The Unheralded Revolution in Psychotherapy Research

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AFFIRMING PSYCHIATRY

In May of this year, The New York Times Magazine published a feature article called, “Does Therapy Really Work? Let’s Unpack That.”¹ I must confess that I am in 2 minds about this article. On one hand, it contains plenty of good, solid information. The writer, Susan Dominus, confesses that she has used therapy herself more than once. “Talk therapy works,” she declares, based not only on her own experience but several important meta-analyses, each described in some detail. She thoughtfully engages a number of eminent researchers, from the more enthusiastic to the more skeptical, and subtly articulates the relational power of psychotherapy.

On the other hand, I have a serious problem with this article: its misplaced ambivalence, starting with the title itself. “Does Therapy Really Work?” This is the title, really? It reminds me of an earlier New York Times article, “How Much Do Antidepressants Help, Really?”² which followed an earlier article, “Mental Illness Is All in Your Brain – or Is It?”³ In this case, ambivalence runs through the entire piece. Dominus asserts that a simple, rosy view of psychotherapy “overpromises.” She quotes researchers who indicate that the efficacy of therapy is frustratingly “limited” and call for more effective treatments, opining that a “paradigm shift” is needed, since we may have reached the limits of what can be done just by talking. In the end, Dominus finds herself unsatisfied, confronting “yet another frustrating unknown in the field,” a field full of “baggy” research.

There is nothing wrong, of course, with such an articulation of nuance and ambivalence about mental health treatment. Most of us feel that ambivalence when we ourselves need treatment. But there is something wrong with the constant drumbeat of disappointment and anxious uncertainty that pervades these public appraisals of our field. Judging by the emotional tone of the above articles, we really do not know how much therapy works. We really do not know how much antidepressants work. We really do not know whether mental illness is biological. The take home message is that psychiatry rests on shaky foundations, and does not quite know what it is doing, rather like a tottering senior citizen feeling their way through a darkened room. Psychiatry, as usual, lags behind the breezy confidence of other medical fields, where no one wrings their hands about whether antihypertensives really work, or whether surgery is just a lingering form of inhuman medieval butchery. Dominus herself finds that friends who are in psychotherapy seem strangely threatened or uninterested when she questions its efficacy with them. Really? I wonder if her friends undergoing chemotherapy for cancer have the same reaction when she questions the efficacy of the therapies they are using?

Dominus is not alone in her equivocal portrayal of psychotherapy, at least in the pages of The New York Times. Other efforts include, “The Evidence for Therapy: Does Talk Therapy Work? It’s Complicated,”⁴ a teaser for Dominus’ article found in the New York Times Newsletter which informed us, “it’s a surprisingly difficult question to answer.” There was also, “Looking for Evidence That Therapy Works,”⁵ from 2013, which noted that there are psychotherapies with good scientific support, but that patients rarely get them because the “biases” of therapists who stick to unproven eclectic approaches. In 2005, there was, “Psychotherapy on the Road to … Where?”⁶ which described psychotherapists as “deeply divided” between humanistic activism and “the cool logic of science,” but did note that “psychotherapy was finding some scientific support.” Finally, in 2014, we had, “My Mother’s Psychotherapy – And Mine: Her relationship with her treatment nearly killed her. How would I fare?”⁷—a title whose ambivalence perhaps explains itself.

What these articles admit, but grossly underemphasize, is the astounding and profoundly important truth that psychotherapy works. It works for young adults, middle aged individuals, older persons, and even children and adolescents (though less well for the latter than for adults).⁸ Cognitive behavioral psychotherapy works, but so does psychodynamic psychotherapy.^9,10 Dialectical behavior therapy works, and so do interpersonal therapy and many others.^11,12 Psychotherapy works for depression, treatment resistant depression, anxiety, posttraumatic stress disorder, personality disorders, functional somatic disorders, and even bipolar disorder and schizophrenia.¹³ No, it is not a cure, but thousands of studies and scores of meta-analyses have confirmed the fact that it works. They have also confirmed that therapy works about as well as medications for most disorders, and (more importantly) that combined treatment with both medications and psychotherapy typically works better than monotherapy.¹³ Psychotherapy is so well established for some disorders, such as depression, that Cuijpers (quoted as a skeptical researcher in the New York Times) et al have suggested there is no point in even doing more randomized controlled trials for psychotherapy of depression: “It is clear that psychotherapies work…. More trials will not add much to this knowledge.”¹⁴

