Tag Archives: Psychotherapy

Is low therapist empathy toxic?

Starting in the 1950s Carl Rogers brought Pers...

Starting in the 1950s Carl Rogers brought Person-centered psychotherapy into mainstream focus. (Photo credit: Wikipedia)

 

Miller and Moyers make the case that low therapist empathy is toxic with a review of some research on the topic.

 

In one study, a single in-session therapist behavior predicted 42% of the variance in clients’ 12-month drinking outcomes: the more the therapist confronted, the more the client drank (Miller, Benefield, & Tonigan, 1993).

Client resistance increased and decreased as a step function in response to counseling style. Teach/Direct (Information/Advice) increased client resistance by 70% in contrast to empathic listening. Resistance dropped back down with resumed listening and jumped backup with a return to Teach/Direct.

In a randomized trial comparing therapist styles with problem drinkers receiving feedback regarding the severity of alcohol-related assessment results, client resistance responses were 70% higher with directive as compared to client-centered counseling (Miller et al., 1993).

 

And, that high therapist empathy should be treated as an evidence-based practice:

 

It appears that therapist empathy can predict meaningful proportions of variance in addiction treatment outcome (e.g., Miller et al., 1993Valle, 1981) that are an order of magnitude larger than the between-treatment differences typically observed in clinical trials (Imel et al., 2008) and typically fall within the range of what addiction treatment providers regard to be a clinically meaningful effect (Miller & Manuel, 2008). In psychotherapy research more generally, therapist empathy may account for as much or more outcome variance than therapeutic alliance or specific intervention (Bohart, Elliot, Greenberg, & Watson, 2002Imel, Wampold, & Miller, 2008). It could be argued that providing accurate empathy in addiction treatment is an evidence-based practice regardless of theoretical orientation and that its absence will reduce the likelihood that clients will change their substance use.

 

 

 

 

 

 

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3 fold preference for talk-therapy

i_love_evidence_based_medicine_key_chains-r33ff90ead6aa425ea368e31ca9ee70e5_x7j3z_8byvr_512I swear I don’t go looking for this stuff.

This post from the British Psychological Society just popped up in my feed reader:

A line was crossed in 2005 as anti-depressant medication became the most widely prescribed class of drug in the USA. …

“It is unclear why the shift toward pharmacologic and away from psychological treatment is occurring,” the researchers said, “although limited access to evidence-based psychological treatments certainly plays some role.”

Kathryn McHugh and her colleagues identified 34 relevant peer-reviewed studies up to August 2011 involving 90,483 people, in which the participants were asked to indicate a straight preference between psychotherapy or drugs. Half the studies involved patients awaiting treatment, the others involved participants who were asked to indicate their preference if they were diagnosed with a psychiatric disorder. The researchers had hoped to study preferences among patients with a diverse range of diagnoses but they were restricted by the available literature – 65 per cent studies pertained to depression with the remainder mostly involving anxiety disorders.

Overall, 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. The preference for therapy remained but was slightly lower (69 per cent) when focusing just on treatment-seeking patients, and when focusing only on studies that looked at depression (70 per cent). Desire for psychotherapy was stronger in studies that involved more women or younger participants.

The author’s noted that, given the evidence showing comparable efficacy for psychotherapy and medication in treating most forms of anxiety and depression, there is strong empirical support for greater use of talk-therapy.

UPDATE: Ross shared this APA post on the cost-effectiveness of talk-therapy:

A quick fix?

The behavioral health management companies that now dominate the field have a good reason to prefer medication to psychotherapy: They don’t have to pay for patients’ pills.

Managed-care companies typically “carve out” the mental health portion of patients’ medical care, assigning that responsibility to specialized behavioral health companies. These companies, however, cover only the cost of providing patients with access to mental health providers and facilities. Responsibility for paying prescription drug costs lies with the original managed-care companies. Since behavioral health companies must squeeze psychotherapy costs out of tight budgets, says Pomerantz, it’s not surprising that they favor general practitioners over psychotherapists and psychopharmacological solutions over psychotherapeutic ones. By doing so, he explains, they shift costs back to the managed-care companies themselves.

Even more importantly, says Pomerantz, behavioral health carve-outs typically have a short-term perspective when they consider their bottom lines. While medication gets doled out over long stretches of time, psychotherapy is typically provided in short but intensive periods. Because health plans’ budgets focus on expenses in a given year, medication has an obvious short-term advantage no matter what the eventual long-term cost.

Although conditions such as schizophrenia and manic depression clearly warrant medication, he adds, behavioral health companies are pushing patients toward medication even when psychotherapy or a combination of psychotherapy and medication would be best for them.

“In a recent survey, almost 90 percent of patients who visit psychiatrists are taking psychotropic medications,” says C. Henry Engleka, assistant executive director for marketing in APA’s Practice Directorate. “Instead of medication being used as an adjunct to psychotherapy, the opposite is generally true in most managed-care practices now.”

