In today's op-ed page for the New York Times, Brown University psychologist Brandon Gaudiano argues that the field of psychotherapy needs to do a better job of marketing itself. The reason? He notes that over the last decade and a half, numbers of outpatient mental health patients being treated with psychotherapy dropped greatly, while those being treated with psychiatric medication rose significantly.
You might think that the reason for this could be one of two things. First, it could be the case that people would simply rather have meds than therapy. Alternatively, people might instead believe that the evidence base is better for medication, so are choosing the treatment with the highest likelihood of success.
As far as the first potential reason goes, that seems very unlikely to be the case. A recent study by Kathryn McHugh in the Journal of Clinical Psychiatry found that out of 90,483 subjects, "75 per cent of participants stated a preference for psychotherapy over drugs. Stated differently, participants were three times as likely to state that they preferred psychological treatment rather than medication." Resoundingly, most folks would rather try to talk their problems out than take a pharmaceutical agent.
That may be what people want, but is it what is best? If medications work better, they should be the first line treatment of choice, right? Well, in most cases, they do not work better. According to Gaudiano:
"for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling."
Part is what is often unreconized in the difficult process of choosing a way forward through psychological difficulties is the essentially radical nature of pharmacological intervention. These agents alter the basic functioning of the brain, a human organ that is still, despite great progress, poorly understood. That is not to say that alteration is not exactly what is called for. But it is prudent for a less invasive intervention with a comparable evidence base to be considered first.
If medications do not enjoy an advantage over therapy in research outcomes, why are they increasing at the same time that therapy is decreasing? Gaudiano argues the issue is one of perception:
"The answer is that psychotherapy has an image problem. Primary care physicians, insurers, policy makers, the public and even many therapists are largely unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries — industries that, not incidentally, also have the money to aggressively market and lobby for those practices."
He goes on:
"My colleague Ivan W. Miller and I recently surveyed the empirical literature on psychotherapy in a series of papers we edited for the November edition of the journal Clinical Psychology Review. It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).
In the short term, these therapies are about as effective as medications in reducing symptoms of clinical depression or anxiety disorders. They can also produce better long-term results for patients and their family members, in that they often improve functioning in social and work contexts and prevent relapse better than medications."
The key here is that mental health professionals need to be sure to employ methods that enjoy empirical support. Not all do. Not incidentally, the methods I employ at Spoon River Counseling & Wellness I learned specifically because they were among the most highly supported methods available- Acceptance and Commitment Therapy, a form of CBT, and various mindfulness-based treatments.
The science behind these treatments is quite solid. Psychotherapy works, and is in many cases the best available treatment.