Recently, Scientific American published a piece called “Are All Psychotherapies Created Equal”? The article reports on a debate that, incredibly, has been going on since 1936, when psychologist Saul Rosenzweig used the metaphor of the Dodo Bird in ‘Alice in Wonderland’ to describe research comparing the effectiveness of different types of psychotherapy. In ‘Alice,’ the Dodo Bird judges a race by declaring the ‘everyone has won, and all must have prizes;’ Rosenzweig believed that this was true of psychotherapy: that all recognized methods of psychotherapy are better than no therapy, and that the type of therapy matters not at all.
In the nearly 80 years since, most researchers have concluded nearly the same thing. To be sure, there are a few exceptions. Behavioral techniques appear to be most effective for severe depression and for some anxiety disorders, for example. And occasionally therapy can do harm: research revealed that ‘critical incident debriefing,’ a technique involving pressuring people who have survived a traumatic event to recount (and relive) that event, actually INCREASED the incidence of Post Traumatic Stress Disorder in these survivors.
Moreover, the research over the last number of decades has only looked at ‘recognized’ treatments, which means that newer techniques wait to be evaluated, and the more ‘fringe’ approaches – past life regression, re-birthing, for example – don’t get studied at all. Specialized techniques, like sex therapy or biofeedback, get little attention in part because they are designed to work with a small sub-population of psychotherapy patients. Of the 500 or more types of psychotherapy out there, only a handful of the most commonly used have been scrutinized.
But still, overall the results look pretty conclusive – and a bit troubling. After all, most therapists spend a great deal of time in training, and that training generally follows a ‘theory’ or ‘model’ of psychotherapy. And though many counselors, particularly seasoned ones, describe their approach as ‘eclectic,’ many others feel wedded to their school of thought, be it psychodynamic, interpersonal, cognitive behavioral, client-centered, or one of the many variations of these ‘Big Four.’ Are all these hours of training wasted? If the type of therapy doesn’t matter – what is graduate school for?
The usual explanation offered for the Dodo Bird Verdict is that other qualities such as empathy and client-therapist match are more important, and indeed the research also confirms this. So-called ‘common factors’ probably account for most of therapy’s effectiveness – to the extent that it IS effective.
But I’d like to propose another explanation. Research on psychotherapy results suffers from a major flaw, one that is commonly cited as a critique of the whole concept of ‘evidence based treatment’ in mental health. For the sake of a neat, clean, easily analyzable research design, subjects must only have ONE big problem – Major Depressive Disorder or Obsessive Compulsive Disorder, for example. And the practicioner must use only ONE approach – whatever is being studied, say, cognitive behavioral or interpersonal therapy. But in the real world, most clients don’t fit one diagnosis perfectly or exclusively, especially the most common diagnoses, mood disorders. In fact, psychiatrists testing the reliability of the diagnoses in the new ‘Bible’ of mental health, the DSM5, found they got the least agreement among clinicians on who was depressed or anxious. The symptoms most people bring to therapy are so mixed, that it’s hard to get a diagnosis that fits precisely.
In addition , therapists use a number of arrows in their quiver, even the ones who purport to follow only one model of treatment . Perhaps this is necessary given the mixed bag of symptoms and problems they see in their offices. Behavioral therapy may work best for someone who suffers from classic clinical depression and nothing else – the guy who stays in bed all day and neglects functions of daily life. But how about the man with an atypical depression, who is agitated and in constant movement spurred by high levels of anxiety? That person may need relaxation or meditation training before behavioral techniques can work.
In other words, neither the people being treated nor the methods used in these research studies bear much resemblance to therapy in the real world, and so the results of this research are of limited usefulness. A woman might come to our practice because she feels a ‘down’ mood in some situations, anxious in others, she’s getting too angry with her kids, and she’s not sure she wants to stay with her partner.
As the therapist working with that woman – I’m not going to just use one approach. It may be that she at first just needs to ‘unload’ with someone who doesn’t have a stake in the outcome of her life. She’s got to vent, and needs some validation that she’s neither crazy nor hopelessly flawed. Together she and I will explore some possibilities for her ‘mood disorders,’ but some of her behavior might need attention first, e.g., her outbursts with the kids. We will consider multiple factors in assessing her problems. Are her symptoms purely biological, related to stresses in her life, to her behaviors and habits, or to her cognitions, her outlook on the world or feelings about herself? In most cases, the answer is more than one of these things. And so the techniques I use will be varied. If it looks like there is a big biological component – half her relatives for four generations have been depressed, she herself has battled down moods for most of her life – I might suggest a medication evaluation. If her habits seem to be contributing – she doesn’t get enough sleep, is drinking too much alcohol, not exercising – we might focus on behavior change. If there are issues with her partner or children, we might need family therapy or couples counseling. And if her outlook is too negative, that might be helped by cognitive therapy, meditation – or getting enough sunlight. In some cases, the roots of the depressive thinking go deep and require digging deeper into her history. If there has been trauma, EMDR might be helpful and if the problems with her partner have a sexual component, sex therapy is indicated.
So, the problem with the ‘psychotherapy outcome research,’ as it is called, is this: therapy is not much like research but very much like psychological problems themselves- messy, complicated, and unpredictable, a winding road with detours and dead ends at times before the solution is reached. And under the best of circumstances, it is guided by the client, not the therapist and especially not the ‘technique.’ I may think psychodynamic therapy is the greatest thing since sliced bread, but if you don’t want to talk about your past, and I can’t be flexible enough to find another approach – the partnership isn’t going to work. Someone once called therapy a process where the counselor leads, one step behind. The best therapists have great intuition, honed by experience. That intuition includes the sense of what an individual person will respond to that is far more important than the ‘theoretical approach’ of the counselor. And that skill is particularly hard to isolate and study in a controlled laboratory experience. I suspect that for a long time to come the Dodo Bird Verdict will stand – because our research just isn’t enough like real life to get any more nuanced results.