Despite the huge growth in the number of psychotherapists, you'd be better off talking to an intelligent friend, Raj Persaud, consultant psychiatrist at the Maudsley Hospital in south London, writes in the Daily Telegraph.

March 24, 2003 - Source: www.connected.telegraph.co.uk

Fifty years ago, psychotherapy was dealt a major blow with the first scientific paper to question seriously whether it worked, and whether therapy might sometimes do more harm than good. The study triggered a debate that has raged for half a century and which some say has failed to generate an adequate response from practitioners.

It does not matter which therapy you have - an incredible result given that each is based on opposing theories of human nature.

It started when a young German psychologist, Hans Eysenck, analysed the first proper clinical trials of therapy at the Maudsley Hospital, London.

Eysenck, who went on to become the most famous psychologist in the world, compared the improvement rate of thousands of people undergoing psychotherapy with a control group who had similar psychological problems, but who merely remained on a waiting list.

While an encouraging 64 per cent of patients receiving psychotherapy improved after two years from their breakdown, 72 per cent of the control group made a similar recovery with no psychotherapeutic assistance.

Of those having the most rigorous and intensive therapy of all, full blown Freudian psychoanalysis, only 44 per cent recovered.

When Allen Bergin, a psychologist at Brigham Young University, looked closely at this kind of research, he found the data were hiding an even more peculiar story.

The "scatter" of measured change plotted on graphs for patients having therapy was much greater than the scatter for those receiving no treatment.

In other words, those that had psychotherapy either did fairly well, or often actually pretty badly. They tended to lie in extremes of the distribution, compared with those who had no therapy, who all improved by more or less the same amount.

Bergin had uncovered a result that has dogged the field since. Therapy could not only do good, but also harm. Further analysis found the greatest potential for harm was when therapists stuck rigidly to particular schools of training, rather than adapting to the patient.

Therapy has splintered into so many differing and often opposing schools - Freudians, Jungians, transactional analysis and a host of others - that it resembles the plethora of small Left-wing political groupings of the Seventies, often more united by a hatred for each other than the natural enemy, which, in the case of therapy, is science.

Contrary to the research evidence that sticking rigidly to a particular therapeutic orientation is bad for patients, these schools tend to emphasise vigorously why they are better than all the others, in order to survive.

But unlike factionalised Left-wing politics, therapy proved enormously successful and is growing at an incredible rate. The British Association of Counselling had just a few hundred members by the mid-Seventies but has now grown more than twelvefold to 16,000 members.

The Department for Employment estimates that 2.5 million workers in Britain today deliver some form of counselling as part of their jobs.

This dramatic growth has occurred despite the fact that scientific research continues to question the assumptions on which much therapy is based.

A key scientific blow to the therapy empire came in 1975 when Lester Luborsky, professor of psychology at the University of Pennsylvania, published a landmark paper with the title "Everyone has won and all must have prizes", known famously as the Dodo bird verdict, which comes from Alice's Adventures in Wonderland. The title is an ironic twist to Eysenck's early habit of titling chapters in his books from Lewis Carroll quotes.

He found that it didn't seem to matter what particular psychotherapy you had - everyone benefits more or less to exactly the same extent.

Given that many schools of therapy are based on fundamentally opposing theories of human nature, this is an incredible result. It appears to be irrelevant whether you have full blown Freudian psychoanalysis, an hour a day for five days a week for several years to probe your unconscious deeply, or just a few sessions of behavioural therapy, where it is assumed that your unconscious and your conscious do not exist.

This finding suggested that what gets you better are the effects of talking to someone who encourages you and activates hope.

This suggestion was confirmed by another major study conducted by psychologists Hans Strupp and Suzanne Hadley of Vanderbilt University in the United States in 1979. They found that depressed patients treated by a group of untrained people did just as well as those treated by trained and experienced psychotherapists.

Indeed, in 15 separate major scientific attempts to pool all the research done into the effects of therapist experience and training on patient outcome, only one ever found a significant positive association between years of therapist experience and patient benefit.

Yet another scientific nail in the therapy coffin was the extensive study conducted by Dr William Piper of the University of Alberta in 1991. He analysed 22,500 therapist interventions from audio tapes of sessions, and found the more interpretations the therapist made, the worse the patient got.

All this welter of scientific evidence points to the fact that much of the benefit you can get from therapy is practically indistinguishable from what you might obtain from confiding in a reliable, understanding and intelligent friend.

The dramatic growth of therapy, despite Eysenck's paper 50 years ago, and all the scientific data since, may be telling us something about the breakdown of relationships in our society, and the decline of conventional coping mechanisms, such as religion and the nuclear family.

On the other hand, the American Handbook of Psychiatry defends therapy by arguing: "Perhaps its effectiveness can never be shown by scientific methods. Perhaps the experience of analysis is like that of beauty, of mysticism, of love - self-evident and world-shaking to him who knows it, but quite incommunicable to another who does not."

This kind of defence of therapy suggests that the rise of counselling is telling us something more worrying, about the continued retreat of scientific and rational thinking in the modern age, in the face of the new primacy of personal anecdotal experience. Only in such an increasingly Alice in Wonderland world can "everyone win and all must have prizes".

* From the Edge of the Couch by Raj Persaud (Bantam Press)

........

Misguided thinking

"I've been in psychotherapy for five years and my analyst has the qualities of genuine interest and tenderness that have enabled me to work through some very painful and disturbing feelings based on trauma events in my life.

"I have been able to gain self confidence, insight and hope for living. I very much doubt Dr Persaud's pills or distanced analytic stance would have helped.

"He should stop constructing misguided and damaging judgements about a form of therapy that can make big differences to people's lives."

Mark Bertram, vocational services manager for the South London and Maudsley NHS Trust and occupational therapist, March 26, 2003

Psychotherapy offers more than talking to a friend

"Dr. Persaud, while presumably a very intelligent man, has written an article so full of subtle rhetorical fallacies and inappropriate logical gymnastics as to completely sap the value from his interesting and important message.

"He accuses therapy of being unscientific and no better than a placebo for the friends that we poor alienated postmodernites lost years ago. This is contentious, but I will leave it alone and let those more qualified to pick it apart do so.

"What distresses me the most about the article is Persaud's deliberately obtuse reading of Luborsky et al.'s Dodo Bird Hypothesis which states that for psychotherapies "all have won and all must have prizes." From this, he concludes that therapy is no better than overglorified conversation. How his mind was able to jump from one to the other is a complete mystery to me. Luborsky et al. performed a meta-analysis of studies of psychotherapeutic efficacy many of which included placebo therapy. Without exception, therapy performed better than placebo. I would especially direct him to their 1996 meta-analysis for this data.

This is a very confusing point, since the data appear to show that what is common to all psychotherapies is more important than what is different. This is, in fact, true, but not in the way Persaud would have us believe. The commonalities do seem, according to the data, to be more important than the difference but the commonalities cannot be reduced to "talking to a friendly listener." In suggesting that they can, Dr. Persaud does a disservice to the therapeutic community and to his own argument.

"I am not sure I buy everything therapy has to offer, but arguments like Dr. Persaud's are of no service to anyone seeking a solid and honest conclusion. Therapists undoubtably have some hard questions to ask themselves. Whatever the answers, I can rest assured that Dr. Persaud's will not be among them.

J. Scott, Psychology/Premedical student, University of Pennsylvania, USA. March 28, 2004

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