Emerging research

That’s too bad, says Pomerantz, because over the long run psychotherapy is often more effective, and thus cheaper, for many conditions. Although psychotherapy requires more of an upfront investment, he explains, it pays off by getting the job done and preventing relapses. By contrast, patients on medication often relapse once their medication stops and may require a lifetime of expensive pills. In a column in Drug Benefit Trends, Pomerantz cites several studies from the ever-increasing literature on this topic to prove his point:

  • In a randomized, controlled trial, researchers assigned 75 outpatients with recurrent major depression to three groups: acute and maintenance treatment with antidepressants, acute and maintenance cognitive therapy and acute antidepressants followed by maintenance cognitive therapy. Cognitive therapy proved as effective as medication in both the acute and maintenance phases, with a trend favoring cognitive therapy’s long-term efficacy (British Journal of Psychiatry, 1997, Vol. 171, p. 328-334).
  • In another study, researchers randomly assigned 40 patients who had been successfully treated with medication for recurrent major depression to two groups: clinical management or cognitive-behavioral therapy. Over 20 weeks, antidepressants were tapered off and then discontinued in both groups. Two years later, only 25 percent of the patients who received cognitive-behavioral therapy had relapsed compared with 80 percent of the other group [Archives of General Psychiatry, 1998, Vol. 55(9), p. 816-820].
  • In a meta-analysis of studies published between 1974 and 1994, researchers compared controlled trials of cognitive-behavioral therapy and pharmacological treatment for patients with panic disorder. While both treatments worked in the short run, the results were more positive and longer lasting for cognitive-behavioral therapy (Clinical Psychology Review,1995, Vol. 15, p. 819-844).

There are plenty of other studies with similar results, says psychologist Steven D. Hollon, PhD, of Vanderbilt University, citing the work of psychologists like David H. Barlow, PhD, on panic disorders and G. Terence Wilson, PhD, on bulimia. Hollon’s own research on depression has also found that people who receive focused psychotherapy stay better longer than people who just receive medication.

If the insurance industry would only listen to this research, says Hollon, the implications could be far-reaching.

“Just do the math,” he says, noting that pharmacotherapists may keep depressed patients on expensive antidepressants for the rest of their lives. “If you can get with four months of psychotherapy the same benefits you get from a year and a half to two years of continuous medication, you begin to break even after about a year’s time even though it’s more expensive upfront to provide psychotherapy. If the benefits extend over a half decade or decade, your savings really start piling up. But managed-care folks don’t think that way.”

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Why is talk therapy going out of favor?

Despite the evidence, a decline Between 1998 and 2007 the percentage of patients in outpatient mental health facilities receiving psychotherapy alone fell from 15.9 percent to 10.5 percent, while the percentage of patients receiving medication alone increased from 44.1 percent to 57.4 percent. Credit: Olfson & Marcus, 2010

Despite the evidence, a decline
Between 1998 and 2007 the percentage of patients in outpatient mental health facilities receiving psychotherapy alone fell from 15.9 percent to 10.5 percent, while the percentage of patients receiving medication alone increased from 44.1 percent to 57.4 percent. Credit: Olfson & Marcus, 2010

A special issue of Clinical Psychology Review examines the decline of talk therapies:

Psychotherapy has issues. Evidence shows that some psychosocial treatments work well for common mental health problems such as anxiety and depression and that consumers often prefer them to medication. Yet the use of psychotherapy is on a clear decline in the United States. In a set of research review papers in the November issue of the journal Clinical Psychology Review, psychologists put psychotherapy on the proverbial couch to examine why it’s foundering.

Their diagnosis? Much as in many human patients, psychotherapy has a combination of problems. Some of them are of its own making while some come from outside the field itself. Fundamentally, argue Brandon Gaudiano and Ivan Miller, Brown University professors of psychiatry and human behavior whose review paper introduces the section they edited, the psychotherapy community hasn’t defined, embraced, and articulated the ample evidence base clarifying their practice, while drug makers and prescribers have done so for medications. In a system of medicine and health insurance

that rewards evidence-based practice and looks upon biology as a more rigorous science, psychotherapy has lost ground among physicians, insurers and policymakers.

Starting in the 1950s Carl Rogers brought Pers...

Starting in the 1950s Carl Rogers brought Person-centered psychotherapy into mainstream focus. (Photo credit: Wikipedia)

“One might think that this deep and expanding evidence base would have promoted a similar increase in the use of psychosocial interventions that at least would have paralleled the one witnessed over the recent years by psychotropics, but it decidedly has not,” Gaudiano and Miller wrote. “Thus a time that should have been a relative boon for psychotherapy based on scientific standards has become more of a bust.”

Specifically, between 1998 and 2007 the proportion of patients in outpatient mental health facilities receiving psychotherapy alone fell from 15.9 percent to 10.5 percent, while the number of patients receiving medication alone increased from 44.1 percent to 57.4 percent, according to a 2010 study in the American Journal of Psychiatry. Depressed patients receiving both psychotherapy and medication fell from 40 percent to 32.1 percent. Psychotherapy was once in the picture for more than half such patients but is not now.

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