email page print pageAll Topic Reviews
Maximizing Effectiveness in Dynamic Psychotherapy Self-Compassion in Psychotherapy101 Healing StoriesA Clinician's Guide to Legal Issues in PsychotherapyA Map of the MindA Primer for Beginning PsychotherapyACT With LoveActive Treatment of DepressionAffect Regulation, Mentalization, and the Development of SelfAlready FreeBad TherapyBecoming an Effective PsychotherapistBefore ForgivingBeing a Brain-Wise TherapistBetrayed as BoysBeyond Evidence-Based PsychotherapyBeyond MadnessBeyond PostmodernismBinge No MoreBiofeedback for the BrainBipolar DisorderBody PsychotherapyBoundaries and Boundary Violations in PsychoanalysisBrain Change TherapyBrain Science and Psychological DisordersBrain-Based Therapy with AdultsBrain-Based Therapy with Children and AdolescentsBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Therapy Homework PlannerBuffy the Vampire Slayer and PhilosophyBuilding on BionCare of the PsycheCase Studies in DepressionCaught in the NetChild and Adolescent Treatment for Social Work PracticeChoosing an Online TherapistChronic DepressionClinical Dilemmas in PsychotherapyClinical Handbook of Psychological DisordersClinical Intuition in PsychotherapyClinical Pearls of WisdomCo-Creating ChangeCognitive Therapy for Challenging ProblemsCompassionConfessions of a Former ChildConfidential RelationshipsConfidentiality and Mental HealthConfidingContemplative Psychotherapy EssentialsControlConversations About Psychology and Sexual OrientationCoping with BPDCouch FictionCounseling in GenderlandCounseling with Choice TheoryCouple SkillsCrazy for YouCreating a Life of Meaning and CompassionCreating HysteriaCritical Issues in PsychotherapyCrucial Choices, Crucial ChangesDeafness In MindDecoding the Ethics CodeDeconstructing PsychotherapyDeep Brain StimulationDemystifying TherapyDepression 101Depression in ContextDialogues on DifferenceDissociative ChildrenDo-It-Yourself Eye Movement Techniques for Emotional HealingDoing CBTE-TherapyEarly WarningEncountering the Sacred in PsychotherapyEnergy Psychology InteractiveErrant SelvesEssays on Philosophical CounselingEssentials of Wais-III AssessmentEthically Challenged ProfessionsEthics and Values in PsychotherapyEthics in Plain EnglishEthics in Psychotherapy and CounselingExpectationExploring the Self through PhotographyExpressing EmotionFacing Human SufferingFairbairn's Object Relations Theory in the Clinical SettingFamily TherapyFavorite Counseling and Therapy Homework AssignmentsFear of IntimacyFlourishingFolie a DeuxForms of Intersubjectivity in Infant Reasearch and Adult TreatmentFoundations of Ethical Practice, Research, and Teaching in PsychologyFreud and the Question of PseudoscienceFrom Morality to Mental HealthFundamentals of Psychoanalytic TechniqueGenes on the CouchGod & TherapyHalf Empty, Half FullHandbook of Clinical Psychopharmacology for TherapistsHandbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual ClientsHandbook of Evidence-Based Therapies for Children and AdolescentsHealing the Heart and Mind with MindfulnessHeinz KohutHelping Children Cope With Disasters and TerrorismHigh RiskHistory of PsychotherapyHow and Why Are Some Therapists Better Than Others?How Clients Make Therapy WorkHow People ChangeHow Psychotherapists DevelopHow to Fail As a TherapistHow to Go to TherapyHypnosis for Inner Conflict ResolutionHypnosis for Smoking CessationI Never Promised You a Rose GardenIf Only I Had KnownIn Others' EyesIn SessionIn Therapy We TrustIn Treatment: Season 1Incorporating Spirituality in Counseling and PsychotherapyInside the SessionInside TherapyIs Long-Term Therapy Unethical?Issues in Philosophical CounselingIt's