How effective is psychotherapy, really?
Though Sigmund Freud and his followers regularly published case histories describing how patients could be cured of their psychological problems through therapy, exactly how treatment effectiveness could be measured was rarely discussed. Even as psychotherapy became more popular and new kinds of treatment were developed, few therapists seemed interested in putting actual science into psychotherapy to bring it up to the same standard as regular medicine.
Then along came Hans Eysenck and psychotherapy would never be quite the same again…
A German-born psychologist who spent most of his life in Great Britain, Eysenck is likely best remembered for his work on intelligence, personality, and genetics. He is less well-known as a major critic of psychoanalysis despite this being where he most influential. In 1952, he published one of the first comprehensive reviews looking at research studies evaluating psychoanalysis and other psychotherapies. Based on the limited number of studies available, Eysenck concluded that only 44% of psychoanalysis patients receiving Freudian treatment showed any kind of real improvement over a five-year period. Though the numbers were somewhat higher for eclectic therapy (64%), the improvement rate was still well below the 72% rate for patients treated in hospitals or by general practitioners.
While only focusing on treatment of neurosis, Eysenck argued for an inverse correlation between psychotherapy and recovery. In other words, the more psychotherapy you got, the less likely you were to recover. As Eysenck put it, his data “fail to prove that psychotherapy, Freudian or otherwise, facilitates the recovery of neurotic patients.” Despite the controversy that erupted, Eysenck followed up his 1952 paper with a 1961 study having essentially the same results.
Not that this challenge went unanswered for long. Hans Herman Strupp, a German-born psychoanalyst who was one of the pioneers of psychotherapy research published his own critique of Eysenck’s research in 1963. Strupp’s critique, titled “The Outcome Problem in Psychotherapy Revisited”, blasted Eysenck’s methodology and conclusions and offered his own recommendations for effective psychotherapy research. Predictably, Eysenck wrote his own rebuttal to Strupp's comments which he branded as “irrelevant, incompetent and immaterial.” This was then followed by Strupp’s response in which he pointed out that “The controversy about the value of psychotherapy has been with us for some time, and it is not likely to be resolved by argument or counterargument.”
In the 50 years since the famous Eysenck-Strupp debate, there have been thousands of research studies looking at psychotherapy effectiveness though many of the basic questions raised by Eysenck and Strupp are still difficult to answer. While we know more about what does or doesn’t work as far as psychotherapy is concerned, the question of how to measure treatment outcome is still controversial.
According to Bruce E. Wampold, professor and chair of counseling psychology at the University of Madison-Wisconsin, the impact of the Eysenck-Strupp debate continues to influence psychotherapy researchas well as public perception of psychotherapists in general. In a recent article published in the journal Psychotherapy, Wampold weighs the current legacy of the debate using a “spaghetti western” model presenting his opinions on both Eysenck and Strupp in terms of “the good, the bad, and the ugly” effect they have had on psychotherapy research.
Hans Eysenck’s research forced psychotherapists to ask awkward questions largely neglected up to that time. During the 1950s, psychotherapy usually meant Freudian psychoanalysis although other types of therapy were available by then as well. Since psychoanalysis was mainly practiced by medical doctors, the public assumed that it was established medical procedure and just as valid anything else supported by medicine. By introducing psychotherapy outcome research, both Eysenck and Strupp set the standard that later researchers needed to follow. Simply assuming that psychotherapy worked based on case histories was no longer enough and outcome studies using randomized trials with control groups became more common.
Eysenck and Strupp were not impartial over what worked in psychotherapy. They both had a bias since Eysenck was a behaviour therapist while Strupp was a psychoanalyst. Hans Eysenck’s research were largely intended to show that behaviour therapy was more effective than psychoanalysis. Still, he never put behaviour therapy to the test the way he had with psychoanalysis and eclectic psychotherapy. Strupp’s criticism of Eysenck’s research was largely aimed at defending psychoanalysis while arguing against Eysenck’s own bias.
Part of the “ugly” surrounding the psychotherapy debate was the tendency for therapists to define what was healthy rather than letting the patient decide. Well into the 1960s, both Strupp and Eysenck advocated “treating” homosexuality to make them fit their own view of “normal” behaviour. Though reparative therapy is no longer accepted, any type of treatment that lets the therapist impose his or her own view of “normal” on a patient, whether the patient agrees or not, is going to be a problem.
