Psychotherapy: The Good, the Bad, and the Future

The Good. Psychotherapy works-the results of outcome studies conducted over the past 75 years reveal that individuals treated are better off compared to people on waitlists or not receiving treatment [1]. In fact, the effect size of therapy (.08) is on par or better than many medical interventions (Acute MI, CHF, Graves Hyperthyroidism, medication treated erectile dysfunction, stages II and III breast cancer, cataract surgery, acute stroke, etc. Psychotherapy is also cost-effective; results of studies reveal that participation in therapy results in reductions in inpatient stays, consultations with primary-care physicians, use of medications, care provided by relatives, and general health care expenditures by 60% to 90% [2,3].

The Bad. Yet, psychotherapy outcomes have not appreciably improved over the past 40 years [1]. Perhaps even more troubling, research suggests that premature termination or dropout rates average about 47% for adults [4] and the range between 28% to 85% for children and adolescents [5,6]. The news gets worse results of outcome research also reveal that many clients (30% to 50%) do not benefit from therapy [7], [8] and in fact, some get worse; deterioration rates among adult clients ranges between 12% and 20% [9]. Miller estimates that these non-progressing or deteriorating clients are responsible for 60-70% of the total expenditures in the health care system and often clog up therapists’ caseloads. In general, clinicians fail to identify those clients not progressing, deteriorating, or at risk for dropping out of treatment [10]. Simply stated, we know psychotherapy works, but there is room for improvement. Given the traditional ways of training and professional development do not seem to be improving client outcomes or producing better therapists, coupled with the fact that a sizable percentage of clients do not benefit from therapy, new models are needed to better address these issues. The Future. We contend that a paradigm shift is needed in terms of psychotherapy training, practice (including supervision), and continuing education programs. Despite attempts to identify specific ingredients in psychotherapy, research has found that a core group of general therapeutic factors is responsible for successful outcomes, regardless of the approach or model [11,12]. Given that client level of engagement is one of the best predictors of success [13], training and continuing education programs should shift the primary focus from specific factors (models, techniques) to more general factors with particular emphasis on alliance building and how to access client strengths and preferences. Moreover, training programs (and by extension students) would be well-served by embedding a feedback-informed philosophy within the curriculum in which instructors and students are using feedback as a way to improve and refine behaviors to better meet each other’s needs.

According to Miller, clients whose therapists incorporate client feedback into the therapy process on an ongoing basis are 2.5 times more like to experience benefit from treatment [1]. These concepts (collecting feedback, alliance-building) are pantheoretical and can be applied regardless of the therapist’s preferred model. Psychotherapy works-those treated are better off than untreated, but given the lack of improvement over time, coupled with the alarming retention rates, new ideas are needed to ensure therapists are aware when the process is not working and can collaboratively revise the approach, method, or refer out as needed.

1. Miller SD (2011) Psychometrics of the ORS and SRS. Results from RCTs and meta-analyses of routine outcome monitoring & feedback. The Available Evidence. Chicago, IL, USA.

2. Chiles J, Lambert MJ, Hatch AL (1999) The impact of psychological interventions on medical cost offset: A meta-analytic review. Clinical Psychology 6(2): 204-220.

3. Kraft S, Puschner B, Lambert MJ, Kordy H (2006) Medical utilization and treatment outcome in mid- and long-term outpatient psychotherapy. Psychotherapy Research 16(2): 241-249.

4. Wierzbicki M, Pekarik G (1993) A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice 24(2): 190-195.

5. Garcia JA, Weisz JR (2002) When youth mental health care stops: Therapeutic relationships problems and other reasons for ending youth outpatient treatment. Journal of Consulting and Clinical Psychology 70(2): 439-443.

6. Kazdin AE (1996) Dropping out of child psychotherapy: Issues for research and implications for practice. Child Clinical Psychology 1(1): 133-156.

7. Hansen N, Lambert MJ, Forman EM (2002) The psychotherapy dose-response effect and its implication for treatment delivery services. Clinical Psychology: Science and Practice 9(3): 329-343.

8. Lambert MJ, Ogles BM (2004) The efficacy and effectiveness of psychotherapy. In: MJ Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5^th edn), Wiley, New York, USA, pp. 139-193.

9. Warren JS, Nelson PL, Mondragon SA, Baldwin SA, Burlingame GA (2010) Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings. Journal of Consulting and Clinical Psychology 78(2): 144-155.

10. Hannan C, Lambert MJ, Harmon C, Nielsen SL, Smart DW, et al. (2005) A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology: In Session 61(2): 155-163.

11. Hubble MA, Duncan BL, Miller SD (1999) The heart and soul of change: What works in therapy. American Psychological Association, Washington, DC, USA.

12. Lambert MJ (1992) Implications of outcome research for psychotherapy integration. In: Norcrossm JC, Goldfried MR (Eds.), Handbook of psychotherapy integration Basic Books: New York, USA, pp. 94-129.

13. Horvath AO, Symonds BD (1991) Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology 38(2): 139-149.