Not as Bad as It SeemsItís Your HourLearning from Our MistakesLearning Supportive PsychotherapyLetters to a Young TherapistLife CoachingLogotherapy and Existential AnalysisLove's ExecutionerMadness and DemocracyMaking the Big LeapMan's Search for MeaningMetaphoria: Metaphor and Guided Metaphor for Psychotherapy and HealingMind GamesMindfulness and AcceptanceMindfulness-Based Cognitive Therapy for DepressionMindworks: An Introduction to NLPMockingbird YearsMoments of EngagementMomma and the Meaning of LifeMotivational Interviewing: Preparing People For ChangeMulticulturalism and the Therapeutic ProcessMultifamily Groups in the Treatment of Severe Psychiatric DisordersNarrative PracticeOn the CouchOne Nation Under TherapyOur Inner WorldOur Last Great IllusionOutsider ArtOutsider Art and Art TherapyOvercoming Destructive Beliefs, Feelings, and BehaviorsOverexposedPathways to SpiritualityPersonality and PsychotherapyPhilosophical CounselingPhilosophical Counselling and the UnconsciousPhilosophical Issues in Counseling and PsychotherapyPhilosophical PracticePhilosophy and PsychotherapyPhilosophy for Counselling and PsychotherapyPhilosophy PracticePhilosophy's Role in Counseling and PsychotherapyPillar of SaltPlan BPlato, Not Prozac!Polarities of ExperiencesPower GamesPractical Psychoanalysis for Therapists and PatientsPrinciples and Practice of Sex TherapyPsychologists Defying the CrowdPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychosis in the FamilyPsychotherapyPsychotherapyPsychotherapy and ConfidentialityPsychotherapy As PraxisPsychotherapy for Children and AdolescentsPsychotherapy for Personality DisordersPsychotherapy Is Worth ItPsychotherapy Isn't What You ThinkPsychotherapy with Adolescent Girls and Young WomenPsychotherapy with Children and AdolescentsPsychotherapy without the SelfPsychotherapy, American Culture, and Social PolicyRapid Cognitive TherapyRational Emotive Behavior TherapyRational Emotive Behavior TherapyRationality and the Pursuit of HappinessRebuilding Shattered LivesReclaiming Our ChildrenRecovery OptionsRelationalityRent Two Films and Let's Talk in the MorningSaving the Modern SoulScience and Pseudoscience in Clinical PsychologySecond-order Change in PsychotherapySelf-Compassion in PsychotherapySelf-Determination Theory in the ClinicSelf-Disclosure in Psychotherapy and RecoverySerious ShoppingSex, Therapy, and KidsSexual Orientation and Psychodynamic PsychotherapySigns of SafetySoul Murder RevisitedStaring at the SunStraight to JesusStrangers to OurselvesSubjective Experience and the Logic of the OtherTaking America Off DrugsTales of PsychotherapyTales of UnknowingTalk is Not EnoughTalking Cures and Placebo EffectsTelling SecretsThe Behavioral Medicine Treatment PlannerThe Body in PsychotherapyThe Brief Couples Therapy Homework Planner with DiskThe Case Formulation Approach to Cognitive-Behavior TherapyThe Challenge for Psychoanalysis and PsychotherapyThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Couch and the TreeThe Couples Psychotherapy Treatment PlannerThe Crucible of ExperienceThe Cure of SoulsThe Death of PsychotherapyThe Education of Mrs. BemisThe Ethical Treatment of DepressionThe Ethics of PsychoanalysisThe Gay and Lesbian Psychotherapy Treatment PlannerThe Gift of TherapyThe Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work The Healing JourneyThe Heart & Soul of ChangeThe Heroic ClientThe Husbands and Wives ClubThe Love CureThe Making of a TherapistThe Mindful TherapistThe Mirror Crack'dThe Mummy at the Dining Room TableThe Neuroscience of PsychotherapyThe Neuroscience of Psychotherapy: Healing the Social BrainThe New Rational TherapyThe Older Adult Psychotherapy