Psychological therapies based on the efficacy of their clinical outcomes

"I haven't seen my psychoanalyst in 200 years. He was a strict Freudian and if I'd seen him in all that time I'd be almost cured by now."

Woody Allen

What is the image people have of "doing therapy"? But also: is it appropriate to choose any type of therapy...?

It is difficult to answer question 1 with an answer that goes beyond a mere opinion, or a set of opinions drawn from a small sample of known people (whether they are therapists or not). However, it is easier to answer question 2, and perhaps thereby attempt to answer question 1.

There is the media and entertainment industry, and the recent digital streaming platforms, which inundate us with content, often associated with a presumed psychological world.

In general, the therapist is shown as someone who strokes his or her chin, takes notes, listens and "asks questions about life".

If it is a woman, she generally wears glasses and dresses somewhat executive.

The patient is shown as someone who has lost control or autopilot over his will, desires, fantasies and emotions.

Thus, we already have two great stereotypes: what we could call "the lay priestly listening" of the therapist, and an individual who has lost the government over his mind, the government of himself. What assumptions people make about what is "their mind" would lead us to an extremely difficult and unfinished reflection. But, as a tentative comment, we could say that people sometimes imagine their mind as the scenario of a video game, where everything is controllable from a series of commands. Sometimes, however, the scene can get out of control, or very unexpected things can emerge in the scene, and the commands become unresponsive or distorted. Some strange factor or mechanism has "hacked" our mind.

For many people the mind is something like an invisible, intangible gadget that can be manipulated without major consequences. But already the ancient Hellenes -such as the Stoics-, or figures like Buddha in the East, warned about these consequences based on imprudence or the excesses of the spirit.

Be that as it may, for these problems that are as old as the history of the species itself (there is no serious scientific or common sense reason to suppose that ancient Hellenes did not suffer from mood disorders, that Vikings did not have emotionally disruptive behaviors, or that medieval peasants did not get depressed), the modern world has tried to provide answers as scientific as possible in the last 150 years, so "psychology" (which is far from being a unique field), is something very new in human cultural history. If we talk about mental conditions and problem behaviors, we are talking specifically about clinical psychology, which is only one area within psychology.

Types:

Within this short history (seen in historical perspective), psychoanalysis has been a landmark, and even its remnants are very powerful in areas such as the Rio de la Plata (Argentina, Uruguay), with multiple detachments, disseminations of all kinds of therapeutic models that, to some extent, would have theoretical components of psychoanalysis.

The truth is that, in much of the world, since the 1980s, psychoanalysis has tended to be ignored due to lack of empirical evidence about the effectiveness of its clinical approaches. Mentioning the already classic study "The Black Book of Psychoanalysis...", or Hans Eysenck's "Decline and Fall of the Freudian Empire" implies a declaration of war for many, since psychoanalytic organizations continue to have lobbying power and their figures are invited to the media.

In North America, in the late 1970s, a team of experts led by Hans Strupp was given the task of investigating the negative effects of therapeutic approaches in institutions. It was a time when the use of public money had to be optimized as much as possible due to the fiscal deficit. What this research (1977) found was that many times, much more than desirable, psychotherapies in institutional contexts increased mental distress and ended up reinforcing the patients' problems. One of the main factors was that the therapeutic alliance of therapist/patient was not governed by any protocol model, but was left entirely to inventiveness, which often turned out to be arbitrary. At that time, most therapists came from psychodynamic models, largely clinical detachments from the original psychoanalysis. Moreover, they realized that it was necessary to define precisely what psychotherapy is: psychotherapy cannot be merely a helpful human intervention. In other words, what Strupp and his team were subtly saying is that the therapist cannot be an inspired counselor, a well-meaning lecturer, a guru or a charlatan. You are totally free to choose a guru; it is just a good idea to know that this is not psychotherapeutic treatment.

Hans Strupp

Moreover, the lack of unanimity in implementing therapeutic intervention models often led to the same patient being considered "healthy" by therapist A and "sick" by therapist B.

