Science and Psychotherapy

Most people closely associate medicine and science, but how many of us think of psychotherapy and science as being related? Maybe we don’t, but we should. A recent research article that has received significant media attention has drawn attention to this issue.

While it's true that psychotherapy has little to do with scientific tools like Petri dishes and test tubes, the process of determining which types of psychotherapy are most helpful for specific problems is a scientific one. For decades, major universities and other research institutions have investigated whether some approaches to psychotherapy are more effective than others. Fortunately, after thousands of such rigorously conducted studies, we now possess scientific knowledge about whether specific psychotherapies are helpful for specific problems. Sounds like good news, right? It is! But here’s the bad news. There is no guarantee that a visit to your local therapist will result in your receiving the best-established type of therapy for your problem.

If you see your primary care doctor for advice on high cholesterol, you’re likely to be counseled on which changes to your diet might be helpful and which medications might be appropriate. You wouldn’t expect to be told to take up model boat building, however useful the physician might deem that to be. Why? Because early last century, medicine committed to the use of a scientific approach in selecting treatments. That means that if research shows that iron supplements are more helpful for anemia than, say, leeches, your physician will recommend iron (even if he is an amateur leech farmer).

Unfortunately, this approach has not been as widely accepted by psychotherapists as it has by physicians. Two important reasons for this involve therapist training and accountability. Many therapists attend training programs in only one type of therapy, and graduate from training thinking that this type of therapy is superior and appropriate for many (or all) types of problems. This represents a shortcoming of some therapy training programs. The other factor creating ambiguity around the standard of care among therapists has to do with accountability. If your doctor gives you penicillin for your melanoma, you can file a complaint with the state licensing board. You might even be able to bring legal action. However, therapists are typically not held accountable in the ways physicians are.

There are many reasons -- some very good -- for the different standards. For one, the consequences of applying the wrong treatment are typically different in psychotherapy than in medicine. Additionally, it’s often much clearer whether or not a broken arm is healing as opposed to whether someone’s depression has improved. So while it may be inappropriate hold therapists to the same standards we have for physicians, it is certainly reasonable to expect that therapists be cognizant of the research base for any type of therapy they provide.

Psychotherapy for OCD

For people suffering from OCD, it can be hard to find help. Being an informed consumer can make all the difference.

It is common for people who think they might have OCD to say, "I'd better see someone," and go to see a psychotherapist. So far, so good. However, there are different types of therapy for OCD, and evidence suggests that some work better than others. Many people who seek help for obsessions or compulsions with a psychotherapist find that sometimes, after months or years of therapy, their symptoms are still a problem. There can be many possible reasons for this.

One possibility is that OCD is not the only problem that the patient has. Other co-occurring conditions (e.g., depression, eating disorders) can worsen prognosis.

Another possibility involves the fact that even the most effective treatments for OCD don't work for everyone. Exposure and Ritual Prevention (ERP), a kind of psychotherapy for OCD, is often found to produce significant improvement in two thirds to three quarters of patients in clinical research studies (e.g, as described in a previous post). This means that a significant proportion of people trying this type of therapy will not see significant improvement.

The most alarming possibility, perhaps, is that the patient sees no improvement, and is not receiving the appropriate type of therapy. Many people have called me over the years saying that they are contemplating switching therapists. When asked why, they often say something like, "Well, I really like my therapist and all, but we've been talking about my childhood and my parents for 2-3 years now, and I'm still checking my kitchen stove 30 times a day. I'm getting tired of it!" If you think you may have OCD and decide to see a therapist to work on it, ask them whether they recommend ERP for you. They may have a good reason for not recommending it; however if they're not familiar with it, you might consider seeking out a second opinion.