Metadata →
- Tags: crítica evidencia favorito investigación psicoterapia
[!summary]The document discusses how a study revealed that psychotherapy takes time for meaningful change to occur, with clients showing substantial improvement after about six months and even more after a year. It contrasts this with health plans limiting therapy duration, potentially affecting outcomes. The research emphasizes that real-world therapy often lasts longer than the commonly studied 8-12 sessions, with significant improvement typically seen around the six-month mark, challenging the prevailing notion of brief, manualized therapies.
Highlights
id712699285
Meaningful change began at about the six-month mark, and clients who stayed in therapy for a year did substantially better. Those who stayed for two years improved still more. There was an unmistakable dose–response curve: “The longer people stayed in therapy, the more they improved.” This dovetailed with earlier research that also found a dose–response relation between amount of therapy and amount of improvement.
id712699364
people had poorer outcomes when the type or duration of therapy was restricted by their health plans. “This suggests that limited mental health insurance coverage, and the new trend in health plans—emphasizing short-term therapy—may be misguided.”
id712699453
The three outcome questions left it to respondents to decide whether they’d gotten what they needed: 1) How much did treatment help with the specific problem that led you to therapy? 2) Overall, how satisfied were you with the therapist’s treatment of your problems? 3) How would you rate your overall emotional state compared to when you started treatment, from very poor (I barely managed to deal with things) to very good (life was much the way I liked it to be)? This is different from how most psychotherapy research is done. More often, academic researchers decide up front, without consulting clients, what their therapy is meant to accomplish
id712699503
Generally, psychotherapy researchers have been remarkably uninterested in the input of real-world therapists
id712699639
CBT therapists reported that successful therapy took much longer than the 8 to 16 sessions common in research trials. The mean number of sessions for successful real-world CBT ranged from 33 to 44—a little over six months of weekly therapy to almost a year
id712699695
Academic researchers promoting brief manualized therapies tell us therapy is finished in 8 to 12 sessions. But if we believe the expert therapists—psychologists and psychiatrists of diverse theoretical orientations with an average of 18 years of practice experience—meaningful therapy has barely started
id712700019
It took 21 sessions, or about six months of weekly therapy, for 50 percent of clients to see clinically significant change. It took more than 40 sessions, almost a year of weekly therapy, for 75 percent to see clinically significant change.
id712700060
Nothing of deep and lasting value is cheap or easy, and changing oneself and the course of one’s life may be most valuable of all. Consider what it takes to master any new and complex skill, say learning a language, playing a musical instrument, learning to ski, or becoming adept at carpentry. With six months of practice, you might attain beginner- or novice-level proficiency, maybe. If someone promised to make you an expert in six months, you’d suspect they were selling snake oil. Meaningful personal development takes time and effort. Why would psychotherapy be any different?
id712700217
Norms regarding therapy duration now tend to be calibrated by the cost-cutting agenda of health insurance companies, and by academic research based on assumptions that don’t realistically reflect how psychotherapy works. In the psychotherapy research world, the lion’s share of research focuses on brief, fixed-duration therapies conducted by following step-by-step instruction manuals—known as manualized therapy
id712700245
These terms, especially evidence-based therapy, are problematic because they’re misleading. People take them to mean that clients get well. That is not so. Rather, evidence-based therapy means the treatment is delivered in a standardized way by following an instruction manual, and it has been studied using specific research methods. It doesn’t refer to the percentage of people who get well, or how much they improve, or whether they themselves consider their therapy successful.
id712700556
In the psychotherapy research world, studies using randomized controlled trial (RCT) research designs are given the highest stamp of approval. The method involves random assignment of research subjects to a treatment or control group (usually no intervention, or a placebo intervention not meant to target the client’s problems). The treatment must be conducted by following a manual to ensure it’s delivered in a uniform way by all therapists in the study. Researchers select subjects with a specific DSM diagnosis, say generalized anxiety disorder, major depressive disorder, or PTSD, and the disorder is the focus of the treatment. Desired outcome is defined by the researchers, not clients or therapists, and is measured by scores on symptom checklists based on the DSM diagnosis.
id712758674
meaningful and lasting psychological change comes from focusing not on symptoms, but on the personality patterns that underlie them
id712922015
A basic flaw in the logic of instruction-manual therapies is that clients come to therapy primarily for symptom reduction. Often, they want something else and something more. Probe them on how they themselves define good outcome and they refer to things like new ways of relating to others, improved self-understanding, improved self-worth, and self-acceptance
id712922045
What clients seek from therapy squares with the type of changes therapists desire for their clients. Psychologist David Orlinsky spearheaded an international survey of over 5,000 mental health professionals of diverse theoretical backgrounds who were asked to rank-order treatment goals they most wanted their clients to realize. The top of the list, by far, was “have a strong sense of self-worth and identity.” Next was “improve the quality of their relationships.” A close third was “understand their feelings, motives, and/or behavior,” and “integrate excluded or segregated aspects of experience” came after that. “Experience a decrease in their symptoms” ranked a distant fifth
id712922208
In a year-long study of community-based psychodynamic psychotherapy with 65 clients, Refael Yonatan-Leus at Hebrew University of Jerusalem and colleagues found that treatment becomes incrementally more effective as it progresses over time with experienced therapists. As therapy unfolds, clients learn to confidently expect understanding and sensitivity, which in turn fuel greater emotional truth-telling and unguarded disclosure.
id712922225
Early dropout is a neglected topic in our field. A 2010 article in the American Journal of Psychiatry reported on a sample of 30,000 psychotherapy clients and found that nearly 40 percent had dropped out within the first two sessions, and 80 percent before attending 10 sessions
id712922542
Clients need to know their therapist not only cares enough to listen, but knows how to listen carefully enough to hear what matters. Clients need plenty of space and time to tell their agonizing life stories in the nonlinear, scattershot way distressed humans are apt to do. Silences leave room for deeper feelings and realizations to bubble up. Subtle head nods, wry smiles, and knowing groans by the therapist are reminders to clients that they are being heard.
id712922896
Scott Miller, a passionate scholar of “what works” in psychotherapy, pulls no punches here. “In psychotherapy, who provides the treatment is between five and nine times more important than what particular treatment approach is provided,” he says—which is why he counsels beginning therapists to work on relationship skills.
id712923157
when you put in the years of personal therapy and self-examination necessary to be good enough at embodying sustained empathy, genuine regard, and careful and caring listening, most clients keep coming back. Encountering someone who is patient, doesn’t leap in to provide answers and fix problems, and lets them untangle their issues at their own pace frees clients up to accept that real and lasting change takes time.