Thus, it began to be seen that psychotherapeutic services in health institutions were iatrogenic, i.e., that the institution itself produced an unintended negative effect on the patient. If public funds were to be put to good use for purposes that were certainly useful in terms of mental health, it became necessary to define and create therapeutic models that maximized the benefits and minimized the negative effects. After this, the challenge was to train professionals accordingly.

Then, empirical research began to investigate the effects and therapeutic efficacy of certain models, aiming to create models based on evidence of their efficacy. This is called EBT ("evidence-based treatment"). The method par excellence for obtaining evidence of the therapeutic efficacy of different forms of psychological intervention is the so-called RCTs: randomized controlled trials. An RCT is an experimental study (or controlled trial). It is a statistical research study that involves the collection of empirical data and evidence that is measurable. The most robust version of an experimental study is the RCT. In these, participants are randomly assigned (using random number generators) to treatment groups (experimental group) to receive - or not - one or more interventions that are being compared to each other, and the other group (the control group) receives no such intervention, or receives various placebos, or no intervention at all. The main objective of an RCT is to create groups that are as similar as possible, with the intervention being the differentiating factor.

In the case of clinical psychology, efficacy is assessed by calculating the aggregate differences between symptom levels before and after treatment, as we can see in this chart:

Although these investigations began under the presidency of Jimmy Carter, concrete reforms began to be implemented under the administration of Ronald Reagan. This is where the "hot" and spicy component of the issue comes in, since it is from here that the issue begins to be ideologized. A whole narrative has been fabricated in which these reforms would respond to the "neoliberal" ideological paradigm, to the reduction of the "present State", and where the new emerging therapies (mainly cognitive behavioral therapy, CBT), would be in alliance with the large pharmaceutical multinationals to establish their hegemony and "sweep human therapies" off the face of the Earth. Thus, many cry "here come the Chicago Boys" to "cover up the symptom with behavioral techniques" and to "over-adapt, force human desire into neoliberal consumer societies".

All this is a very amusing narrative, typical of a leafy conspiracy theory, because there is not the slightest indication that the conditions of their claims are met: neither CBT works by "covering up symptoms", nor are pharmaceutical companies too interested in individuals undergoing psychotherapy, nor are the accusers too clear on the concept of "neoliberalism", nor are their advocated therapies necessarily "humane" (assuming we understand what they really mean by that), nor did these reforms begin with Reagan. Nor does any of it have anything to do with the proven therapeutic efficacy of certain therapies. Those who take an ideological stance (based on a conspiracy theory) on this issue should not only question their bioethics, but they are also science denialists (they often claim that science is nothing more than a "narrative", etc.). Amazingly, even today (even in certain parts of Europe), CBT therapy is seen as a "conservative right-wing onslaught on the subject".

To top it all off, the psychoanalytically derived strands, due to organizations such as the Frankfurt School, have become intertwined with revisionist positions of Marxism, such as the famed Freudo-Marxism, forming an impenetrable and rather sloppy ideological cocktail. This establishes great distortions in the dialogue between different organizational groupings, academies, and guilds of mental health professionals.

For example, let's take the case of depression: depression, except for chronic, severe, and resistant cases, tends to subside after approximately 7-9 months. That is to say, after this period, the person will feel better. It has been studied in children the so-called "regression phenomenon to the mean" to verify how a child diagnosed with depression, when treated by drinking energizing drinks or hugging a pet, after a while they feel better. So, let's suppose that a person starts a non-evidence-based therapy in the initial stage of his depression: the tendency is that the picture remits, but a false attribution of causality could make the patient believe that it was thanks to be talking about his childhood or carrying out "free associations" on a couch that his picture improved...

The Australian Psychological Society states the following:

"Evidence-based practice has become a delivery of health care services in Australia and internationally. Best practice is based on a thorough evaluation of published research evidence from studies that identify interventions to maximize the opportunity for benefit, minimize the risk of harm and deliver treatment at an acceptable cost. Health programs sponsored by governmental organizations reasonably require the use of treatment interventions that are evidence-based as a means of discerning funding allocation. It is appropriate that these interventions have been shown to be effective according to the best available research evidence." (p.2)

The following are recognized as evidence-based therapies: cognitive behavioral therapy (CBT), interpersonal therapy, hypnosis-based hypnotherapy, dialectical behavioral therapy (DBT), family therapy, schema theory-based therapy, EMDR, acceptance and commitment therapy (ACT), and metacognitive therapy (MCT).