Treatment PlannerThe Other Side of DesireThe Pastoral Counseling Treatment PlannerThe Philosopher's Autobiography The Pornographer's GriefThe Portable CoachThe Portable Ethicist for Mental Health Professionals The Present Moment in Psychotherapy and Everyday LifeThe Problem of EvilThe Problem with Cognitive Behavioural TherapyThe Psychodynamics of Gender and Gender RoleThe Psychotherapy Documentation PrimerThe Psychotherapy Documentation PrimerThe Psychotherapy of HopeThe Real World Guide to Psychotherapy PracticeThe Schopenhauer CureThe Sex Lives of TeenagersThe Talking CureThe Therapeutic "Aha!"The Therapist's Guide to PsychopharmacologyThe Therapist's Guide to Psychopharmacology, Revised EditionThe Therapist's Ultimate Solution BookThe Trauma of Everyday LifeThe Trouble with IllnessThe UnsayableThe Way of the JournalTheory and Practice of Brief TherapyTherapy with ChildrenTherapy's DelusionsTheraScribe 3.0 for WindowsTheraScribe 4.0Thinking about ThinkingThinking for CliniciansThinking for CliniciansThoughts Without a ThinkerThriveToward a Psychology of AwakeningTracking Mental Health OutcomesTrauma, Truth and ReconciliationTreating Attachment DisordersTreatment for Chronic DepressionTreatment Plans and Interventions for Depression and Anxiety DisordersUnderstanding Child MolestersUnspeakable Truths and Happy EndingsWhat the Buddha FeltWhat Works for Whom?What Works for Whom? Second EditionWhen the Body SpeaksWhispers from the EastWise TherapyWittgenstein and PsychotherapyWorking MindsWoulda, Coulda, ShouldaWriting About PatientsYoga Skills for Therapists:Yoga Therapy
Roth and Fonagy have tackled an
enormous and difficult question with all the nuance and intellectual muscle required
in their second edition of What Works for Whom? They have not shied
away from deeply examining the pros and pitfalls of quantitative psychotherapy
research, and they have scoured the English language evidence thoroughly in
their search for randomized controlled trials and meta-analyses. They have
also organized their book by disorder, primarily relying on categorical
definitions of disorder, as found in DSM-IV-TR1, though disorders can be easily matched to their ICD-10 counterparts2. The book has a tremendous potential for good use and misuse, and the authors are aware of this, taking pains in many places to point out the limits of what their findings do and do not support, especially in terms of managed care. This book is not for a lay audience, and general readers might quickly find themselves lost in a whir of scientific terminology, nuanced philosophical debate, and truckloads of statistics. For anyone with an interest in psychotherapy research of a quantitative nature, or for anyone with an interest in the philosophy of science, this is an
excellent discussion of theoretical issues and a timely, exhaustive reference.
The book starts with an effort at "Defining
the Psychotherapies," accepting Strupp's definition of "an
interpersonal process designed to bring about modifications of feelings,
cognitions, attitudes and behavior which have proved troublesome to the person
seeking help from a trained professional." They next point out that Kazdin
identified over 400 therapies in 1986 and state they will focus on "major
orientations," defined as psychodynamic psychotherapy, behavioral and
cognitive-behavioral psychotherapy, interpersonal psychotherapy, strategic or
systemic psychotherapies, supportive and experiential psychotherapies, group
therapies, and counseling (p. 6). The remainder of the chapter goes on to
define these schools, and steers the reader toward seminal works by founders or
modifiers of the various schools.