Why, given the fact that less than half of individuals with mental illness get treatment for it, do we not trumpet this fact in our city squares? Psychology is currently in a replication crisis, and it is excruciatingly difficult to prove anything in the social sciences to the highest standard. Yet we can show psychotherapy to be effective in just this way. Given that one quarter of us suffer from mental illness every year, and that good news is so hard to come by in these troubled times, there ought to be congratulations and high-fives all around, if not a few chocolate cigars distributed. What we have instead is an unheralded scientific revolution. Thirty years ago, psychotherapy could legitimately (if controversially) be questioned as psychobabble. Today, it is as solid and substantiated a medical treatment as any other. While we see passing references to this research in our media, we see nothing of the sense of wonder, relief, and enthusiasm that should accompany such news.

Something big has happened, but our culture treats it as a ‘meh.’ When members of our media repeatedly portray such tepid ambivalence about psychotherapy, millions of suffering individuals get a vague and misleading impression of a widely available treatment that could ease their suffering and profoundly benefit their lives. Perhaps reporters avoid outright positive stories because they know that it is controversy and anxiety that grab attention and get clicks. Maybe so. But giving the truth the attention and emphasis it deserves would, in this case, save lives. Perhaps that is worth some trumpeting in the streets.

Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

References

1. Dominus S. Does therapy really work? Let’s unpack that. The New York Times Magazine. May 16, 2023. Accessed August 17, 2023. https://www.nytimes.com/2023/05/16/magazine/does-therapy-work.html

2. Moyer M. How much do antidepressants help, really? The New York Times. April 21, 2022. Accessed August 17, 2023. https://www.nytimes.com/2022/04/21/well/antidepressants-ssri-effectiveness.html

3. Szalai J. Mental illness is all in your brain – or is it? April 24, 2019. Accessed August 17, 2023. https://www.nytimes.com/2019/04/24/books/review-mind-fixers-psychiatry-biology-mental-illness-anne-harrington.html

4. Lopez G. The evidence for therapy: does talk therapy work? it’s complicated. The New York Times Newsletter, The Morning. May 21, 2023. Accessed August 17, 2023. https://www.nytimes.com/2023/05/21/briefing/therapy.html

5. Gaudiano B. Psychotherapy’s image problem. The New York Times. September 29, 2013. Accessed August 17, 2023. https://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html

6. Carey B. Psychotherapy on the road to … where? The New York Times. December 27, 2005. Accessed August 17, 2023. https://www.nytimes.com/2005/12/27/science/psychotherapy-on-the-road-to-where.html

7. Sayrafiezadeh S. My mother’s psychotherapy – and mine: her relationship with her treatment nearly killed her. How would I fare? The New York Times. October 25, 2014. Accessed August 17, 2023. https://archive.nytimes.com/opinionator.blogs.nytimes.com/2014/10/25/my-mothers-psychotherapy-and-mine/

8. Cuijpers P, Karyotaki E, Eckshtain D, et al. Psychotherapy for depression across different age groups: a systematic review and meta-analysis. JAMA Psychiatry. 2020;77(7):694-702.

9. Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.

10. Leichsenring F, Luyten P, Hilsenroth MJ, et al. Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria. Lancet Psychiatry. 2015;2(7):648-660.

11. Kliem S, Kröger C, Kosfelder J. Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling. J Consult Clin Psychol. 2010;78(6):936-951.

12. Cuijpers P, Donker T, Weissman MM, et al. Interpersonal psychotherapy for mental health problems: a comprehensive meta-analysis. Am J Psychiatry. 2016;173(7):680-687.

13. Leichsenring F, Steinert C, Rabung S, Ioannidis JP. The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta‐analytic evaluation of recent meta‐analyses. World Psychiatry. 2022;21(1):133-145.

14. Cuijpers P, Miguel C, Harrer M, et al. Psychological treatment of depression: a systematic overview of a ‘Meta-Analytic Research Domain.’ J Affect Disord. 2023;335:141-151.