In turn, the American Psychological Association (APA) (not the American Psychiatric Association, also acronym APA), states: the average client receiving psychotherapy turns out to be better off than 79% of clients not treated with psychotherapy.

Although psychotherapy does not work perfectly for all clients, it is simply remarkably effective (Prochaska & Norcross, 2013).

Although there is still no exact consensus about what "psychotherapy" is, officially the APA highlights evidence-based therapies from hundreds of empirical studies, which provide reliable results in the areas of: therapeutic relationships, treatment format, theoretical bases, and patient disorders.

At the same time, to date, there is no psychotherapeutic model that works in 100% of the disorders for 100% of the individual cases.

Demographic dimension of different pathologies and their evidence-based treatments:

WHO attaches great importance, not only to evidence-based therapies, but also to the concept of "burden of disease" ("burden of Disease"). What is "burden of disease"?

The burden of disease is a concept that was developed in the 1990s by the Harvard School of Public Health, the World Bank, and the World Health Organization to describe the loss of health due to diseases, injuries and risk factors for all regions of the world.

The burden of a particular disease or condition is estimated by summing:

- The number of years of life a person loses as a result of dying prematurely due to:

- The disease (called years of life lost); and:

- The number of years of life a person lives with a disability caused by the disease (called Years of Life Lived with Disability).

Depression:

1 in 6 people will experience depression at some point in their lives. It is statistically estimated that by 2030, depression will be the most affecting pathology of all people, including medical illnesses. By 2017, there were 264 million people in the world affected by this disorder.

Cognitive behavioral therapy is considered to be the primary level for this disorder (Level 1), and new studies after 2010 show that metacognitive therapy is even more efficient. Mindfulness and ACT-based therapies are considered Level 3 for this disorder.

Regarding the use of metacognitive therapy for depression, 74% of patients compared to 52% in standard cognitive behavioral therapy treatment met formal criteria for post-treatment recovery. Clinical benefits have been found to be maintained over follow-up periods of 6 to 12 months. (Callesen, Pia, Reeves, David, Heal, Calvin & Wells, Adrian, 2020) At a 3-year follow-up, 60% of patients showed no depressive events. (Solem et al., 2019)

Of all psychotherapeutic interventions, cognitive behavioral therapy was the most frequently investigated intervention (139 studies, 70%), whereas social skills training was the least frequently investigated (seven studies, 4%). The most common control condition was waiting list (75 studies, 38%). More than half of the studies investigated psychotherapeutic interventions in an individual, face-to-face setting. Most studies were conducted in the United States (115 studies, 58%). In a review of 15,118 patients with depression, interpersonal therapy has been found to be superior to supportive therapy.

Bipolar Disorder: As of 2017, 46 million people suffered from this disorder worldwide.

Cognitive behavioral therapy is considered Level 2, in conjunction with an appropriate psychopharmacological plan. It has not been possible to find a Level 1 therapeutic form with proven efficacy. States the Australian Psychological Society, "There are no definitive studies of psychotherapies as stand-alone interventions in bipolar disorder and should only be used as an adjunct to pharmacotherapy and are most effective during the maintenance phase."

Generalized anxiety and panic: In 2017, 284 million people suffered from this pathology worldwide.

Cognitive behavioral therapy is considered Level 1 for this disorder, and psychodynamic approaches Level 2, especially for young patients. In turn, metacognitive therapy, more recently, has shown even more efficacy than cognitive behavioral therapy. The metacognitive MCT model is more effective and leads to significantly higher recovery rates (65% for metacognitive therapy and 38% for classical cognitive behavioral therapy). These differences were maintained at two years of follow-up, compared to cognitive behavioral therapy studies that only establish follow-ups between 6-12 months.