Chapter 2, "Research and
Practice: Methodological Considerations and Their Influence on This Review"
is, in my view, the foundation of the book and possibly its most important
contribution to the theoretical literature on psychotherapy research. I would
insult the chapter by attempting to summarize it, but it does tackle a number of
important issues which can be made plain. Psychotherapy is a very complex
interaction between two or more people. It involves a sufferer and an
individual attempting to understand and bring relief. These individuals are
informed by their life experiences, temperaments, expectations, and, in the
case of the therapist, theoretical orientations within psychotherapy. The
number of potential variables which need to be controlled in order for a
quantitative approach to produce meaningful results is fiendishly large.
For instance, what and who defines
suffering? The suffering reported by the individual is frequently at odds with
what is observed, but quantitative methods rely on observation. How do we know
when therapy proper is taking place, as opposed to say, a sympathetic hearing?
Psychotherapy can be defined in a very broad way, as in the Strupp definition,
but operationalizing it for research purposes is difficult. Then the issue
arises, even once a technique can be recorded in a manual, and even if an
inexperienced therapist is fully adherent to the letter of the manual,
something of the spirit may get lost. What are the differences between people
recruited into psychotherapy trials through newspapers compared with those who
present with difficulties at clinics? We know very little about what motivates
someone with psychological difficulties to seek help from a clinic versus
responding to an ad, therefore it is difficult to generalize from research
findings to clinical practice.
There are also questions about
research populations. On what basis can we make generalizations from a highly
selected research population to a completely unselected clinical population? Research
populations need to be as homogenous as possible, for example, depressives
only, with no comorbid anxiety, or substance abuse, so that the study minimizes
confounding variables and maintains internal validity. However, the clinic
takes all comers, with all degrees and combinations of symptomatic
difficulties. Studies of efficacy, based on homogenous clinical samples
studied under controlled research conditions do not establish effectiveness,
which is the ability of a modality to handle the problems typically seen in a
real-world clinic, where comorbidity of 50% to 90% between DSM disorders is
common (p. 487).
Questions about placebo controls or
other control interventions are important as well. Sitting on a waiting list
or, "doing nothing," is currently one of the controls used, with
assessment instruments applied to wait-list controls and individuals in
therapy. Just about every psychotherapy looks good against doing nothing, and
effect sizes diminish remarkably when two therapies are compared head-to-head.
Allegiance effects are also known, whereby the preferred therapy, often CBT, is
administered by experienced therapists, versus the "control therapy,"
which is often done by inexperienced therapists (p. 95). Regression analysis
virtually eliminates the superiority of the preferred modality.
The questions go on and on, with
very deft handling by the authors, who frequently conclude that there are
neither easy nor self-evident replies. Quantitative approaches are limited in
what they can tell us. Roth and Fonagy further note that there are
psychotherapeutic schools, such as psychoanalytic or psychodynamic, which
thoroughly repudiate quantitative approaches as wrong-headed, preferring
qualitative, in-depth case studies. As a result of this bias, the voice of
psychodynamic therapy is notably absent in the book. The authors appeal to
psychodynamic practitioners to consider the potential usefulness of controlled
trials in proving the usefulness of their approaches. Peter Fonagy, the Freud
Memorial Professor of Psychoanalysis at University College of London, can
hardly be said to be a detractor of psychodynamic approaches, but he clearly
swims against the psychoanalytic stream with his interest in quantitative
research. The second chapter will be of greatest interest to philosophers and
students of quantitative methodology, and this is why it garners the lion's
share of this review.
The third chapter is largely a
warning to those who fund mental health services not to simplistically handle
evidence. For instance, good evidence shows that depression responds to 16
sessions of CBT. A mental health planner might conclude that only CBT will be
funded for depression, for up to 16 sessions. But good evidence also shows
that people who have only had 16 sessions have only a 25% chance of being well
one year later, while those getting maintenance therapy are more likely to
avoid a relapse. But maintenance therapy is expensive. Economically, it may
make more sense for an insurance company to limit treatment to 16 sessions and
then not renew the individual's benefits because of their high risk of
Further, absence of evidence for a
particular brand of therapy is not the same as proof of inefficacy, and what
counts as evidence is very much in the eye of the beholder, whether that is the
therapist, researcher, patient, or payer. Roth and Fonagy point out that rigid
funding policies would eliminate second line treatments, necessary for those
not responding to initial approaches. These policies would also dampen
clinical innovation. There would be little point innovating if it wouldn't end
up being paid for due to its non-evidence-based status.
