Re: thoughts on psychotherapy

From: Robin Hanson (
Date: Thu Jul 06 2000 - 13:08:52 MDT

At 11:39 AM 7/6/2000 -0700, you wrote:
>A few years ago, Bergin (I believe) conducted a
>meta-analysis study which reviewed and integrated a
>large number of those studies.

I'd be interested in a cite for that.

>There's a good article on effectiveness by a quite
>famous psychologist (Martin Seligman) at:

I disagree with this section of this article:

The five properties that follow characterize psychotherapy as it is done in
the field. Each of these properties are absent from an efficacy study done
under controlled conditions. If these properties are important to patients'
getting better, efficacy studies will underestimate or even miss altogether
the value of psychotherapy done in the field.

1.Psychotherapy (like other health treatments) in the field is not of fixed
duration. It usually keeps going until the patient is markedly improved or
until he or she quits. In contrast, the intervention in efficacy studies
stops after a limited number of sessions—usually about 12—regardless of how
well or how poorly the patient is doing.

2.Psychotherapy (again, like other health treatments) in the field is
self-correcting. If one technique is not working, another technique—or even
another modality—is usually tried. In contrast, the intervention in efficacy
studies is confined to a small number of techniques, all within one modality
and manualized to be delivered in a fixed order.

3.Patients in psychotherapy in the field often get there by active shopping,
entering a kind of treatment they actively sought with a therapist they
screened and chose. This is especially true of patients who work with
independent practitioners, and somewhat less so of patients who go to
outpatient clinics or have managed care. In contrast, patients enter
efficacy studies by the passive process of random assignment to treatment
and acquiescence with who and what happens to be offered in the study
(Howard, Orlinsky, & Lueger, 1994).

4.Patients in psychotherapy in the field usually have multiple problems, and
psychotherapy is geared to relieving parallel and interacting difficulties.
Patients in efficacy studies are selected to have but one diagnosis (except
when two conditions are highly comorbid) by a long set of exclusion and
inclusion criteria.

5.Psychotherapy in the field is almost always concerned with improvement in
the general functioning of patients, as well as amelioration of a disorder
and relief of specific, presenting symptoms. Efficacy studies usually focus
only on specific symptom reduction and whether the disorder ends.

It is hard to imagine how one could ever do a scientifically compelling
efficacy study of a treatment which had variable duration and
self-correcting improvisations and was aimed at improved quality of life as
well as symptom relief, with patients who were not randomly assigned and had
multiple problems. ...

For <~$100M one could do a study like the RAND health insurance experiment.
Take a few thousand families, randomly assign half to free therapy and half
to full price therapy for five years. At the end look at thirty different
general mental health measures.

Or course $100M is a lot of money. And odds are you'd see the same thing
they saw in the RAND HIE study - basically no effect.

Robin Hanson
Asst. Prof. Economics, George Mason University
MSN 1D3, Carow Hall, Fairfax VA 22030
703-993-2326 FAX: 703-993-2323

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