Regarding social anxiety (or social phobia in European nomenclature), cognitive behavioral therapy (CBT) is also indicated as Level 1, and other approaches, such as ACT (acceptance and commitment therapy) or interpersonal approaches, as Level 3.

Phobias: Cognitive behavioral therapy, once again, is indicated as Level 1 for these disorders. In turn, the EMDR approach has shown very interesting results especially with phobias associated with high levels of anxiety and/or traumatic disturbances. De Jongh & ten Broeke (2007) emphasize that it is useful to combine a CBT approach with EMDR: first EMDR for the reprocessing of traumatic memories, and then CBT for a gradual exposure process to the phobic stimulus.

Post-traumatic stress disorder (PTSD): Both cognitive behavioral therapy (CBT) and the EMDR approach are recognized as first-line (Level 1).

In turn, the metacognitive model (MCT) for PTSD does not require exposure and has been shown to be as effective as other treatments, such as the EMDR approach, although the authors (Nordahl et al suggest that more research is needed). As it were, MCT does not use exposure or revival of trauma memories, and this could be advantageous in reducing aversivity to treatment by both patient and therapist.

About EMDR, state Pagani et al (2015), "We can speculate that during EMDR the memory retention of the traumatic event moves from regions with implicit emotional valence to areas of association in which the experience is integrated and consolidated. In this regard, post-treatment deactivation (Figure 2A) of the primary visual cortex along with activation of the fusiform cortex involved in explicit representation of faces, words, and abstract thoughts could be associated with higher-level cognitive processing of event-related imagery."

Obsessive-compulsive disorder: again, cognitive behavioral therapy (CBT) is generally recognized by consensus as first-line (Level 1) for this disorder, with different evidence-based studies showing Level 4 for approaches such as ACT. On the other hand, the metacognitive MCT model is proving to be as or more effective than the classical CBT approach. The MCT approach gives rise to new techniques, which propose to go beyond the perhaps already classical Exposure with Response Prevention to Exposure with Response Commission, as well as other new ways of treating this disorder (Wells, 2009).

Substance use disorders: 970 million people worldwide suffered from the consequences of this disorder in 2017.

Again, cognitive behavioral therapy is referred to as Level 1 along with motivational interviewing. The results are statistically significant, although meager. About one year into treatment, approximately 70% of patients tend to relapse. Motivational interviewing has been shown to be more effective in affecting patients with problematic cocaine use at least 15 days per month.

From the MCT metacognitive model, work is being done on the development of the "three-phase model" to understand and treat substance use disorder, although for now this has been investigated mainly in cases of problematic alcohol use.

Anorexia and Bulimia: for anorexia, there is Level 2 evidence that the family therapy approach may be the most interesting for now. In the case of bulimia, cognitive behavioral therapy is indicated as Level 1. By 2017, it was estimated that 16 million people suffered from these disorders worldwide.

 

Again, cognitive behavioral therapy is referred to as Level 1 along with motivational interviewing. The results are statistically significant, although meager. About one year into treatment, approximately 70% of patients tend to relapse. Motivational interviewing has been shown to be more effective in affecting patients with problematic cocaine use at least 15 days per month.

From the MCT metacognitive model, work is being done on the development of the "three-phase model" to understand and treat substance use disorder, although for now this has been investigated mainly in cases of problematic alcohol use.

Borderline personality disorder: evidence indicates that dialectical behavior therapy (DBT) is first line for this condition, and Level 2 schema therapy with interesting results.

Psychotic disorders: together with a psychopharmacological plan, there is good evidence for CBT together with family therapy, although the conclusions are not conclusive.

As for the metacognitive model MCT, there has been little study of its intervention in this disorder, but there is recent preliminary evidence that it helps to reduce delusional symptoms, an improvement in the patient's capacity for introspection, as well as the reduction of delusional associations. By 2017, 20 million people were suffering from this disease.

Attention deficit hyperactivity disorder (adults): cognitive behavioral therapy (CBT) is indicated as Level 2, and DBT as Level 3, in conjunction with a pharmacological plan. There is not much evidence. In CBT-oriented group treatments, 31% have reported some immediate improvement, and 97% some moderate benefit/achievement.

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