Why therapy works

By Martin E.P. Seligman, PhD
APA President

I will resist the temptation of trumpeting the year?s accomplishments in my last presidential column. Let it suffice that I believe that the year ends with APA a healthier organization and with psychology more forward-looking.

It is more my style to discuss a substantive matter. I want to bring to your attention a paradox about psychotherapy: We have strong evidence that psychotherapy works, but when active treatments are compared specific effects are hard to find. The fact is there are only a handful of psychotherapy techniques that show big, specific effects when compared to another form of psychotherapy or drug treatment. Among them are applied tension for blood and injury phobia, penile squeeze for premature ejaculation, cognitive therapy for panic, relaxation for phobia, exposure for OCD and behavior therapy for enuresis. (My book, "What You Can Change and What You Can?t," documents the specifics and reviews the relevant literature).

More typically, however, when one treatment is compared to another treatment specificity tends to disappear or becomes quite a small effect. Lester Luborsky?s contribution and the National Collaborative Study of Depression are typical examples. The lack of robust specificity is also apparent in much of the drug literature as well. Methodologists argue over flaws in such outcome studies, but they cannot hatchet the basic findings away. The fact is that almost no psychotherapy technique that I can think of (with the exceptions above) shows specific effects when compared to another form of psychotherapy or drug, adequately administered. Finally, add to this stew the large "placebo" effect found in almost all studies of psychotherapy and drugs.

Let me speculate on this pattern of outcomes. Much of the relevant ideas have been put forward under the derogatory misnomer "nonspecifics." I am going to rename two classes of "nonspecifics" as "tactics" and "deep strategies." Among the tactics of good therapy are attention, authority figure, rapport, alliance, tricks of the trade (e.g., "Let?s pause here," rather than "Let?s stop here"), paying for services, trust, opening up, naming the problem and others.

Building strengths

The deeper strategies need not be mysteries. Rather, I believe they can be the subject of a large-scale science of new techniques that maximize them and of extensive, replicable training to make better therapists. One strategy?instilling hope?is often discussed elsewhere in the literature on placebo, on explanatory style and hopelessness and on demoralization.

The other is the "Building of Buffering Strengths." I believe that it is a common strategy among almost all competent psychotherapists to help their patients build a large variety of strengths, rather than just deliver specific damage-healing techniques. Among the strengths built in psychotherapy are courage, interpersonal skill, rationality, insight, optimism, honesty, perseverance, realism, capacity for pleasure, putting troubles into perspective, future mindedness and finding purpose.

Assume for a moment that the buffering effects of strength-building strategies have a larger effect size than the specific "healing" ingredients that have been discovered. If this is true, the relatively small specificity found when different active therapies and different drugs are compared and the massive placebo effects would all follow.

Another more fundamental idea follows from the possibility that building strength produces larger improvements for most disorders than the specific damage-healing moves: By working in the medical model and looking solely for the salves to heal the wounds, we have misplaced much of our science and much of our training.

So, it is possible that by creating a science of positive psychology and with it creating a replicable technology of building these strengths, we will be able to account for and improve the efficacy and effectiveness of psychotherapy. It is also possible that the search for empirically validated therapies has in its present form handcuffed us by focusing only on the specific techniques that repair damage and that also map uniquely into DSM-IV disorders. Let me suggest that a scientific understanding of the general strategies that build the buffering strengths will improve our profession and will create an understanding of why psychotherapy is generally highly effective.

Your gift to me

In closing, I will try to answer a question often asked of me during the last year: why I ran for APA president. I ran because I thought I had a mission but I did not know what it was. In being president I believed I would discover it and I did. The mission I found was to partake in launching a science and redirecting a profession whose aim is the building of what makes life most worth living. This opportunity was your gift to me and my fondest hope is that I will repay your trust.