Recognition of Psychotherapy Effectiveness
Approved August 2012
This resolution reports on the general effectiveness of psychotherapy. In addition, APA is in the process of creating clinical treatment guidelines. These guidelines will help identify specific treatments which are most effective for particular problems or patients.
Council voted to adopt as APA policy the following Resolution on the Recognition of Psychotherapy Effectiveness1:
WHEREAS: psychotherapy is rooted in and enhanced by a therapeutic alliance between therapist and client/patient that involves a bond between the psychologist and the client/patient as well as agreement about the goals and tasks of the treatment (Cuijpers, et al., 2008, Lambert, 2004; Karver, et al., 2006; Norcross, 2011; Shirk & Karver, 2003; Wampold, 2007);
WHEREAS: psychotherapy (individual, group and couple/family) is a practice designed varyingly to provide symptom relief and personality change, reduce future symptomatic episodes, enhance quality of life, promote adaptive functioning in work/school and relationships, increase the likelihood of making healthy life choices, and offer other benefits established by the collaboration between client/patient and psychologist (American Group Psychotherapy Association, 2007; APA Task Force on Evidence-Based Practice, 2006; Burlingame, et al., 2003; Carr, 2009a, 2009b; Kosters, et al., 2006; Shedler, 2010, Wampold, 2007, 2010);
WHEREAS: evidence-based practice in psychology is "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences" (APA Task Force on Evidence Based Practice, 2006, p. 273);
WHEREAS: a working definition for Psychotherapy is as follows: "Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable" (Norcross, 1990, p. 218-220 );
WHEREAS: a working definition for Treatment is as follows: Treatments when used in the context of health care, refer to any process in which a trained healthcare provider offers assistance based upon his or her professional expertise to a person who has a problem that is defined as related to "health" or 'illness." In the case of "mental" or "behavioral" health, the conditions for which one may seek "treatment" include problems in living, conditions with discrete symptoms that are identified as or as related to illness or disease, and problems of interpersonal adjustment. The treatment consists of any act or services provided by a bonafide health provider intended to correct, change or ameliorate these conditions or problems (Beutler, 1983; Frank, 1973);
Research on Effectiveness
WHEREAS: the effects of psychotherapy are noted in the research as follows: The general or average effects of psychotherapy are widely accepted to be significant and large, (Chorpita et al., 2011; Smith, Glass, & Miller, 1980; Wampold, 2001). These large effects of psychotherapy are quite constant across most diagnostic conditions, with variations being more influenced by general severity than by particular diagnoses—That is, variations in outcome are more heavily influenced by patient characteristics e.g., chronicity, complexity, social support, and intensity—and by clinician and context factors than by particular diagnoses or specific treatment "brands" (Beutler, 2009; Beutler & Malik, 2002a, 2002b; Malik & Beutler, 2002; Wampold, 2001);
WHEREAS: the results of psychotherapy tend to last longer and be less likely to require additional treatment courses than psychopharmacological treatments. For example, in the treatment of depression and anxiety disorders, psychotherapy clients/patients acquire a variety of skills that are used after the treatment termination and generally may continue to improve after the termination of treatment (Hollon, Stewart, & Strunk, 2006; Shedler, 2010);
WHEREAS: for most psychological disorders, the evidence from rigorous clinical research studies has shown that a variety of psychotherapies are effective with children, adults, and older adults. Generally, these studies show what experts in the field consider large beneficial effects for psychotherapy in comparison to no treatment, confirming the efficacy of psychotherapy across diverse conditions and settings (Beutler, 2009; Beutler, et al., 2003; Lambert & Ogles, 2004; McMain & Pos, 2007; Shedler, 2010; Thomas & Zimmer-Gembeck, 2007; Verheul & Herbrink, 2007; Wampold, 2001). In contrast to large differences in outcome between those treated with psychotherapy and those not treated, different forms of psychotherapy typically produce relatively similar outcomes. This research also identifies ways of improving different forms of psychotherapy by attending to how to fit the interventions to the particular patient's needs (Castonguay & Beutler, 2006; Miklowitz, 2008; Norcross, 2011);
