What kind of psychotherapy is the best, and why does psychotherapy work? If you are looking for a therapist, this may be a question you ask yourself, and it’s a question that academic researchers and insurance companies ask, too. Why does it work, and can we make it work faster and be less expensive? How does it work, and can we turn it into a workbook that you can fill out at home? What are the important factors associated with effective treatment, what therapeutic approach is best, what kind of professional is best?
Ultimately, of course, the answers to those questions are individual, and determined by factors that aren’t easily defined and measured. Although Cognitive Behavioral Therapy practitioners frequently claim that theirs is the most effective treatment, a number of studies (e.g., Consumer Reports, 1995; American Psychology, 1995; American Psychological Association Monitor, 2010) indicate that this is not true.
The Consumer Reports study was a large-scale, naturalistic survey of 4,100 people. The results of that study showed that
- no specific type of psychotherapy is better than any other, for any disorder;
- psychotherapy alone is equally as effective as medication plus psychotherapy;
- long-term treatment is considerably better than short-term treatment;
- psychologists, psychiatrists, and social workers are equally effective across the board, and all are better than marriage counselors and family physicians; and
- patients whose length of therapy or choice of therapist is limited by insurance or managed care do worse than those who do not have to work with such managed-care restrictions.
A recent meta-analysis by Shedler revealed that psychodynamic psychotherapy, which focuses self-reflection and self-examination to get at the root of suffering, is at least as effective as symptom-oriented treatments like CBT or medication. In fact, the same study notes that psychodynamic psychotherapy was about three times more effective per treatment than the most popular antidepressant medication, and the benefits of psychodynamic psychotherapy persist and even grow larger over time. Another meta-analysis conducted in 2008 (“Person-Centered/Experiential Therapies Are Highly Effective,” Elliott & Freire) showed that relationship-focused therapies tend to produce large changes for patients, and that the gains are maintained over time.
It’s important to note that the quality of the relationship between patient and therapist was not captured in any of these research studies. Relationship is an elusive concept, and not easily defined or measured in any systematic, large-scale study. It includes how the therapist and patient feel about each other, and the various ways in which their personalities match. Psychotherapy is a two-person system, and over and above what gets talked about, and the psychotherapist’s theoretical orientation, the patient-therapist relationship may itself be the most potent therapeutic agent.
Despite the difficulties measuring such elusive factors as patient-therapist interaction, there has been some research which demonstrates the importance of the ‘fit’ or the ‘match’ between the psychotherapist and the patient in successful psychotherapy. For example, Pilkonis (1984) found that differences in outcomes are more often attributable to differences among therapists, and to interactive effects between specific patient characteristics and a specific way of doing therapy. In his book on psychotherapy (Contemporary Clinical Psychology, 2004) Plante states that “factors such as warmth, empathy, honesty, and interest on the part of the psychotherapist are important and even vital to treatment outcome.” Beutler’s (2006) review of the research indicates that at least when treating substance abuse, the match between treatment style and patient is important for both short- and long-term success. Beutler also found that treatment is enhanced when therapists develop a positive working alliance with their patients.
Overall, studies show that patients benefit substantially from psychotherapy. Further, the most important factor in successful therapy may be the ways in which a therapist and patient experience each other. This may be more important than theoretical orientation, or the specific techniques applied. The implication for choosing a therapist is that feelings of comfort and connection should be taken very seriously.