Looking for Evidence That Therapy Works

Mental-health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release “evil spirits.”

Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.

The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.

C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient’s feelings and that often include exposure therapy and other activities.

Instead, many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist’s biases and training than from the latest research findings. And even professionals who claim to use evidence-based treatments rarely do. The problem is called “therapist drift.”

“A large number of people with mental health problems that could be straightforwardly addressed are getting therapies that have very little chance of being effective,” said Glenn Waller, chairman of the psychology department at the University of Sheffield and one of the authors of the meta-analysis.

A survey of 200 psychologists published in 2005 found that only 17 percent of them used exposure therapy (a form of C.B.T.) with patients with post-traumatic stress disorder, despite evidence of its effectiveness. In a 2009 Columbia University study, research findings had little influence on whether mental-health providers learned and used new treatments. Far more important was whether a new treatment could be integrated with the therapy the providers were already offering.

The problem is not confined to the United States. Two years ago, Dr. Waller studied C.B.T. therapists in Britain treating adults with eating disorders to see what specific techniques they used. Dr. Waller found that fewer than half did anything remotely like evidence-based C.B.T.

“About 30 percent did something like motivational work, and 25 percent did something like mindfulness,” said Dr. Waller. “You wouldn’t buy a car under those conditions.”

Why the gap? According to Dianne Chambless, a professor of psychology at the University of Pennsylvania, some therapists see their work as an art, a delicate and individualized process that works (or doesn’t) based on a therapist’s personality and relationship with a patient. Others see therapy as a more structured process rooted in science and proven effective in both research and clinical trials.

“The idea of therapy as an art is a very powerful one,” she said. “Many psychologists believe they have skills that allow them to tailor a treatment to a client that’s better than any scientist can come up with with all their data.”

The research suggests otherwise. A study by Kristin von Ranson, a clinical psychologist at the University of Calgary, and colleagues published last year concluded that when eating-disorder clinicians did not use an evidence-based treatment or blended it with other techniques for a more eclectic approach, patients fared worse, compared with those who received a more standardized treatment.

Therapists who skew toward the “artistic” side say that so-called manualized treatment devalues crucial aspects of therapy like empathy, warmth and communication — the “therapeutic alliance.”

“If you want a patient to be using a treatment that works, what’s most likely to get them there is the relationship you build with them,” said Bonnie Spring, a professor of psychiatry at Northwestern’s Feinberg School of Medicine.

But some experts believe this is a false choice. “No one believes it’s a good idea to have a bad relationship with your client,” said Dr. Chambless. “The argument is really more, ‘Is a good relationship all we need to help a patient?’ ”

Besides, evidence-based treatments like C.B.T. still require expertise, clinical judgment and skill from practitioners, noted Terry Wilson, a professor of psychology at Rutgers University. “A stereotype of manualized treatment is: you go buy a book and it’s a rigid, lock step thing,” he said. “But when done competently, it’s anything but.”

Differences in background and education play a role in a therapist’s perspective on evidence-based treatment. “You can become a therapist with very little training in how to think scientifically,” said Carolyn Becker, a professor of psychology at Trinity University in San Antonio. Psychiatrists, clinical psychologists, social workers and other mental-health professionals complete years of rigorous schooling and apprenticeships, but it is possible to practice therapy without such a foundation.

“A lot of students come in and say, ‘I hate science, but I’m good with people. I like to listen and help them,’ ” said Dr. Becker. There is little incentive for therapists to change what they are doing if they believe it works. But “every clinician overestimates how well they’re doing,” said Dr. Spring. Often patients simply feel they can’t tell a therapist when things aren’t going well.

“A lot of times, therapists just don’t know,” Dr. Chambless said. “People will say, ‘Thank you, I’m fine now, goodbye,’ and go into a different therapy.”

Despite the gap between research and practice, some experts are cautiously optimistic. Dr. Wilson believes mental health practitioners, especially younger clinicians, are slowly moving toward more evidence-based treatments. He pointed to a parallel shift among physicians that took place, he said, when medicine committed itself to science rather than to producing medical artists or gurus.

“As a field, clinical psychology needs to do the same thing,” he said. “We need to commit ourselves to science.”

Need to find a therapist well-grounded in the latest research? Experts recommend interviewing prospective providers before starting therapy, especially if you are looking for a specific type of treatment. Useful questions include:

¶What kind of trainings have you done, and with whom?

¶What professional associations do you belong to? (If you’re looking for a C.B.T. therapist, for instance, ask whether the therapist belongs to the Association for Behavioral and Cognitive Therapies, where most top C.B.T. researchers are members.)

¶What do you do to keep up on the research for treating my condition?

¶How do you know that what you do in treatment works?

¶Do you consider yourself and your approach eclectic? (Therapists who subscribe to an eclectic approach are less likely to adhere to evidence-based treatments.)

¶What manuals do you use?

¶What data can you show me about your own outcomes?

“A clinician who can’t tell you how many patients get well isn’t going to care that much if you get well,” said Dr. Waller.

by HARRIET BROWN