This document provides a critical review of psychotherapy efficacy research. It discusses various types of psychotherapy and important terms in research methodology. While efficacy research aims to establish causal relationships through controlled trials, its results often lack external validity and generalizability. Comparative studies generally find no significant differences between major psychotherapy approaches. The document concludes that common factors like the therapeutic alliance, rather than specific techniques, are crucial for effective therapy. More research is still needed to determine the most effective treatments for specific disorders.

1. A CRITICAL REVIEW OF PSYCHOTHERAPY
EFFICACY RESEARCH
Amitkumar Chougule
Junior Resident
Psychiatry

2. A SEARCH FOR ELUSIVE WINNER:
A CRITICAL REVIEW OF PSYCHOTHERAPY EFFICACY
RESEARCH

3. INTRODUCTION
PSYCHOTHERAPY
EFFICACY
PSYCHOTHERAPY EFFICACY RESEARCH
CRITICAL REVIEW
ELUSIVE WINNER
CONCLUSION

4. What is Psychotherapy ?
Strupp (1986) specified that psychotherapy is the systematic
use of a human relationship for therapeutic purposes of
alleviating emotional distress by effecting enduring changes in a
patient’s thinking, feelings, and behavior

5.  Psychotherapy refers to all forms of treatment in which:
1. The primary therapeutic agent is a person
2. Who relies exclusively on verbal, psychoeducational, or
behavioral methods
3. To ameliorate a broad array of behavioral and psychological
problems
4. Which fall under the contemporary medical terms, “mental
illnesses” and “psychiatric disorders

6. Major types of Psychotherapy
1. Psychoanalytically informed
2. Cognitive behaviorally informed
3. Experientially informed
4. Strategic systematically informed

7. Important terms in research methodology
Efficacy:
1. The efficacy of treatment is determined by a clinical trial or trials
2. Variables are carefully controlled
3. To demonstrate that the relationship between the treatment and
outcome are relatively unambiguous
4. Efficacy studies emphasize the internal validity of the experimental
design
5. Enhances the ability of the investigator to make causal inferences
based on the findings

8. Internal validity
The confidence with which a causal relationship can be assumed to
exist between a study’s :
independent variables (e.g., forms of therapy) and
dependent variables (e.g., outcomes or effects in a therapy study)

10. Effectiveness
1. The effectiveness of a treatment is studied in natural clinical
settings
2. Effectiveness studies emphasize the external validity of the
experimental design
3. Demonstrate that the treatment can be beneficial in a typical
clinical setting in which fewer experimental variables are
controlled

11. External validity
 The confidence with which findings can be assumed to
“generalize” or extend to situations, people, measures, times, and
so on other than those particular to the study

13. Effect size:
1. A statistic that often is used in therapy research
2. Indicates the magnitude of the difference in outcomes (or “effects”)
found in a research study between alternative treatments

14. Psychotherapy research:
 Psychotherapy research is a relatively young field
 Goal is to create a scientific foundation for the practice of
psychotherapy
 Hans Eysenck ( 1952 ) expressed doubts about the overall
efficacy of psychotherapy

15. DICHOTOMIES AFFECTING PSYCHOTHERAPY
RESEARCH
Dichotomies have affected research at all levels:
At the level of participants (client versus therapist)
Types of therapy (cognitive therapy versus interpersonal therapy)
Duration of therapy (brief versus long-term)
Effective components (specific techniques versus common factors)
Therapy results (process versus outcome)
Areas of psychological research methods (qualitative versus
quantitative)
Statistical outcomes (significant versus not significant)

16. NIMH Treatment of Depression Collaborative Research
Program (TDCRP)
TDCRP was the first time that:
A collaborative, multisite outcome study of psychotherapies was
conducted using the randomized controlled clinical trial research
strategy

17.  From the mid-1980s to the present an increasing number of
outcome studies include:
1. Psychotherapeutic interventions
2. Pharmacological interventions
3. Their combination
 Boundaries between psychotherapy and psychopharmacology
research became blurred

