begin with, it may be wise to consider first one’s objectives and motivations for entering treatment. A thoughtful appraisal of one’s own goals can serve as a map through the maze of alternative treatments, therapy agencies, and diverse professionals providing psychotherapeutic services. In addition, one should learn about the professionals in one’s area by speaking with a family physician, a religious adviser, or friends who have previously sought psychotherapeutic services. It is also important to locate a licensed professional with whom one feels comfortable, because the primary ingredients for success are patient and therapist characteristics. All therapists and patients are unique individuals who provide their distinctive perspectives and contributions to the therapy process. Therefore, the most important factor in psychotherapeutic outcome may be the match between patient and therapist.
Results of Meta-analysis
Although the roots of psychotherapy can be traced back to antiquity, psychotherapy research is a recent development in the field of psychology. Early evidence for the effectiveness of psychotherapy was limited and consisted of case studies and investigations with significant methodological flaws. Considerable furor among therapists followed psychologist Eysenck’s claims that psychotherapy is no more effective than naturally occurring life events are. Other disagreements followed the rapid development of many alternative and competing forms of psychotherapy in the 1960s and 1970s. Claims that one particular approach was better than another were rarely confirmed by empirical research. Still, psychotherapy research is a primary method in the development, refinement, and validation of treatments for diverse patient groups. Advancements in research methodology and statistical applications have provided answers to many important questions in psychotherapy research.
Rather than examining the question of whether psychotherapy works, researchers are designing sophisticated research programs to evaluate the effectiveness of specific treatment components on particular groups of patients with carefully diagnosed mental disorders. Researchers continue to identify specific variables and processes among patients and therapists that shape positive outcomes. The quality of interactions between patient and therapist appear to hold particular promise in understanding psychotherapy outcome.
To address the complexity of psychotherapy, research must address at least two important dimensions: process (how and why does this form of therapy work?) and outcome (to what degree is this specific treatment effective for this particular client in this setting at this time?). In addition, empirical comparisons between psychotherapy and medications in terms of effectiveness, side effects, compliance, and long-term outcome will continue to shape clinical practice for many years to come. As one example, the National Institute of Mental Health (NIMH) sponsored a large comparative psychotherapy and drug treatment study of depression. In that investigation, the effectiveness of individual interpersonal psychotherapy, individual cognitive therapy, antidepressant medication, and placebo conditions were tested. While findings from initial analyses revealed no significant differences among any of the treatment conditions, secondary analyses suggested that severity of depression was an important variable. For the less severely depressed, there was no evidence for the specific effectiveness of active-versus-placebo treatment conditions. The more severely depressed patients, however, responded best to antidepressant medications and interpersonal therapy. Future reports from the NIMH team of researchers may reveal additional results that could further shape the ways in which depressed patients are treated.
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