The Effects of Psychotherapy—An Evaluation
THE recommendation of the Committee on Training in Clinical Psychologyof the American Psychological Association regarding the training of clinicalpsychologists in the field of psychotherapy has been criticized by the writerin a series of papers [10, 11, 12]. Of the arguments presented in favor ofthe policy advocated by the Committee, the most cogent one is perhapsthat which refers to the social need for the skills possessed by the psychotherapist.In view of the importance of the issues involved, it seemed worthwhile to examine the evidence relating to the actual effects of psychotherapy,in an attempt to seek clarification on a point of fact.
BASE LINE AND UNIT OF MEASUREMENT
In the only previous attempt to carry out such an evaluation, Landis haspointed out that "before any sort of measurement can be made, it is necessaryto establish a base line and a common unit of measure. The only unitof measure available is the report made by the physician stating that thepatient has recovered, is much improved, is improved or unimproved. Thisunit is probably as satisfactory as any type of human subjective judgment,partaking of both the good and bad points of such judgments" (26, p. 156).For a unit Landis suggests "that of expressing therapeutic results in termsof the number of patients recovered or improved per 100 cases admitted tothe hospital." As an alternative, he suggests "the statement of therapeuticoutcome for some given group of patients during some stated interval oftime."
Landis realized quite clearly that in order to evaluate the effectiveness ofany form of therapy, data from a control group of nontreated patientswould be required in order to compare the effects of therapy with the spontaneousremission rate. In the absence of anything better, he used the ameliorationrate in state mental hospitals for patients diagnosed under the headingof "neuroses." As he points out:
There are several objections to the use of the consolidated amelioration rate . . . ofthe . . . state hospitals . . . as a base rate for spontaneous recovery. The fact that psychoneuroticcases are not usually committed to state hospitals unless in a very bad condition ;the relatively small number of voluntary patients in the group ; the fact that such patientsdo get some degree of psychotherapy especially in the reception hospitals ; and the probablyquite different economic, educational, and social status of the State Hospital groupcompared to the patients reported from each of the other hospitals—all argue againstthe acceptance of [this] figure . . . as a truly satisfactory base line, but in the absence ofany other better figure this must serve (26, p. 168).
Actually the various figures quoted by Landis agree very well. The percentageof neurotic patients discharged annually as recovered or improvedfrom New York State hospitals is 70 (for the years 1925-1934); for theUnited States as a whole it is 68 (for the years 1926-1933). The percentageof neurotics discharged as recovered or improved within one year of admissionis 66 for the United States (1933) and 68 for New York (1914). Theconsolidated amelioration rate of New York state hospitals, 1917-1934,is 72 per cent. As this is the figure chosen by Landis, we may accept it inpreference to the other very similar ones quoted. By and large, we may thussay that of severe neurotics receiving in the main custodial care, and verylittle if any psychotherapy, over two-thirds recovered or improved to aconsiderable extent. "Although this is not, strictly speaking, a basic figurefor "spontaneous" recovery, still any therapeutic method must show anappreciably greater size than this to be seriously considered" (26, p. 160).Another estimate of the required "base line" is provided by Denker:
Five hundred consecutive disability claims due to psychoneurosis, treated by generalpractitioners throughout the country, and not by accredited specialists or sanatoria, werereviewed. All types of neurosis were included and no attempt made to differentiate theneurasthenic, anxiety, compulsive, hysteric, or other states, but the greatest care wastaken to eliminate the true psychotic or organic lesions which in the early stages of illnessso often simulate neurosis. These cases were taken consecutively from the files of theEquitable Life Assurance Society of the United States, were from all parts of the country,and all had been ill of a neurosis for at least three months before claims were submitted.They, therefore, could be fairly called "severe," since they had been totally disabled for atleast a three months' period, and rendered unable to carry on with any "occupation forremuneration or profit" for at least that time (9, p. 2164).