18. How Psychotherapy Research Relates to Other Mental Health
Research
 Psychotherapy research is different from other types of clinical
mental health research such as psychopharmacology (medication)
research
 Psychotherapy research relies on outcome studies to measure the
effect of intervention

19. Outcome studies
1. Outcome studies measures the client’s response to
psychotherapy
2. Measures clinical significance of a change for the individual
client rather statistical significance
Definition of clinical significance is :
1. The client move from the “dysfunctional” to the “functional”
range on the measure
2. The client’s change is greater than a chance fluctuation due to
the measurement error of the instrument

20. Outcome studies are designed primarily to:
1. Test hypotheses
2. Answer questions about the effects of psychotherapy
 Outcome is used as a synonym for effects
 Outcome studies can be designed to answer comparative
treatment questions
 Careful researchers need to pick the type of outcome measure
that will best answer their research question

21. Use of RCT in Psychotherapy research
 The efficacy studies of psychotherapy are carried out by using RCTs
 Superiority of a specific therapy can only be addressed by “head to
head” randomized control trials (RCT)
 Here variables likely to influence outcome are controlled like:
1. Therapist experience
2. Treatment length, etc.
 Studies also ensure that treatments are carried out in conformity
with their theoretical description

22. EFFICACY IN PSYCHOTHERAPY RESEARCH:
A CRITICAL REVIEW
 Study of efficacy through clinical trials has many benefits for
psychotherapy research:
1. Methodology of clinical trials allows for improved internal validity
through minimizing attrition
2. Ability to determine the specific factors that contribute to therapy
outcome by controlling for confounding variables

23. Continued…
3. Trials increase internal validity by controlling the types of
patients included in the study
4. Prospective participants of a clinical trial are usually screened to
ensure that participants meet predefined criteria
5. Participants with additional disorders are excluded

24. Continued…
6. Efficacy studies use treatment manuals to standardize
treatment delivery between therapists
7. The standardization of treatment delivery between therapists is
ensured by:
a) Training therapists prior to the study
b) Monitoring therapist adherence to the treatment during the
study
c) Supervising therapists who deviate from the treatment protocol

25. Continued…
8. Efficacy studies help in managing the “dose” of treatment by
ensuring that each patient has:
a) Undergone the complete treatment
b) Received sufficient dose needed for positive response
9. Efficacy studies are able to identify the impact of therapy from a
fixed number of sessions across treatment groups

26. Limitations of efficacy research are usually associated with
its strengths
1. Main limitations are associated with the degree to which results
can be generalized to routine practice
2. In routine clinical practice, clinicians must help patients even when
they have multiple disorders, are extremely disturbed, or are even
subclinical
3. Clinician cannot undergo extensive training, monitoring or
supervision during practice

27. 4. Patients often receive multiple treatments (e.g., medication,
group therapy) simultaneously
5. The presence of an untreated control group would provide an
ideal benchmark for studying efficacy but it is not ethically
viable to withhold treatment
6. Most of efficacy studies compare psychosocial interventions
with medication or the addition of psychosocial interventions to
pharmacological treatment

28. 7. RCTs are the gold standard in evidence-based medicine, but the
results of these trials are often hard to apply in the context of a
medical practice (Rothwell 2005)
 Individuals participating in clinical trials not always resemble the
patients that a clinician sees in psychotherapy

29. In general “research therapy” appears more effective than clinical
practice (Weisz and Jensen 1999)
 This may relate to methodological issues like:
1. Use of focused and structured manualized treatments
2. Careful attention to ensure therapist adherence to protocol
3. Participants recruited by advertisement rather than through
clinical services
Because of the rigorous design demands clinical trials are limited in
their ability to generalize to routine practice
Thus they must be followed by effectiveness research studies

30. Solution for efficacy vs. effectiveness dilemma
 Debate between efficacy and effectiveness research has a negative
impact on psychotherapy research
 Efficacy research is viewed as the gold standard for building and
promoting evidence-based practice which has its origins in
evidence-based medicine
 The practice of evidence-based medicine means integrating
individual clinical expertise with the best available external clinical
evidence from systematic research (Sackett et al., 1996, p. 71)

