The Tyranny of Time: How Long Does Effective Therapy Really Take? Shedler and Enrico Gnaulati (2020)
Patient Surveys. In the 1990s Consumer Reports surveyed 4,000 psychotherapy patients. The report found that most respondents were satisfied with the therapy they received and had “made strides toward resolving the problems that led to treatment.” The report also found that effective therapy took time. “Meaningful change began at about the six-month mark, and clients who stayed in therapy for a year did substantially better.”
Psychotherapist Surveys. Drew Weston (Emory University) surveyed 270 psychotherapists who had been in practice an average of 18 years, and his findings were similar to those of Consumer Reports. When asked when they first saw clinically significant reductions in the patients’ primary symptoms, the therapists provided a median number ranging between 16 and 20. When asked when both “patient and therapist agreed that the outcome was reasonably successful,” they gave a median answer of 52 sessions for patients with panic disorder and 75 sessions for patients with depression.Standardized Measures. Michael Lambert (Brigham Young University) studied the results of the Outcome Questionnaire-45, a self-report measure that asks patients to rate the domains of symptoms, interpersonal relationships, and quality of life and work. Looking at responses over time from 10,000 patients, Lambert found that it took 21 sessions for 50 percent of patients to report clinically significant change and that it took 40 sessions for 75 percent of patients to report such change.
Shedler and Gnaulati write: “This is consistent with what clinical theorists have been telling us for the better part of a century. It should come as no surprise. 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?”
Evidence-Based Treatment. Given these findings, it would seem that researchers would want to study therapies lasting at least six months. However, most psychotherapy research focuses on brief treatments lasting 8-16 sessions. Such therapy is called “evidence-based,” but all this means is that the treatment is “delivered in a standardized way by following an instruction manual.” “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.”
Evidence Against Evidence-Based Treatment. Shedler recently conducted a study of evidence-based research studies over the past 30 years and found that “the percentage of depressed clients who got well and stayed well, even for brief follow-up periods of 12 to 18 months, hovered around 25 percent.”
One reason evidence-based treatments fail is that they “gloss over the mix of attachment insecurities, personality quirks, and psychological defenses that make most clients in the everyday world of clinical practice anxious and depressed.” They continue: “Limiting research to “pure” cases of a diagnosis and restricting the meaning of outcome to symptom checklists make for elegant experimental research designs but miss the complexity of the psychological difficulties most clients experience.”
Most therapy patients present with problems that are “embedded in, and inseparable from, personality — a person’s characteristic and enduring patterns of thinking, feeling, fantasizing, desiring, fearing, coping, defending, attaching, relating, and experiencing self and others.” Indeed experienced therapists have found that “meaningful and lasting psychological change comes from focusing not on symptoms, but on the personality patterns that underlie them.”
Shedler and Gnaulati write: “This is consistent with what clinical theorists have been telling us for the better part of a century. It should come as no surprise. 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?”
Evidence-Based Treatment. Given these findings, it would seem that researchers would want to study therapies lasting at least six months. However, most psychotherapy research focuses on brief treatments lasting 8-16 sessions. Such therapy is called “evidence-based,” but all this means is that the treatment is “delivered in a standardized way by following an instruction manual.” “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.”
Evidence Against Evidence-Based Treatment. Shedler recently conducted a study of evidence-based research studies over the past 30 years and found that “the percentage of depressed clients who got well and stayed well, even for brief follow-up periods of 12 to 18 months, hovered around 25 percent.”
One reason evidence-based treatments fail is that they “gloss over the mix of attachment insecurities, personality quirks, and psychological defenses that make most clients in the everyday world of clinical practice anxious and depressed.” They continue: “Limiting research to “pure” cases of a diagnosis and restricting the meaning of outcome to symptom checklists make for elegant experimental research designs but miss the complexity of the psychological difficulties most clients experience.”
Most therapy patients present with problems that are “embedded in, and inseparable from, personality — a person’s characteristic and enduring patterns of thinking, feeling, fantasizing, desiring, fearing, coping, defending, attaching, relating, and experiencing self and others.” Indeed experienced therapists have found that “meaningful and lasting psychological change comes from focusing not on symptoms, but on the personality patterns that underlie them.”
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