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Subject: FW: NYTimes.com Article: For Psychotherapy's Claims, Skeptics Demand Proof
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For Psychotherapy's Claims, Skeptics Demand Proof
August 10, 2004
By BENEDICT CAREY
Good therapists usually work to resolve conflicts, not
inflame them. But there is a civil war going on in
psychology, and not everyone is in the mood for healing.
On one side are experts who argue that what therapists do
in their consulting rooms should be backed by scientific
studies proving its worth.
On the other are those who say that the push for this
evidence threatens the very things that make psychotherapy
work in the first place.
Which side prevails may shape not only how young therapists
are trained and what techniques practitioners use in the
future, but also how tightly health insurers restrict the
therapies they are willing to pay for, and thus how much
the estimated 20 million Americans who enter psychotherapy
each year have to pay out of their own pockets. Ultimately,
some experts say, the survival of one-on-one counseling, or
talk therapy, as an accepted mode of treatment for mental
disorders may hang in the balance.
The issue of which therapies are based on science and which
are not has recently become so divisive that the incoming
president of the American Psychological Association, Dr.
Ronald Levant of Nova Southeastern University in Fort
Lauderdale, Fla., said in a telephone interview that he had
already assembled a task force to address the controversy,
and to find some common ground on which to anchor future
practice.
The topic was debated before a raucous, packed hall at the
annual meetings of the American Psychological Association
in Honolulu, held July 28 to Aug. 1. The association, with
more than 150,000 members, is the largest professional
association of psychologists. "The split in the field is
bigger than it ever has ever been," said Dr. Drew Westen, a
professor of psychology, psychiatry and behavioral sciences
at Emory University. "The intensity of the acrimony, the
distaste, has never been so high."
At bottom, the dispute is over the nature of psychotherapy:
Is it an intuitive process, more art than science? Or is it
more a matter of a therapist following specific procedures
that reliably help people get better?
Over the last decade, a group of academic researchers has
argued for the instruction-manual approach, compiling a
list of short-term therapies that studies show work for a
variety of mental disorders.
The techniques are standardized, easily described in
manuals for therapists, and can quickly help people with
phobias, panic attacks and other problems. They include
cognitive therapy, in which people learn to refute
pessimistic or degrading thoughts, and exposure therapy, in
which they overcome anxieties by gradually learning to face
the situations they fear.
This evidence-based approach already has had a significant
impact in the marketplace. Some managed care companies,
including Magellan Health Services, the country's largest
managed mental health insurer, base their coverage for
psychotherapy on what the research says and expect their
therapists to practice techniques that are backed by
studies. Some companies also limit the number of sessions
they will authorize for a given diagnosis based on the
findings of research.
And many insurers now require therapists, patients or both
to document therapeutic progress, providing evidence that
what is taking place in the consulting room is working.
Dr. Jerome V. Vaccaro, a psychiatrist and the president of
PacifiCare Behavioral Health, a large mental health insurer
based in California, said his firm closely monitored how
well each patient being seen by therapists in PacifiCare's
system is doing. Patients fill out questionnaires at their
first therapy session, and then after their fourth or
fifth, he said.
"If things are going well, there's improvement, fine,
that's what we want to see," Dr. Vaccaro said. "If things
aren't going well, or the person's getting worse after a
few sessions, then we'll be calling the therapist to ask
what they're doing."
The idea, he said, "is to make you, the therapist,
accountable for outcomes."
Some of the country's top clinical psychology programs,
like those at Indiana University and the University of
Maryland, have a strong emphasis on evidence-based
therapies. But in a field where practitioners are used to
following their own instincts, this "show me" approach has
stirred outrage.
Some therapists say that the healing they offer in their
offices every day is too complex to be captured in standard
studies, and that having to justify it to a third party is
a breach of patient privacy. They argue that to insist on
proof that a therapy works denies many people adequate
treatment, or the forms of treatment that they most need.
One middle-aged woman, who entered therapy after her father
died, was distraught when her insurer recently stopped
coverage after 10 sessions, citing lack of evidence for
more, said Dr. Patricia Dowds, the woman's therapist.
No one tracks how many people have been dropped from
therapy based on such arguments. But "every colleague I
know has stories," Dr. Dowds said.
Some therapists even worry they might be sued for not
practicing techniques on the hard-evidence list, though
experts say they know of no such cases so far. An article
in the March 2002 newsletter of the California State Board
of Psychology warned that therapists working with families
"who use any procedures not validated by empirical research
would do well to fear examination by an attorney
knowledgeable of the research."
Dr. Glen O. Gabbard, a psychiatrist and psychoanalyst who
teaches therapeutic technique at the Baylor College of
Medicine in Houston, said, "The move to worship at the
altar of these scientific treatments has been destructive
to patients in practice, because the methods tell you very
little about how to treat the real and complex people who
actually come in for therapy."
For more than a century, the practice of psychotherapy rode
on the shoulders of charismatic figures, from Freud and
Jung to Fritz Perls, Carl Rogers and other luminaries of
the so-called human potential movement. Primal scream and
rebirthing therapies vied with more traditional approaches.
The effectiveness of these methods was established not by
studies but by the force of the therapist's personality,
and testimonials of recovered patients.
But in the late 1980's, the increasing use of drugs like
Prozac and the arrival of managed care forced therapists to
start justifying their methods with better evidence. In
1995, a group of leading psychologists published a report
identifying what it called empirically validated therapies.
