Comments What Price Psychotherapy ?

In 1952 Eysenck threw down the gauntlet, when he claimed that psychoanalytical forms of psychotherapy were no more effective than spontaneous remission. As we trudge through the fourth decade of this debate, its quality remains as divisive and acrimonious as ever. Professor Michael Shepherd (1979, 1980) has latterly taken on Eysenck's mantle, averring that psycho therapy is not only ineffective but may actually harm patients. In an editorial in the British Medical Journal (1984), he launched yet a further attack, arguing on this occasion that the psychotherapist is little more than a â€ ̃¿ placebologist' exerting his effects through non specific means. Why bother with highly trained therapists when an inert pill will produce the same result? In criticising psychotherapy as he does, Professor Shepherd's scholarly vision is, in our opinion, distorted by a lack of objectivity. This is particularly evident in the editorial, where he latches on to a review of outcome studies of psychotherapy by Prioleau et al (1984), whichpurportsto showthat â€ ̃¿ for real patients there is no evidence that the benefits of psychotherapy are greater than those of placebo treatment' . In supporting this conclusion, Shepherd reveals a dis regard for the several weaknesses of the Prioleau work, as well as a neglect of a number of other recent reviews of the literature on the outcome of psycho therapy, which are substantially more sound and relevant (Smith et a! , 1980; Andrews & Harvey, 1981; Landman & Dawes, 1982; Shapiro & Shapiro, 1982; Dush eta! , 1983; Miller & Berman, 1983; Nicholson & Berman, 1983; Quality Assurance Project, 1983). Prioleau et a! (1984) adopted what has become a popularapproachinrecentyearsâ€”meta-analysis. This radically innovative procedure enables the magnitude of the effects of treatment to be calculated, thus avoiding the limitations inherent in traditional review ing methods, in which there is an obligation to arrive at a qualitative judgement about the effectiveness of a particular mode of therapy. A statisticâ€”the â€ ̃¿ effect size'â€”is applied to the results of outcome studies published in the literature, and is calculated as the mean difference between treated and control (no treatment or placebo) subjects, divided by the stan dard deviation of the control group. We ourselves would have assigned a low priority to the Prioleau review, compared to other meta-analyt ical studies, but since Shepherd relied very heavily on it, we are obliged to consider their work carefully. In fact, using a previous meta-analysis by Smith et a! (1980), the Prioleau team extracted studies (but deleting those that were exceedingly flawed) compar ing psychotherapyâ€”loosely defined as the exploration and clarification of a patient's emotional experi encesâ€”with a placebo control, operationally defined as any procedure described by the researcher as a placebo in which the potential of benefit is conveyed to the patient. The effect sizes in the 32 studies were then calculated, yielding a mean of . 42 which indicates that the average recipient of treatment would be better off than 70% of the placebo control group. But, because the distribution included one extreme value, the authors also derived a median effect sizeâ€”of . 15â€”and focussed on this latter figure to support their conclu sion of the equal efficacy of therapy and placebo. That such a conclusion is misleading, inaccurate, and constitutes a massive generalisation is shown by the following observations: 1. The psychotherapy treatment was quite un representative of conventional clinical practice; only eight studies, for instance, involved real' patients. Subjects in the other 24 studies included college students with speech anxiety, disruptive schoolchil dren, institutionalised adolescent orphans, and under achieving high school pupils (in fact 13 studies were of children and ten of college students). What a hodge podge! The same could be said of the therapists, who ranged from elementary school teachers, an education graduate student, graduate students in counselling, and junior high school counsellors to psychologists, psychiatric social workers, and psychiatrists. It is obvious that many and probably most of these therapists had had limited training and even less clinical experience. Furthermore, the average dura tion of treatment was quite unlike conventional dynamic psychotherapy: the modal amount of treat