WHEREAS: comparisons of different forms of psychotherapy most often result in relatively nonsignificant difference, and contextual and relationship factors often mediate or moderate outcomes. These findings suggest that (1) most valid and structured psychotherapies are roughly equivalent in effectiveness and (2) patient and therapist characteristics, which are not usually captured by a patient's diagnosis or by the therapist's use of a specific psychotherapy, affect the results (Castonguay & Beutler, 2006; Livesley, 2007; Norcross, 2011);
WHEREAS: in studies measuring psychotherapy effectiveness, clients often report the benefits of treatment not only endure, but continue to improve following therapy completion as seen in larger effect sizes found at follow-up (Abbass, et al., 2006; Anderson & Lambert, 1995; De Maat, et al., 2009; Grant, et al., 2012; Leichsenring & Rabung, 2008; Leichsenring, et al., 2004; Shedler, 2010);
WHEREAS: research using benchmarking strategies has established that psychotherapy delivered in routine care is generally as effective as psychotherapy delivered in clinical trials (Minami, et al., 2008; Minami, et al., 2009; Minami & Wampold, 2008; Nadort, et al., 2009; Wales, Palmer, & Fairburn, 2009);
WHEREAS: the research evidence shows that psychotherapy is an effective treatment, with most clients/patients who are experiencing such conditions as depression and anxiety disorders attaining or returning to a level of functioning, after a relatively short course of treatment, that is typical of well-functioning individuals in the general population (Baldwin, et al., 2009; Minami, et al., 2009; Stiles, et al., 2008; Wampold & Brown, 2005);
WHEREAS: research will continue to identify factors that make a difference in psychotherapy, and results of this research can then be reported to clinicians who can make better decisions (Gibbon, et al., 2010; Kazdin, 2008);
WHEREAS: researchers will continue to examine the ways in which both positive and possible negative effects of psychotherapy occur, whether due to techniques, client/patient variables, therapist variables, or some combination thereof, in order to continue to improve the quality of mental health interventions (Barlow, 2010; Dimidjian & Hollon, 2010; Duggan & Kane, 2010; Haldeman, 1994; Wilson, Grilo, & Vitousek, 2007);
Effectiveness Related To Health Care Policies
WHEREAS: the effects produced by psychotherapy, including the effects for different age groups (i.e. children, adults, and older adults) and for many mental disorders, exceed or are comparable to the size of effects produced by many pharmacological treatments and procedures for the same condition, and some of the medical treatments and procedures have many adverse side-effects and are relatively expensive vis-a-vis the cost of psychotherapy (Barlow, 2004; Barlow, Gorman, Shear, & Woods, 2000; Hollon, Stewart, & Strunk, 2006; Imel, McKay, Malterer, & Wampold, 2008; Mitte, 2005; Mitte, Noack, Steil, & Hautzinger, 2005; Robinson, Berman, & Neimeyer, 1990; Rosenthal, 1990; Walkup, et al., 2008; Wampold, 2007, 2010);
WHEREAS: a substantial body of scholarly work (e.g., Henggeler & Schaeffer, 2010; Roberts, 2003; Walker & Roberts, 2001; Weisz et al., 2005) have documented the effectiveness of psychotherapy across a range of problems affecting children and adolescents;
WHEREAS: large multisite studies as well as meta-analyses have demonstrated that courses of psychotherapy reduce overall medical utilization and expense (Chiles, Lambert, & Hatch, 2002; Linehan, et al., 2006; Pallak, Cummings, Dorken, & Henke, 1995). Further, patients diagnosed with a mental health disorder and who received treatment had their overall medical costs reduced by 17 percent compared to a 12.3 percent increase in medical costs for those with no treatment for their mental disorder (Chiles, Lambert, & Hatch, 2002);
WHEREAS: there is a growing body of evidence that psychotherapy is cost-effective, reduces disability, morbidity, and mortality, improves work functioning, decreases use of psychiatric hospitalization, and at times also leads to reduction in the unnecessary use of medical and surgical services including for those with serious mental illness (Dixon-Gordon, Turner, & Chapman, 2011; Lazar & Gabbard, 1997). Successful models of the integration of behavioral health into primary care have demonstrated a 20-30 percent reduction in medical costs above the cost of the behavioral/psychological care (Cummings, et al., 2003). In addition, psychological treatment of individuals with chronic disease in small group sessions resulted in medical care cost savings of $10 for every $1 spent (Lorig, et al., 1999);
