Back to Garden/Back to Anteroom

ARTICLES

Does therapy really help?

By Sally Davies, MA (Clinical psychology)

Scientific psychology is often concerned with the outcome of psychotherapy - whether it works, how it works, who is best suited, what problems respond best to what types of treatment, and so on. This research is often obscure and of little interest to anyone but scientists - sometimes not even therapists pay much attention to it.

A few years ago in the USA, a rather different study was done, this time by the highly-respected Consumer Reports magazine (November 1995 issue). Instead of arranging sophisticated comparisons, they simply asked a very large number of people about their real life experiences of therapy - and the findings make interesting reading.

Firstly, it was clear that millions of Americans who might well benefit from therapy never even give it a try; fewer than one third find their way to professional help. If therapy doesn't help, or doesn't help most people, that's not a concern - but the survey found just the opposite. "Convincing evidence" that therapy makes an important difference in people's lives abounded, based on reports from over four thousand people! The people were mostly well educated with an average age of 46, and about half were women. They were certainly in trouble, describing life at the time as "pretty tough" or saying that "I barely managed to deal with things". Problems mentioned included depression, anxiety, panic, phobias, marital or sexual problems, problems with children or work, with grief, stress and alcohol or drugs.

Where to get help

The help basically came from five sources: family doctors, psychologists, psychiatrists (doctors with specialist mental health training), social workers and self help groups. On the whole, people were satisfied with all the different types of professionals - with the possible exception of marriage therapists. They were most satisfied with mental health specialists and self-help groups, particularly AA (Alcoholics Anonymous), which did a huge amount to change lives for the better and has won a lot of loyalty. The family doctor - first port of call? Although people who consulted their doctors generally did well (certainly better than those who did nothing about their problem), there were some important limitations. While doctors were usually perceived as more available and consulting them as more comfortable, the services offered by medical practitioners tended to be shorter, usually less than two months. People were more likely to get psychiatric drugs from general practitioners than from any of the other groups - 83% compared with 20% elsewhere. Psychologists and social workers don't prescribe, but will refer for medication if they think it's necessary; psychiatrists do prescribe, but tended to be more conservative. Unfortunately, almost half of those who consulted a doctor for emotional problems were given drugs without being offered ongoing counselling. And yet, these were not the most severely affected - those with severe emotional distress tended to get themselves into specialist care, with less medication and more therapy. So consulting a GP is more likely to attract a medical response to your problem.

The lack of therapy in doctors' rooms may be the reason why only half of their patients were satisfied, compared to 62% who consulted other providers. Family doctors referred only one in four to mental health specialists, so it seems that they feel confident in what they are doing, at least! It appears that if all you need is to get back on your feet, your family doctor is a good bet, but if you need anything more than that, it is better to consult a specialist to begin with. Previous research has found that GPs may fail to diagnose 50 - 80% of psychological problems; they also show uncertainty about the correct use of psychiatric drugs, frequently prescribing them for too short a time or at too low a dose. Therapists in South Africa have raised similar concerns, with the additional complaint that many family doctors are prescribing addictive drugs inappropriately and for too long. Nevertheless, it is clear that the family doctor plays a crucial role in mental health diagnosis and short-term treatment; they are often first on the scene and may well be the person with whom the patient feels most at home.

The value of psychotherapy

Scientific studies have often claimed that psychotherapy is more effective when combined with medication, but the Consumer Reports Survey showed that psychotherapy alone actually worked as well as psychotherapy combined with medications. At present in the USA and other countries, including South Africa, there is pressure from health insurance groups to keep therapy short, sometimes imposing very restrictive limits. The consumer study strongly suggests that this is misguided. In fact, the longer a therapy continued, the more the client improved. Yet, as one spokesperson for a Mental Health Association said, "insurers would just as soon cover us from the neck down!"

Effectiveness

How well did therapy work? Its effect was impressive. About 44% of those whose state was "very poor" at the start said that they now felt good; another 43% who started out "fairly poor" also reported a significant (though less dramatic) improvement. Nearly all said that in their opinion, therapy had helped. No matter what the condition, the same pattern of improvement occurred. Most of those who left treatment, said they did so because their problems were resolved or because they felt more able to deal with their problems. The less satisfactory performance of marital therapy is probably as a result of: a) the relative severity of a problem before people seek help; b) the known difficulty of couple therapy; and c) the fact that many marriage therapists are NOT properly trained or qualified. As Consumer Reports says, "in most places, the title 'marriage counsellor' is up for grabs".

Drug treatments got a more mixed reception. About 60% of those who took drugs for their problems said it "helped a lot"; but the majority of respondents, who received psychotherapy alone, improved just as much as those who got the drugs as well as the therapy. People complained about side effects, such as feeling disorientated or drowsy. More worrying, 40% of those prescribed anti-anxiety drugs (i.e. valium and its relatives) were still taking them a year later, and 25% continued to "pop" tranquillisers after two years! This, despite scientific research showing that after two months, such drugs tend to perform no better than placebos, and abundant clinical evidence that people become habituated to them - needing larger and larger doses to achieve the same calming effect. The fact is, the tranquilliser habit is very hard to kick, because when you stop the drug you are punished by symptoms returning full force and sometimes worse than before.

How much therapy is enough?

Most people who get therapy in the US average between four and eight sessions, and it is not clear whether they stop mainly for financial or other reasons. Clearly, brief therapy can be useful - as few would deny - but this survey found that the longer people worked with their therapists, the better the outcome. Staying in therapy for at least six months was much more productive than short term treatment, and improvements continued up to a year or more. The very best outcomes were reported by people whose therapy went on for two or more years - but these were also the more seriously affected to begin with so they had more to gain.

How did therapy help?

First, the problems bothering them were eased or overcome. Secondly, they were helped to cope in many areas of life - more able to relate to other people, more productive at work, and more able to handle everyday stress. Finally, people said that therapy enhanced personal growth: they felt they had more confidence and self esteem, a better understanding of themselves, and more capacity to enjoy life. Life just got richer - what a return on an investment! While the therapist was obviously important, the attitude of the client also contributed to this success. Those who were active consumers, approaching more than one therapist, checking experience and credentials, and even speaking to previous clients, got the best results. This seems to be because - once they began their therapy - these clients formed an active partnership with the therapist of their choice, were honest and open, and worked on issues in between sessions. Therapy can be hard work, but it also offers rich rewards.

Clearly, there is no need to continue struggling with overwhelming problems or emotional distress that interferes with one's ability to live life to the full - help is available from every quarter. Both "talk therapy" and medication help by relieving and supporting people with a wide range of problems, even when despair is deep. And such people run into their millions. So why are we putting up with misguided limits on insurance coverage from the private sector, and with governments who treat mental health as a "Cinderella" among health services? The battle over mental health care is far from over - but at least now the voice of the consumer cannot any longer be ignored.