Chapters 4 through 15 are the meat
of the book, where Roth and Fonagy explore various specific disorders, looking
at published controlled trials comparing various therapies to controls or else
to each other head-to-head. The main message that jumps out from these
chapters is that the proponents of CBT have clearly done their homework.
Researchers have tried CBT in a randomized controlled trial for virtually every
psychiatric disorder, and it often produces positive results, particularly for
depression and anxiety, the two sorts of disorders which have always been most
responsive to psychotherapy. Other modalities have a long way to go,
particularly psychodynamic, that is, if their proponents ultimately decide that
there is anything to be gained from a quantitative effort.
Chapter 16, "The Contributions
of Therapists and Patients to Outcome," is another interesting exploration
of both published literature and theoretical discussion. It turns out to be
rather hard to account for why different therapists produce detectably
different outcomes (p. 475). Studies looking at associations typically have
too few patients per therapist to detect meaningful differences. Studies
looking at therapist experience tend to confound the fact that experienced
therapists usually end up with the most difficult patients, so on paper may
look much less effective than novice therapists. To date, all studies of
therapist characteristics have been in the secondary analysis, not built into
the initial design features of the study, which severely limits their value.
The study which randomizes patients to therapists, rather than to therapeutic
modality, has not yet been undertaken.
The book's "Conclusions and
Implications" (Chap 17) are again long, nuanced, and replete with
cautions, all well justified by the discussion. Furthermore, even when only
one disorder is cornered, it is clear that the symptoms themselves could be the
result of numerous causal pathways, even if they look broadly similar across
patient or study populations. Thus far, psychotherapy research has looked only
at diagnoses, not at whether particular psychotherapies may be uniquely suited
to particular causal factors such as childhood abuse. Crucially, they also
note that researchers only tend to publish results showing a positive
difference due to their espoused intervention. Negative or neutral studies get
filed away, so the scientific literature is replete with publication bias.
There is much more I'd like to have
discussed in this book, but it's just too jam-packed for a short review to do
it adequate justice. The issues are of critical relevance to those who seek
psychotherapy, those who provide it, and those who pay for it. There are also
warnings and guidance to those who wish to conduct adequate research using an
RCT paradigm. Payers like insurance companies look to shibboleths like the
American Psychological Association's "Empirically Supported Therapies"
for guidance and possibly as a defensive shield. To gain the APA's imprimatur,
a therapy has to have been proven by RCT. Unsurprisingly, CBT has far and away
been the winner, bolstered by legions of researchers who ascribe to the cognitivist
presuppositions which currently undergird modern psychology yet are seldom
scrutinized critically. As a result, access to psychotherapy has massively
eroded across the United States, and patients are the losers. It is
interesting that the U.K. Department of Health chose to reject the EST approach
in its mental health policy (p. 51). A close reading of Roth and Fonagy is an
important tonic, cutting through a lot of dogma and forcing the reader to confront,
again and again, that the answer to the question "What works for whom?"
if phrased simply would be, "Some things, some of the time, for reasons
which aren't yet very clear."
1. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American
Psychiatric Association, 2000.
2. World Health Organization. International
Statistical Classification of Diseases and Related Health Problems 10th
Revision [Web Page]. 2003; Available at
Robert Tarzwell is in his 5th
and final year of psychiatry residency at Dalhousie University in Halifax, Canada.
He is interested in the philosophy of psychiatry. He is also interested in
critical approaches to psychiatric literature, particularly randomized
controlled trials of drugs and psychotherapies. His main clinical interest is
intensive dynamic psychotherapy.