WHEREAS: there is strong scientific evidence to support the links between mental and physical health, and a growing number of models and programs support the efficacy of the integration of psychotherapy treatment within the primary health care system (Alexander, Arnkoff, & Glass, 2010; Felker, et al., 2004; Roy-Byrne, et al., 2003). In fact, early mental health treatments that include psychotherapy reduce overall medical expenses, simplifies and provides better access to appropriate services and care to those in need, and improves treatment seeking;
WHEREAS: many people prefer psychotherapy to pharmacological treatments because of medication side-effects and individual differences and people tend to be more adherent if the treatment modality is preferred (Deacon & Abramowitz, 2005; Paris, 2008; Patterson, 2008; Solomon et al., 2008; Vocks et al., 2010). Research suggests that there are very high economic costs associated with high rates of antidepressant termination and non-adherence (Tournier, et al., 2009), and psychotherapy is likely to be a more cost effective intervention in the long term (Cuijpers, et al., 2010; Hollon, et al., 2005; Pyne, et al., 2005);
Effectiveness with Diverse Populations
WHEREAS: the best research evidence conclusively shows that individual, group and couple/family psychotherapy are effective for a broad range of disorders, symptoms and problems with children, adolescents, adults, and older adults (American Group Psychotherapy Association, 2007; Burlingame, et al., 2003; Carr, 2009a, 2009b; Chambless, et al., 1998; Horrell, 2008; Huey & Polo, 2008, 2010; Knight, 2004; Kosters, et al., 2006; Lambert & Archer, 2006; Norcross, 2011; Pavuluri, Birmaher, & Naylor, 2005; Sexton, Alexander, & Mease, 2003; Sexton, Robbins, Hollimon, Mease, & Mayorga, 2003; Shadish & Baldwin, 2003; Stice, Shaw, & Marti, 2006; Wampold, 2001; Weisz & Jensen, 2001);
WHEREAS: the development and/or adaptation of evidence-based psychotherapy practices for each age group have further demonstrated effectiveness in reducing symptoms and improving functioning across the lifespan. Specific challenges that emerge with age are addressed by developmental research that pinpoints the most efficacious content, vocabulary, and techniques used for different ages. As a result, substantial evidence supports psychotherapy as a front line intervention for community dwelling older adults, older adults with medical illnesses, who are low-income, ethnic minority and have co-occurring mild cognitive impairments. In addition, increasing evidence has documented that older adults respond well to a variety of forms of psychotherapy and can benefit from psychological interventions to a degree comparable with younger adults. Furthermore, many older adults prefer psychotherapy to antidepressants, and psychotherapy is an important treatment option for older adults who are often on multiple medications for management of chronic conditions and are more prone to the adverse effects of psychiatric medications than younger adults (Alexopoulos, et al., 2011; APA, 2004; Areán, et al., 2005a; Areán, et al., 2005b; Areán, Gum, Tang, & Unutzer, 2007; Areán, et al., 2010; Arnold, 2008; Gum, Areán, & Bostrom, 2007; Cuijpers, van Straten & Smit, 2006; Kazdin, et al., 2010; Kaslow, et al., 2012);
WHEREAS: researchers and practitioners continue to develop culturally-relevant, socially-proactive approaches and modalities that will allow psychologists to extend psychotherapeutic services to vulnerable and currently underserved populations such as adults, children, and families living in poverty (Ali, Hawkins, & Chambers, 2010; Belle & Doucet, 2003; Goodman, Glenn, Bohlig, Banyard, & Borges, 2009; Smith, 2005, 2010; Smyth, Goodman, & Glenn 2006);
WHEREAS: both evidence-based psychotherapy practice for the general population and culturally adapted interventions are generally effective with racial/ethnic minorities, psychologists who work with marginalized populations, such as people living in poverty and/or other socially-excluded groups, can improve the effectiveness of their interventions through awareness of unintentional age, race, class, and/or gender bias. The acquisition of multicultural competence and the adaptation of psychotherapy, whether in content, language, or approach, can improve client engagement and retention in treatment and can enhance development of the therapeutic alliance (Griner & Smith, 2006; Horrell, 2008; Huey & Polo, 2008, 2010; Miranda, et al., 2005; Miranda, et al., 2006; Vasquez, 2007; Whaley & Davis 2007);
