作者: Christian Jarrett/BP / 2484次阅读 时间: 2017年4月06日
来源: 陈明翻译
Have we overestimated the effectiveness of psychotherapy?
Christian Jarrett/BPS 著

Most people who undertake psychotherapy seem to benefit from it. How do we know? Arguably, the most important evidence comes from meta-analyses that combine the results from many – sometimes hundreds – of randomly controlled trials. Based on this, it’s been estimated that psychotherapy is effective for about 80 per cent of people (meanwhile, between five to 10 per cent of clients may suffer adverse effects).


But now the more concerning news: a team of researchers led by Evangelos Evangelou at the University of Ioannina, Greece has assessed the quality of 247 of these psychotherapy meta-analyses and they report in Acta Psychiatrica Scandinavica that many of them have serious methodological short-comings.

但是,现在出现了相关与此的更多的消息:由希腊的艾奥尼纳大学Evangelos Evangelou领导的一个研究小组评估了发表在斯堪的纳维亚精神病学学报的247个心理治疗的元分析质量报告,其中的很多研究都有非常严重的方法学缺陷。

Coincidentally, a separate research group led by Brent Roberts at the University of Illinois, Urbana-Champaign has just published in Journal of Personality some of the first observational data on how people’s personalities change after undertaking psychotherapy. In contrast to what’s been found in the clinical literature, they report that people who’ve been in therapy seem to show negative changes in personality and other psychological outcomes.

巧合的是,一个由伊利诺伊大学厄本那-香槟分校的Brent Roberts领导独立的研究小组,在刚刚出版的《人格期刊Journal of Personality》上发表了关于接受心理治疗后人格的变化的第一手的观察数据。与临床文献中发现的相反,他们报告说,那些一直在治疗的人,似乎表现出负面的人格变化和其他心理结果。

In their “umbrella review” of the psychotherapy literature, Evangelou and his team chose to include published meta-analyses covering any form of psychotherapy and almost any kind of target mental health condition, but with the proviso that each meta-analysis had itself combined the results from a minimum of ten studies. Their comprehensive search resulted in 247 unique meta-analyses which collectively synthesised data from over five thousand randomly controlled trials.


Overall, 80 per cent of the published psychotherapy meta-analyses had reported a significant and positive benefit of whatever form of psychotherapy was their focus. This sounds impressive at first, but after applying “state-of-the-art” tests of their robustness, Evangelou and his colleagues report that just 16 of the 247 meta-analyses had provided “convincing evidence”.


The researchers identified a number of issues:

研究人员 发现了一些问题:

  • Many meta-analyses showed a statistically significant amount of heterogeneity between the trials that they’d combined. The worry is that too many meta-analyses are comparing apples and oranges, although there is scholarly debate about what level of heterogeneity is unacceptable.   


  • The researchers found many instances of the “small study bias”, which is the tendency for smaller, less robust studies to report larger effects.   


  • They found evidence of “excess significance bias“, which is when an over-abundance of trials seem to report positive findings given what we know so far about psychotherapy’s effectiveness. This suggests negative findings are remaining unpublished for whatever reason.   


Evangelou and his team conclude that the field of psychotherapy research needs to work harder to ensure that negative results are published as well as good news results, especially given the findings of another recent paper suggesting that the field has a problem with undeclared researcher allegiance to particular therapeutic approaches. One way round this is to ensure all trials and meta-analyses are preregistered before they are conducted, alongside information on the statistical tests that are planned.


For the reader undertaking psychotherapy or who knows someone who is, it is worth keeping some perspective: this is just one critique and the weight of evidence still suggests that psychotherapy is, more often than not, beneficial.


For scholars, the methodological concerns raised by this new paper feed into an already contentious field. Some experts believe that, high-quality or not, randomly controlled trials (and by extension, meta-analyses based on those trials) are not really an appropriate way to gauge the effectiveness of psychotherapy because of all complex, myriad factors involved in the dynamic between a client and his or her therapist.


An alternative approach is to look at observational data. Rather than signing people up to a controlled trial, with all the contrivances that that entails (such as standardising the delivery of therapy as much as possible), this approach is less hands-on and involves looking instead at the outcomes of people who happen to have been in therapy and those who haven’t.


Brent Roberts and his colleagues found two sources of this kind of data: hundreds of students in Tübingen who were enrolled in a long-term personality study and who’d completed measures twice across four years; and a group of thousands of older Americans who similarly had completed personality and other measures twice across four years.

Brent Roberts和他的同事们发现,这类数据的两个来源:在宾根的数百个学生参加了一项长期的人格研究,他们在在四年内完成两次完整的测量;以及数千名美国老年人在4年内完成了同样两次人格测量。

Crucially, both these longitudinal surveys included a question about whether the participants had undertaken psychotherapy in the intervening period between the two data collection points. One hundred and twenty-eight of the Tübingen students had completed some therapy and, compared to the other students, they showed negative changes in their personality in terms of higher scores in neuroticism, less extraversion and conscientiousness, as well as reductions in self-esteem, increases in depression, and less life satisfaction. It was a similar story for the older American adults who’d been in therapy: they showed negative changes in personality and other psychological outcomes.

关键的是,这两个纵向调查包括了一个问题,参与者是否在两个数据收集点之间进行心理治疗。宾根大学生128人已完成一些治疗的学生和相比其他学生,在神经质、外向性和责任心的高分中,他们的人格表现出了负面的变化,较少的外向性和严谨性,以及自尊的降低,抑郁症的增加,和更少的生活满意度。参与治疗的美国老年人 也有相同的状况:在他们的人格和其他心理结果中表现出了消极的变化。

There are problems with how to interpret these findings – an obvious shortcoming of observational data of this kind is that it’s less controlled than an experimental trial. For example, perhaps undertaking therapy was a consequence of these unwelcome psychological changes rather than the cause (although this still wouldn’t explain why the therapy hadn’t been more helpful, more often). Whatever the explanation, however, the results stand in contrast to the findings from controlled psychotherapy trials which have pointed overwhelming to positive personality changes arising from therapy. As Roberts and his team conclude, “the gravity of the issue necessitates that researchers investigate the apparent discrepancy between these findings and those from well-controlled trials”.


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