They argued that these therapies had good track records and
that clinicians should be aware of them and receive
training in using them. An empirical grounding, many hoped,
would also help re-establish the field's respectability and
repair its image among insurers as a money sink.
"When I started in practice as an intern, these therapies
were just emerging," said Dr. Dianne Chambless, a professor
of psychology at the University of Pennsylvania, who led
the panel. "I used them on my clients, and they worked; it
was a powerful thing to see."
The champions of an empirical approach say that, despite
skeptics' complaints, accountability has brought more
credibility, and insurers and policy makers are gradually
becoming more convinced that psychotherapy is a rigorous
treatment, not indulgent and open-ended. The move to
science, the empiricists assert, also has given the field a
base from which to evaluate and discredit fringe therapies
or those that promise instant healing.
"It deeply frosts me, these people who are against
measurement and evidence," said Dr. David Burns, a
psychiatrist who trains residents at Stanford University
School of Medicine. "It's a kind of narcissism in our field
to say, 'I'm so great, I know what I'm doing,' and it puts
us back 2,000 years to a time of cults, when every snake
oil salesman's got something and the parade just goes on."
Those who oppose the use of treatment manuals and lists of
approved therapies respond in kind. "This entire approach
to develop manuals and require practicing psychologists to
use them is fundamentally insane," Dr. Levant said.
So the arguments continue, and passions on either side,
experts say, are not likely to cool any time soon.
Recently, however, some researchers have been trying to
find some accommodation between the two camps by focusing
on what it is about any therapy that makes it effective,
rather than holding one method above another.
Studies suggest, for example, that factors like how
motivated patients are, their readiness for change, the
gifts of the therapist, and the strength of the bond
between patient and therapist all make a difference in
whether psychotherapy is successful.
Ken Heideman, a 45-year-old meteorologist in Boston, said
that his own experience in therapy illustrated this.
Mr. Heideman has struggled with severe recurrent depression
since college, he said, and over the years he has tried a
variety of drugs and visited many therapists. But
eventually, he found someone who helped free him from his
disabling moods for the first time in his adult life.
"I've been through a whole lot and I feel I can say that
what ultimately is going to move someone toward healing and
resolution, the most important factor, is the chemistry
between client and therapist," he said. "It can be a
psychiatrist, or someone with a degree in social work, and
anywhere in between. What counts is whether there's that
connection between the two people."
Dr. Bruce E. Wampold, a professor in the counseling
psychology department at the University of Wisconsin, has
found that a therapist's competence may be the most
critical variable, whatever the brand of therapy.
Analyzing data from more than 12,000 people treated with a
variety of evidence-based therapies, from cognitive to
interpersonal techniques, mostly for depression, he found
that the treatments worked equally well, regardless of the
specific techniques. More important, Dr. Wampold said, was
the individual therapist: some could help their patients
improve significantly in eight sessions or so, others could
not.
"It's not what treatment you give that matters but how
competently you give it, " he said.
But even a gifted therapist can leave a patient cold. Like
the tango, psychotherapy takes two, and chemistry is hard
to predict or measure.
Dr. Burns has tried to do it by conducting systematic
surveys of the residents he trains at Stanford and the
people these students treat. Most of the time, he said, the
residents assume they are well liked.
"At first it's very upsetting when they read these
evaluations because about 100 percent of the time the
clients don't actually like them," Dr. Burns said. "So
perceptions of what is a good relationship can be really
off base."
Perhaps the only emerging consensus among experts is that
research into psychotherapy should not rely solely on
clinical trials, in which one group of people is given a
treatment and then compared with other people who receive a
placebo.
Though well suited to testing drugs, this kind of study,
said Dr. Westen of Emory, tends to impose artificial limits
on psychotherapy: treatments are by necessity short;
techniques are often standardized in manuals; and many
participants are excluded because their problems are too
complicated for a single diagnosis. The chaos of real life
is blocked out.
Dr. Chambless, Dr. Levant, Dr. Westen and others who have
been strongly divided now argue that researchers should
also follow patients treated in psychotherapy clinics out
in the world, to see how well they do, and why.
"The fact is that we're still in a state where we have very
little knowledge, and the question is not what theory
works, but what works for whom," said Dr. Larry E. Beutler,
a professor of psychology at Pacific Graduate School of
Psychology in Palo Alto, Calif.
It would be nice, for example, if researchers could find a
way to deconstruct why Mr. Heideman, the meteorologist,
feels his therapy has been so successful. After four years
in treatment, he is now able to express his anger once in a
while, he says, adding that his therapist "has angered me,
and challenged me and I just woke up; it was like the Big
Bang for me."
Mr. Heideman's therapy includes cognitive methods, like
challenging his assumption that if he showed anger, some
catastrophe would come about. The therapy, in short, is a
blend of a good therapist match and evidence-based
technique, of intuition and science. Mr. Heideman sees his
success so far as the fulfillment of an article of faith
that many who have suffered mental illness share: when
you're ready to change, the right therapist will turn up.
http://www.nytimes.com/2004/08/10/health/psychology/10ther.html?ex=109
3171486&ei=1&en=d07c02edbfea8840
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Jonathan Schiff ([log in to unmask])
But what physician has not had patients who do not make sense at all?
To tell the truth, they're our stock-in-trade. We talk and write
about the ones we can make sense of. --Walker Percy, The Thanatos
Syndrome
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