The efficacy of psychotherapy

John C. Markowitz
Cornell University Medical College

Articolo apparso sulla rivista Epidemiologia e Psichiatria Sociale, volume 6, Numero 2, Maggio - Agosto 1997

Introduction

Psychotherapy is a century old. Most of its hundred years have been dominated by psychoanalysis and psychodynamic
psychotherapy, which have been passed from generation to generation almost as a creed. In effect, each analytic supervisor told his supervisee, "This is what I was taught, and what I believe works." Notwithstanding occasional cautions that psychoanalysis was an exploratory process that promised no results, its efficacy was assumed.

Yet efficacy remained a belief, inasmuch as there were scarcely any attempts to empirically validate psychoanalytic treatment. The psychoanalytic literature consists of single case reports and small, uncontrolled case series. The complexity of psychoanalytic treatment was and is used to argue against testing its efficacy. Confident in their hegemony, and working in a paradigm removed from a formally scientific medical model, psychoanalysts felt little need to test their approach. Psychodynamic therapy was widespread, although controlled scientific evidence for its utility was nearlynonexistent.

In recent years much has changed (Russell & Orlinsky, 1996). In the 1960's and 1970's, researchers in psychiatry and psychology such as Aaron Beck, M.D., Gerald L. Klerman, M.D., and Lester Luborsky, Ph.D. began to assess psychotherapy outcome by scientific method rather than focusing, as had previous researchers, purely on psychotherapy process.
Psychoanalysis retreated as alternatives and derivatives, including the tested time-limited psychotherapies (TLPs), took the field. In the last decade, social pressures to cut mental health costs in the United States resulted in managed care (really managed cost), severely limiting the reimbursement of psychotherapy, and hence its length. American consumers (as patients are now frequently termed) also demand quicker and proven results. Fortunately, researchers have some evidence to show them.

What allowed the testing of psychotherapies? First, the development of nosological systems such as the Diagnostic and Statistical Manuals for Mental Disorders (DSM), beginning with DSM-III in 1980 (American Psychiatric Association, 1980), allowed reliable diagnosis of psychiatric syndromes. These diagnoses defined target disorders for testing of psychotherapeutic interventions. Second, psychotherapies were codified in manuals for research treatments, and treatment sessions were recorded by audiotape or videotape and monitored for adherence. Relatively (not to say purely) homogeneous diagnostic categories of patients, and relatively (not to say rigidly) homogeneous treatments, made it possible to measure the efficacy of psychotherapies for particular groups of patients.

(This is a somewhat American perspective:) Based on psychotherapy outcome research of the past two decades, we now have some idea of which psychotherapies to prescribe for key DSM-IV (American Psychiatric Association, 1994) disorders, just as we do when prescribing pharmacotherapies. Psychotherapists should now consider diagnosis as well as character, and recognize that what looks like character may reflect the effect of state on trait (Hirschfeld et al., 1983). A major shift in outlook since DSM-III gives Axis I diagnoses like major depression or dysthymic disorder primacy over characterological, psychodynamic formulations, since treatment of the seemingly superficial mood disorder may profoundly improve or eliminate what had looked like character pathology. Axis I psychiatric diagnoses should not lead therapists to dehumanize patients or to ignore their idiosyncrasies, but they should strongly influence treatment selection. Treatment choice should depend on scientific knowledge, not therapists' ideology. To ignore these developments in knowledge is a therapeutic indulgence that will increasingly be condemned, both by reimbursement agencies and by ever more educated patients (consumers) themselves.

Assessment of psychotherapy outcome is a relatively new phenomenon, and much remains unknown. Nonetheless, we know far more now than twenty years ago. Empirical evidence supports the efficacy of several TLPs as treatments of mood disorders, anxiety disorders, and other conditions. There are even some data on differential therapeutics (Frances et al., 1984), the science of treatment selection -- e.g., of psychotherapies for depression (Sotsky et al., 1991). We still know little about the efficacy of longer term psychotherapies, but one state-of-the-art treatment study does address maintenance psychotherapy for depressed patients (Frank et al., 1990).

Too much psychotherapy outcome research exists to catalogue here. Instead, I shall describe some principles of TLPs employed in research, and highlight a few key studies that may be less familiar in Italy than in the United States. I shall also focus on interpersonal psychotherapy (IPT) (Klerman et al., 1984 ), as I know from recent workshops in Italy that it has received less exposure here than have psychodynamic and cognitive therapies.