31. Evidence Based Practice
 The term evidence based practice provides the potential for a
complementary term using the concept of chiasmus
 Chiasmus (ky-AZ-mus, n.) refers to a reversal in the order of words in
two otherwise parallel phrases
 The reversal in order of words yields the term practice-based evidence
 Practice-based evidence means integrating both individual clinical
expertise and service-level parameters with the best available evidence
drawn from rigorous research activity carried out in routine clinical
settings

32. Practice Based Evidence and Evidence Based
Practice
The concept of practice-based evidence is crucial as:
1. It identifies an equally valued approach to evidence-based practice by
reversing the order of words to achieve a ‘bottom-up’ approach
originating with the practitioner in contrast to a ‘top-down’ approach in
which evidence derived from (RCT) are channeled down to practitioners in
routine practice settings
2. The two parallel but reverse approaches of evidence-based practice and
practice-based evidence yield a greater product by their interplay than
achieved by either approach alone

33. Is Psychotherapy effective?
 Meta-analytical studies of psychotherapy have demonstrated
unequivocally that psychotherapy is effective
 The study by Smith et al. (1980) demonstrated that 80% of those
patients treated in psychotherapy fared better on outcome
measures than those who received no treatment
 Research has demonstrated that psychotherapy often does pay for
itself in terms of medical-cost offset, increased productivity, and
life satisfaction
(Chiles, Lambert, & Hatch, 2002; Yates, 1994)

34.  The research literature indicates that psychotherapy is safe and
effective across a wide range of psychological, addictive, health, and
relational problems for a large number of :
 Children and youths
(Kazdin & Weisz, 2003; Weisz, Hawley, & Doss, 2004)
 Adults
(Barlow, 2004; Nathan & Gorman, 2002; Roth & Fonagy, 2004; Wampold et al., 1997)
 Older adults
(Duffy, 1999; Zarit & Knight,1996)
 Compared with alternative approaches such as medications
psychological treatments are particularly enduring
(Hollon, Stewart, & Strunk, 2006)

35. The best effect sizes have been reported for:
Cognitive therapy for panic disorder (Clark et al. 1994, 1999 )
Cognitive therapy for post-traumatic stress disorders
(Ehlers and Clark 2003 , Ehlers et al. 2005)
Cognitive therapy for social phobia (Clark et al. 2006 , Clark et al. 2003)
CBT for generalized anxiety disorder
(Dugas et al. 2003 , Ladouceur et al. 2000)
Exposure and response prevention for obsessive-compulsive disorder
(OCD) (McLean et al. 2001 , Whittal et al. 2005 )
Exposure for specific phobias (Ost et al. 2001 , Ost et al. 1997 )

36. COMPARISON OF DIFFERENT TYPES OF
PSYCHOTHERAPIES
 Leichsenrig and colleagues have compared psychodynamic
psychotherapy (14 studies) with CBT (11 studies) in the treatment
of personality disorders (Leichsenrig and Leibling 2003)
 Analysis of the studies demonstrated a large overall effect size
(1.46) for dynamic therapy as compared to (1.00) for CBT
 This meta-analysis indicated that long-term changes with dynamic
treatment were achieved

37. BORDERLINE PERSONALITY DISORDER
 RCTs show that personality disorders are less amenable to CBT
 DBT an outgrowth of CBT is tailored for borderline personality
disorder( BPD)
 Highly effective in treating suicidality and self-harm behaviors in
borderline women but not in treating depression
(Linehan et al. 1991, Linehan et al. 2006)
 Psychodynamic treatment had similar effect sizes but also showed
improvement for depression and anxiety
(Bateman and Fonagy 1999, 2001)
 Head-to-head comparisons showed equivocal results

38. Long-term vs. short term Psychotherapy
 Most psychoanalysts would consider that the efficacy of short-term
once-a-week psychotherapy are not comparable to long-term
psychodynamic psychotherapy
 The Boston Psychotherapy Study (Stanton et al. 1984):
1. RCT for patients with schizophrenia
2. Comparison between long-term psychoanalytic therapy
(2 or >/ week) with supportive therapy for patients (1/week)
3. No difference was found

