How Psychotherapy Works

Bruce E. Wampold, Ph.D., is chair and professor of counseling psychology and clinical professor of psychiatry at the University of Wisconsin-Madison. Dr. Wampold is a groundbreaking researcher and theoretician, bringing the rigor of his training in mathematics and the sciences to understanding psychotherapy. He has published more than 100 scientific articles and is the author of the acclaimed book, “The Great Psychotherapy Debate,” which is a synthesis of empirical research on psychotherapy using sophisticated methods that is situated in a historical and anthropological context.

APA spoke to Dr. Wampold about how psychotherapy works and what the research tells us about different types of treatment, including psychiatric drugs.

Q. How exactly does psychotherapy help people?

A. Patients often come to psychotherapy with explanations for their difficulties that leave them feeling that the distress will continue indefinitely. Every treatment provides an explanation for the distress that is adaptive — that is, the patient understands that he or she can do something to improve his or her situation. This leads the patient into healthy actions in that the psychotherapy improves some aspect of their lives, whether it is thinking more positive thoughts, creating better relationships, more appropriately expressing emotions, or enacting other positive changes. The critical aspect is not which treatment a person receives but rather that the patient believes this particular treatment is effective and works collaboratively with the therapist.

Q. You have studied the research data; are you any closer to understanding what makes psychotherapy work, and what might make one type of psychotherapy more effective than another?

A. From my reading of the research evidence and my own research, it seems that the differences among treatments in terms of benefit to patients are small, if not negligible. This observation applies, however, to treatments that are intended to be therapeutic, are delivered by competent therapists, have a cogent psychological rationale, and contain therapeutic actions that lead to healthy and helpful changes in the patient’s life. When such treatments are compared in clinical trials, the typical finding is that these treatments are superior to no treatment or some type of psychological placebo (usually contact with a therapist who responds empathically but does not actively provide a treatment) but that there are few if any differences among the treatments.

However, there are common elements of effective psychotherapies. For example, there are hundreds of studies that show that a purposeful collaborative relationship between a therapist and the patient – what we call the therapeutic alliance – is related to therapeutic progress. This relationship holds for all types of therapy. The therapeutic alliance is critical even in medication treatments for mental disorders. The most important aspect of effective therapy is that the patient and the therapist work together to help the patient reach their goals in therapy.

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Q. Some therapists consistently produce better outcomes than others, regardless of treatment and patient characteristics. Can you explain why that is?

A. The most effective therapists know the research and have a dynamic approach to treatment options. The research indicates that effective therapists form a strong therapeutic alliance across the range of patients seen in therapy. They are able to form a bond with their patients, regardless of the patient’s characteristics, and induce the patient to accept the treatment and work collaboratively with the therapist. Effective therapists have an ability to perceive, understand and communicate emotional and social messages with their patients. It also appears that effective therapists are cognizant of patient progress, either informally or through the use of outcome measures, and are willing to address issues that impede therapeutic progress, including the relationship between the therapist and the patient.

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Q. Clinical trials have shown that psychotherapy is as effective as psychiatric medications for depression and anxiety without the disagreeable side effects such as weight gain, sleep problems and loss of libido. So why is it that so many people are prescribed drugs first when they are exhibiting psychological distress and psychotherapy second, if at all?

A. It is indeed disturbing to know that, despite the effectiveness and safety of psychotherapy, increasing numbers of patients are being treated with psychiatric medications. The explanation for this phenomenon is complex and intricately woven into the health care system in the United States. First, the pharmaceutical industry spends an inordinate amount of money advertising psychiatric medications to physicians and to the public, resulting in a perception that mental disorders are due to “chemical imbalances in the brain” that can be remediated easily by medications. Second, increasing numbers of mental disorders are being treated in primary care settings and primary care physicians are not trained in or aware of effective psychotherapies, but they are trained to prescribe drugs. Third, psychotropic medications suggest that the problem is biological, which relieves the patient of responsibility for his or her actions. It is simpler to take a pill and go on with one’s life than to accept that changing involves intentional and purposeful work.

Professional organizations and therapists need to promote psychotherapy as an effective healing practice. We have relied on word of mouth, to a large extent — patients who have benefited from psychotherapy are our best advertisement. But we have to be more deliberate and a good place to start is in the training of physicians, who need to understand the importance of behavioral health and psychotherapy.

Q. How do you as a psychotherapist determine when psychiatric drugs are the correct course of action for a given patient? And what is the therapist’s influence when treating a patient who is also on psychotropic medication?

A. Health services are always more effective when care is coordinated. Therapists’ collaboration with primary care physicians and psychiatrists is no exception. Of course, effective psychiatric consultation requires that the therapist be knowledgeable about the disorder and its treatment. There are instances in which psychiatric medication is an appropriate adjunct to psychotherapy - for example, in the treatment of severe and persistent depression, bipolar disorder and some anxiety disorders. There is evidence that effective psychotherapists are often the best judges of when their patients can benefit from a pharmaceutical treatment program and work collaboratively with the patient to get the best response to the medication. Some psychologists are now trained and licensed to prescribe psychiatric medications as part of the treatment.

For the most part, psychiatrists and primary care physicians are not trained to provide psychotherapy and psychotherapy does not fit well into the practices of physicians. However, there are many physicians who work collaboratively with psychologists so that patients can make use of effective psychological treatments. Physicians often are eager to make such referrals or encourage patients to seek psychological help when asked. Patients of primary care physicians who are not aware of the effectiveness of psychotherapy may also seek referrals from friends who have benefitted from psychotherapy or from other sources such as state psychological associations. In any event, from my perspective, behavioral interventions should be the first line of treatment and medications used only when response to the behavioral interventions are not sufficient. Far too many people are receiving psychiatric medications without attention to psychological treatments that might be effective.

Q. If I were a client seeking therapy for the first time, how would I know if someone is an effective caregiver and is offering appropriate treatment? How long should I expect to be in treatment for a given problem?

A. As a starting point, a patient should ascertain that the psychologist he or she is considering is licensed by the state where he/she practices. Ideally, a patient would have evidence that the therapist is effective, has this therapist helped patients in the past? Because this evidence is rarely available, consumers often rely on word of mouth, the testimonial of friends who have benefited from treatment from a particular clinician. After therapy begins, the best cue is the patient’s experience: Does this therapist understand me? Does the treatment plan make sense to me? Do I believe this therapist will help me? And most important, am I making progress? Patients typically experience a positive response to psychotherapy quite rapidly. If a patient is not making noticeable progress in several sessions, the patient should discuss this with the therapist (and similarly, the therapist should initiate this conversation with the patient if adequate progress is not being attained). Together, a patient and therapist determine when treatment should end and often, this happens relatively quickly. Of course, some problems require longer treatment.

Treatment length depends on the problems or disorder, patient goals, patient history and characteristics, events occurring outside of therapy (e.g., divorce, change in employment status), and therapeutic progress. Evidence indicates that therapy typically is terminated when the patient is functioning adequately. Commonly, psychotherapy lasts six to 12 sessions, with more complex difficulties benefiting from longer treatment.

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists. APA's membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting human welfare.

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