These patients were regularly seen and treated by their own physicianswith sedatives, tonics, suggestion, and reassurance, but in no case was anyattempt made at anything but this most superficial type of "psychotherapy"which has always been the stock-in-trade of the general practitioner. Repeatedstatements, every three months or so by their physicians, as wellas independent investigations by the insurance company, confirmed the factthat these people actually were not engaged in productive work during theperiod of their illness. During their disablement, these cases received disabilitybenefits. As Denker points out, "It is appreciated that this fact ofdisability income may have actually prolonged the total period of disabilityand acted as a barrier to incentive for recovery. One would, therefore, notexpect the therapeutic results in such a group of cases to be as favorable asin other groups where the economic factor might act as an important spurin helping the sick patient adjust to his neurotic conflict and illness"(9, p. 2165).
The cases were all followed up for at least a five-year period, and often aslong as ten years after the period of disability had begun. The criteria of"recovery" used by Denker were as follows: (a) return to work, and abilityto carry on well in economic adjustments for at least a five-year period;(b) complaint of no further or very slight difficulties ; (c) making of successfulsocial adjustments. Using these criteria, which are very similar to thoseusually used by psychiatrists, Denker found that 45 per cent of the patientsrecovered after one year, another 27 per cent after two years, making 72 percent in all. Another 10 per cent, 5 per cent, and 4 per cent recovered duringthe third, fourth, and fifth years, respectively, making a total of 90 per centrecoveries after five years.
This sample contrasts in many ways with that used by Landis. The caseson which Denker reports were probably not quite as severe as those summarizedby Landis; they were all voluntary, nonhospitalized patients, andcame from a much higher socioeconomic stratum. The majority of Denker'spatients were clerical workers, executives, teachers, and professional men.In spite of these differences, the recovery figures for the two samples arealmost identical. The most suitable figure to choose from those given byDenker is probably that for the two-year recovery rate, as follow-up studiesseldom go beyond two years and the higher figures for three-, four-, and fiveyearfollow-up would overestimate the efficiency of this "base line" procedure.Using, therefore, the two-year recovery figure of 72 per cent, wefind that Denker's figure agrees exactly with that given by Landis. We may,therefore, conclude with some confidence that our estimate of some twothirdsof severe neurotics showing recovery or considerable improvementwithout the benefit of systematic psychotherapy is not likely to be veryfar out.
EFFECTS OF PSYCHOTHERAPY
We may now turn to the effects of psychotherapeutic treatment. Theresults of nineteen studies reported in the literature, covering over seventhousand cases, and dealing with both psychoanalytic and eclectic types oftreatment, are quoted in detail in Table 1. An attempt has been made to reportresults under the four headings : (a) Cured, or much improved ; (b) Improved ;(c) Slightly improved; (d) Not improved, died, discontinued treatment, etc.It was usually easy to reduce additional categories given by some writersto these basic four; some writers give only two or three categories, and inthose cases it was, of course, impossible to subdivide further, and the figuresfor combined categories are given.f A slight degree of subjectivity inevitablyenters into this procedure, but it is doubtful if it has caused much distortion.A somewhat greater degree of subjectivity is probably implied in the writer'sjudgment as to which disorders and diagnoses should be considered to fallunder the heading of "neurosis." Schizophrenic, manic-depressive, andparanoid states have been excluded; organ neuroses, psychopathic states,and character disturbances have been included. The number of cases wherethere was genuine doubt is probably too small to make much change in thefinal figures, regardless of how they are allocated.
A number of studies have been excluded because of such factors as excessiveinadequacy of follow-up, partial duplication of cases with others includedin our table, failure to indicate type of treatment used, and otherreasons which made the results useless from our point of view. Papers thusrejected are those by Thorley and Craske [37], Bennett and Semrad [2],H. I. Harris [19], Hardcastle [17], A. Harris [18], Jacobson and Wright [21],Friess and Nelson [14], Comroe [5], Wenger [38], Orbison [33], Coon andRaymond [6], Denker [8], and Bond and Braceland [3]. Their inclusionwould not have altered our conclusions to any considerable degree, although,as Miles et al. point out: "When the various studies are compared in termsof thoroughness, careful planning, strictness of criteria and objectivity, thereis often an inverse correlation between these factors and the percentage ofsuccessful results reported" (31, p. 88).