39. Continued..
 The Stockholm Outcome of Psychotherapy and Psychoanalysis
Project (Blomberg et al. 2001, Grant and Sandell 2004, Sandell et al. 2000) :
1. Followed 756 individuals who received National Insurance-
funded treatment for up to three years in psychoanalysis or
psychoanalytic psychotherapy
2. The groups were matched on many clinical variables
3. Analysis 4/5 sessions per week had similar outcomes when
compared with 1/2 sessions per week

40. A Search for elusive winner
 image

41.  Luborsky et al. (1993) have demonstrated that psychoanalytic
psychotherapy is as effective as cognitive, behavioral, experiential,
and group therapies and hypnotherapy
 An ambitious comparison of following therapies for BPD showed
no difference: (Clarkin et al. 2007)
1. Transference focused psychotherapy(TFP)
2. Dialectical Behavior Therapy (DBT)
3. Supportive psychotherapy

42.  Many large-scale careful studies, such as the Helsinki study found
no difference between therapies
(Knekt and Lindofrds 2004)
 Majority of studies in which a behavioral therapy was compared
directly to a non-behavioral therapy (e.g., psychodynamic
psychotherapy) failed to detect statistically significant outcome
differences

43. Research has failed to show that
any one method is more potent than
the others
(with notable exceptions e.g., the superiority of CBT over IPT for
the treatment of OCD and other anxiety disorders)

44. Looking for components which can prove psychotherapy to
be the ultimate winner
 Consistent application of one method appears to be important for good
outcome
 The non specific elements among psychotherapies are the effective
ingredients rather than their specific differences
 One nonspecific component of all therapies that has been investigated is
the quality of the therapist/patient relationship
 Studies revealed that a good therapist/patient relationship is a crucial
factor in the treatment’s outcome
(Lambert 2004, Luborsky et al. 1988)

45. Therapist Factors in Therapy Outcome
 In Kim et al.’s (2006) analysis of the NIMH’s Treatment of
Depression Collaborative Research Project (NIMH TDCRP) dataset
5–10% of the variance in outcomes was shown to be associated
with therapist
 Very large studies with datasets of over 5,000 patients,
consistently report large effects associated with therapists
(Okiishi et al. 2006)

46. Continued…
 Therapist factors have been shown to be associated with the rate
of improvement
 The therapist’s age, gender, and ethnicity appear to have little or
no impact on results
 Findings suggest that the therapist’s experience does not help to
predict outcome

47. The important research challenges that must be addressed to
become winner psychotherapy

48.  Currently the therapist is left with few data supporting the superiority
of one type of psychotherapy over another for a given condition or
disorder
 The important research challenges that need to be addressed are:
1. Determining efficacy for specific disorders
2. Developing treatment guidelines for interpersonal problems and
personality disorders
3. Developing reliable and valid self-report measures for core
conflicts

49. Continued….
4. Measuring potential cost effectiveness of different therapies
5. Matching patients to treatment on the basis of personality,
functional level, or developmental stage
6. Examining whether and how experienced therapists can be
trained in short-term psychoanalytic treatments
7. Learning the limits of brief therapy and conditions or symptoms
for which longer term psychotherapy should be recommended

50. CONCLUSIONS
1. Psychotherapy is effective in treating a wide variety of clinical
conditions
2. The affinity between patient and therapist is a key factor in
effective therapy
3. Level of functioning and the ability to form a therapeutic alliance
are better predictors of outcome
4. Evidence suggests that common factors and not specific
techniques are crucial in therapy

51. Continued..
5. Long term therapy has no significant advantage over
short-term therapy
6. Finally research has failed to show that any one
psychotherapy method is more potent than the
others

52. Research into psychotherapy will require further investigation to
understand:
a) The mechanisms
b) Matching specific techniques with specific types or severity
levels of problems
c) The effect of dose and frequency of the therapy

53. It is the therapist who is winner and not
the therapy
In our struggle to prove a winner
psychotherapy one should make sure that
our patient should not be the loser.....