As for Eysenck, he seemed determined to show that behaviour therapy was superior to all other forms of therapy and often lashed out at critics with personal attacks, no matter how solid their facts were. Even up to his death in 1997, he largely dismissed the numerous research studies showing that other forms of psychotherapy could be as effective as behavior therapy.
As Bruce E. Wampold points out, the fifty years since the Eysenck-Strupp debate has seen a tremendous boom in research articles examining the psychotherapy process and measuring treatment effectiveness. Despite this progress, there continues to be strong resistance to the type of evidence-based treatment that Eysenck and Strupp both endorsed. Finding which treatments work best for specific conditions such as posttraumatic stress disorder has led to new debates that can be just as bitter as the debates of the past.
Despite these disagreements, there is still a general consensus that some treatments based on scientific psychological principles are better than others. Psychotherapists have also come to recognize that actual evidence is more important than opinion in determining what works and what does not. For that reason, therapists need to examine the therapy process and treatment outcome carefully to make sure patients were actually helped by the treatment they received.
Ethical therapists should do no less.
In the 1970s I worked as a psychology lecturer in Hans Eysenck’s department at the Institute of Psychiatry, London. He was a controversial figure, quiet and introverted when met face to face, but on the academic stage a formidable and ruthless opponent. Rod Buchanan’s recent biography, Playing with Fire:The Controversial Career of Hans J Eysenck, nicely captures the complexity of the man, part prolific scientist, and part inveterate showman. Whether it was race and IQ, cancer and smoking or the effectiveness of psychotherapy, Eysenck did not hold back from taking the unpopular position. His 1952 paper challenging the effectiveness of psychotherapy triggered off a fierce debate that resonates today. How do we determine that psychotherapy works? Many therapists believe the question is either meaningless – like asking if medicine works – or has been loudly answered in the affirmative following thousands upon thousands of research trials. But the question is not as simple as it sounds.
In the 1970s I recall researching into Encounter groups that were all the rage then and coming across a statement by Carl Rogers. He claimed that a positive consequence of a successful Encounter group was for the members to become aware of their psychological problems and go on to have individual therapy for them. So the measure of success in Rogers’ terms was (a) having a problem and (b) going into therapy, the opposite of what most people see as psychotherapy’s goals! What Rogers claim illustrates is that any notion of outcome is based upon a set of values. For him authenticity was paramount and therapy was not a means of getting rid of symptoms but a chance to explore oneself, a process of self actualisation that was the key to the well-lived life. To be happy was not to be free of problems but to feel comfortable in oneself and to relate to others in a genuine and empathic way. Attractive as this philosophy may be, it is not one that the researchers into the effectiveness of psychotherapy have adopted. On the contrary, a quasi-medical model has been all powerful. Researchers have sought to prove that any specific therapy works in terms of making people feel better and enabling them to get rid of depression, anxiety, addictions or whatever ‘illness’ they are deemed to have. The problem I have with that it does not describe psychotherapy as I know it. Most psychotherapists realise that these simplicities mask the truly interesting part of therapy which is determining what the client’s problem actually is.
In my memoir, The Gossamer Thread. My Life as a Psychotherapist, I describe my first therapy case whom I call Peter. Peter’s problem was a phobia about using public toilets. His anxiety would rise exponentially when any men came in so he avoided public toilets altogether and led a restricted social life. I took over the therapy from another clinical psychologist (who went on to become a distinguished researcher into psychotherapy) and plugged away at Wolpe’s systematic desensitisation, first in imagination then in reality. The reality I chose was to see Peter in a bar where we would chat and drink beer in a way that is unthinkable today. In the course of these conversations I got to know him well, and he me, since I had no idea about boundaries being young and totally inexperienced. The result was a great success but it was in Rogerian not quasi-medical terms. When by chance two years later I met Peter again, he was a changed man, relaxed, happy in himself, content in his career. When I asked him about the original problem, at first he looked puzzled and then said, ‘Oh, that. I still have it but it doesn’t bother me anymore.’ There was a lesson to be learned about what psychotherapy outcome really means but it took me many years to learn it.
File under: The Art of Psychotherapy, Musings and Reflections