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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 GamesMindfulnessMindfulness 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
Study after study has demonstrated that psychotherapy effectively treats mental disorders. In recent years, new therapies have been shown to be effective for often intractable problems such as schizophrenia, borderline personality disorder and post-traumatic stress disorder. In some studies for depression and anxiety, psychotherapy alone has been shown to be just as effective as medication, with longer lasting effects.
Yet in outpatient mental health, the use of psychotherapy appears to be in decline. The American Journal of Psychiatry recently reported that between 1998 and 2007, the number of patients in outpatient mental health settings declined by 17 percent, while treatment with medication increased. During this period, there was also significant decline in the number of psychotherapy visits patients received when they did enter talk treatment.
In spite of its success, psychotherapy is assumed to be too expensive to be covered fully by insurance benefits. Opponents of the Mental Health Parity Act—the law passed in 2008 that forbids insurance companies from restricting benefits for mental illness unless similar limits are placed on general medical benefits—argued that making therapy more freely available would result in massive cost overruns. It is widely believed that once patients have freer access to psychotherapy, they will become involved in long, expensive treatments.
The authors of Psychotherapy is Worth It: A Comprehensive Review of its Cost Effectiveness argue that the stigma attached to mental disorder leads both insurers and the general public to see patients with mental disorder as "weak willed and self-indulgent." Susan Lazar, the editor of this volume, states in the introduction: "...[A] psychiatric population that is viewed as weak and self-indulgent may be expected not only to seek psychotherapy services needlessly but to never want to end them."
To counteract this impression, the book provides an extensive literature review showing that psychotherapy not only helps those suffering mental and emotional difficulties, but does so in way that may actually reduce general medical costs and indirect expenses such as lost wages and disability payments. And the research indicates that patients generally do not use psychotherapy wastefully.
The book is organized in chapters written by different authors who each focus on a major psychiatric problem, such as schizophrenia, anxiety, depression, substance abuse, and childhood emotional distress. In addition, chapters focus on the use of psychotherapy in chronic medical conditions and the particular utility of longer term psychotherapies. Each chapter follows a similar structure: studies are culled from treatment efficacy literature using searches of the Medline database; relevant research is described and analyzed; and each chapter ends with a chart that helpfully summarizes relevant research. A case example of effective treatment is provided for each of the mental health problems studied.
The book is addressed to policy makers, benefits providers, and therapists. Given the complicated material presented and the challenges of producing a consistent work by multiple authors, the book maintains a consistent format and tone.
Some of the results will be eye-opening, especially for therapy practitioners who may not be aware of the full effects of their work. A study involving employees of a major corporation that provided generous outpatient psychotherapy benefits found that total health care expenses per employee declined by $9 per month, even though the cost of the therapy increased by a third. Another study found that providing psychotherapy led to an average decrease in absenteeism from 10 to 3 days a year, reducing the yearly cost of missed work days by $1,054 per employee. Converging studies by several investigators studying borderline personality disorder show that the cost of providing extended outpatient and partial hospital therapy for these patients is easily recouped in savings in hospitalization and other medical expenses. These studies did not measure the likely additional savings in increased work productivity.
Contemporary attitudes suggest that improvements in mental health are likely to be derived from new miracle drugs. But an international study of treatment for schizophrenia –a disorder for which a number of new medications are generally seen as being far superior to older formulations—found that adding psychotherapy provides significantly better outcomes than switching from older to newer drugs.
While this volume covers the extant literature on the cost-effectiveness of therapy, often there is not enough research of this sort for particular disorders, such as Post-Traumatic Stress disorder. The book thus also reports studies demonstrating that psychotherapy is effective, even if no data is available on cost savings.The reasonable assumption is that since effective therapy has been shown to reduce costs in some studies, any study demonstrating the therapy works also adds to the evidence that therapy is cost effective. But this is purely hypothetical and additional research showing that therapy is "worth it" using direct measures of cost-effectiveness is needed.
The authors are aware that valuing psychotherapy because it reduces other medical expenses—a major focus of studies reported here—is a double-edged sword. Yes, the findings regarding cost savings are welcome, but why does psychotherapy need to be justified because it reduces other medical care expenses? This emphasis perpetuates the stigma associated with mental health problems which are not considered "real illnesses," so that improvement might not be considered significant unless it accounts for changes in "physical health." Fortunately, more recent studies attempt to measure effectiveness not just in terms of cost offset, but in terms of the quality of life achieved.
The studies described in this book raise questions not addressed by the authors. A variety of therapies have been shown to be "worth it" in various studies. Does this confirm the often debated contention that all well-conceived therapies are effective because of common factors that transcend particular theoretical approach or specific technique? Or would differences be found cost-wise if different therapies were measured against each other (only a few such studies are reported in the book). As competition for health care dollars continues to be competitive, we can assume answering this question will become even more urgent.
In recent years, insurance companies have limited reimbursement to short-term, symptom-targeted treatments that cost less than longer-term, more intensive therapies. This is in part because much of the most methodologically rigorous research has involved short term cognitive behavioral treatments, which are easier to study due to their length and narrow focus on discrete symptoms. But critics have argued that these studies do not represent therapy as it is practiced in the real world, where patients' difficulties go beyond discrete symptoms to include more pervasive and longstanding personality problems.
No doubt insurance providers—who often focus on the immediate bottom line, even when the research suggests spending more now will save money later—will attempt to pay for as little therapy as possible. Already, insurance companies are working to find ways around the parity act by restricting benefits without violating the law.
The question for the future, then, may not be if psychotherapy is worth it, but whether changes in the health care system will make it possible for patients to get the best treatment available, even when it's more expensive in the short run. Common sense, as is meticulously documented in this volume, suggests this should occur. Experience suggests, however, that such an outcome is quite unlikely.
Mark Olfson and Steven C. Marcus, National Trends in Outpatient Psychotherapy Am J Psychiatry 2010 167: 1456-1463 Dec 2010
Russell Adams and Avery Johnson," Law Prompts Some Health Plans to Cut Mental-Health Benefits," Wall Street Journal, Dec 28, 2010
© 2011 Robert Cohen
Robert Cohen, Ph.D. is associate professor of psychology at Madonna University in Livonia, Michigan, where he also is director of supervision and training for the Masters of Science in Clinical Psychology Program. He is also an associate faculty member at the Michigan Psychoanalytic Institute. Dr. Cohen practices psychotherapy with adults, children and couples in Ann Arbor, Michigan.