WHEREAS: the research continues to support that psychotherapy, both group and individuals models of clinical interventions, is effective treatment for individuals with disabilities. The studies also indicate that psychotherapy is effective for a variety of disability conditions including cognitive, intellectual, physical, visual, auditory, and psychological impairments. The research supports that psychotherapy is effective for individuals with disabilities over the life span. A sample of the research reflecting the effectiveness of therapy with individuals with disabilities include: Glickman (2009), Hibbard, Grober, Gordon, & Aletta (1990), Kurtz & Mueser (2008), Livneh & Sherwood (2001), Lysaker, Glynn, Wilkniss, & Silverstein (2010), Olkin (1999), Perlman, Cohen, Altiere, Brennan, Brown, Mainka, & Diroff, (2010), Rice, Zitzelsberger, Porch, & Ignagni (2005), Radnitz (2000), and Vail & Xenakis (2007);
WHEREAS: research indicates the beneficial effects of psychotherapy as a means of improving mood and reducing depression among individuals with acute and chronic health conditions (e.g., arthritis, cancer, HIV/AIDS) (Fisch, 2004; Himelhoch, et al., 2007; Lin, et al., 2003);
WHEREAS: although some cultural adaptations already have demonstrated effectiveness as mentioned above, many underserved communities can continue to benefit from specific adaptations or demonstrated effectiveness of evidence-based psychotherapy practice. For example, current psychotherapy research suggests that racial/ethnic minorities, those with low socioeconomic status, and members of the LGBT community may face specific challenges not addressed by current evidence-based treatment. In conducting psychotherapy, practitioners are sensitive to these challenges and pursue appropriate adaptations (Butler, O'Donovan, & Shaw, 2010; Cabral & Smith, 2011; Gilman, et al., 2001; Smith, 2005; Sue & Lam, 2002);
THEREFORE: Be It Resolved that, as a healing practice and professional service, psychotherapy is effective and highly cost-effective. In controlled trials and in clinical practice, psychotherapy results in benefits that markedly exceed those experienced by individuals who need mental health services but do not receive psychotherapy. Consequently, psychotherapy should be included in the health care system as an established evidence-based practice.
Be It Further Resolved that APA increase its efforts to educate the public about the effectiveness of psychotherapy; support advocacy efforts to enhance formal recognition of psychotherapy in the health care system; help ensure that policies will increase access to psychotherapy in the health care system, with particular attention on addressing the needs of underserved populations and encourage integration of research and practice; and support advocacy for funding.
Be It Further Resolved that APA encourages continued and further research on the comparative effectiveness and efficacy of psychotherapy.
1 While statements about the effectiveness of psychotherapy must be accurate yet generalized in a policy document format, research studies have not equitably investigated all factors that either enhance or diminish psychotherapy effectiveness. Full explication of the differential status of any given variable and the state of research of any given factor in the practice of psychotherapy is beyond the scope of this document. The research citations that accompany each statement provide specificity of scope, limitations, and implications for psychotherapy practice and identify the therapeutic circumstances in which research has determined that psychotherapy is soundly effective. Examples of these important moderating variables include client/patient characteristics, clinician characteristics, context factors, diagnostic classification and severity, developmental status, and factors related to such human and cultural diversity as race, ethnicity, gender, sexual orientation and disability status (Bernal, Jimenez-Chafey, & Domenech Rodriguez, 2009; Curry, Rohde, Simons, Silva, Vitiello, Kratochvil, et al., 2006; Hinshaw, 2007; Kazdin, 2007; Kocsis, Leon, Markowtiz, Manber, Arnow, Klein, & Thase, 2009; McBride, Atkison, Quilty, & Bagby, 2006; Miklowitz, Axelson, George, Taylor, Schneck, Sullivan, et al., 2009; Ollendick, Jarrett, Grills-Taquechel, Hovey, & Wolff, 2008).
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