How much does Psychotherapy really help?

by Dr.Harald Wiesendanger– Klartext – 25. Okt. 2022


        What the mainstream media is hiding

There is no question among experts that professional spiritual care is beneficial. Doubts about this are dismissed as completely absurd and scientifically refuted. Wrongly.

“Psychotherapy is one of the most effective procedures in medicine,” a team of authors led by Professor Ulrich Schnyder, director of the Clinic for Psychiatry and Psychotherapy at the University Hospital of Zurich and ex-chairman of three industry associations, assures us in the magazine Dernervarzt. Impressive treatment effects have now been “scientifically proven for almost all psychiatric disorders.” (1)

“Psychotherapy is effective,” of course, is also spread by the Federal Chamber of Psychotherapists (BPtK) and adds: “The longer, the better.” It refers to “many controlled studies” in which there is “proof” of the effectiveness of psychotherapy “in almost everyone mental illnesses were provided” (2)

As proof, she cites a complex “quality monitoring” from 2011, with 1,708 patients and 400 psychotherapists, commissioned by the Techniker Krankenkasse: 65 percent showed “a decrease in the problem.” (3) Wow. Such a rate would even eclipse proven medical measures for physical illnesses, such as bypass surgery for blocked blood vessels or medication for arthritis.

All in all, it seems crystal clear: psychotherapy works. Almost one in four of around 250 large overview papers on the state of research with regard to its benefits came to this conclusion. (4) No textbook fails to point out this supposedly solid data.

To say the least, such self-praise misses the whole truth not just by a hair but by miles. Under the acid test, the alleged evidence crumbles like fluffy cookies under strong thumb pressure.

Poor evidence

Steven Hollon, a well-known therapy researcher from Vanderbilt University in Nashville, Tennessee, experienced this, for example. (5) Together with two Dutch colleagues, he took a close look at the scientific evidence available for cognitive behavioral therapy (CBT) for depression: a treatment approach that is intended to encourage patients to replace dark, even dark, thoughts about themselves and the world with more realistic ones replace and actively participate in life.

Emerging in the 1970s, CBT is now considered the “gold standard for the treatment of numerous disorders.” (6) Hollon’s team looked at all 55 studies of cognitive behavioral therapy for depression that the National Health Service (NHS), the nation’s top health agency, sponsored between 1972 and 2008. A lot of “underreporting” came to light: the results of almost one in four studies had never been published.

Why were they kept secret? When we asked the respective study leaders, it emerged that CBT had performed significantly worse in the unpublished studies than in the ones that had become known. If everyone were to be evaluated, the brilliant track record would have to be adjusted significantly downwards – it would be even worse than that for administering antidepressants.

But that’s not all: the supposedly successful therapy studies obtained their magnificent statistics largely through methodological sloppiness. Subjects were not assigned to the treatment or comparison group in a strictly randomized manner by an independent third party, a random number generator, or sealed envelopes. Data were not analyzed “blindly,” i.e., by someone who knew nothing about the group allocation. Only those patients who participated from start to finish were considered, rather than including those who dropped out early.

By the same standard, of 115 other depression studies, 104 were found to be poorly done. But their figures were brilliant: psychotherapy seemed to help one in two depressed people. The eleven perfectly carried out examinations proved the opposite: only one out of eight patients benefited. (7)

This shortcoming is by no means limited to the treatment of depression. “The specialist literature on psychotherapy,” admits health psychologist James Coyne from the University of Groningen in the Netherlands, “is currently of too poor quality to be a reliable aid for therapists, patients, and those responsible in decision-making bodies.” (8)

Vangelis Evangelou can only agree. In 2017, the Greek statistician from the University of Ioannina undertook more than 247 meta-analyses of 5,157 seemingly high-quality research papers on psychotherapy effects: so-called “controlled” studies (RCTs). 196 of these reviews concluded that psychotherapy had a significant positive impact. Evangelou was particularly interested in the course structure and the fine print. He found numerous indications of bias: many smaller studies reported successes that could not be confirmed in larger ones. If a representative of a particular form of psychotherapy conducted the study themselves, it appeared to be significantly more effective than if others tested it. Only less than ten percent of the studies analyzed did not exhibit such biases. (9)

Pampered track record

An often preferred data collection method enhances the statistics: half of the test subjects are treated immediately, and the other half is initially put on a waiting list and serves as a comparison group. However, the forced waiting is not good: it frustrates and suggests to those who are being held back that no improvement can be expected for the time being because the therapy is yet to follow. This fatally creates a nocebo effect (Latin for “it will harm me”), the dark underside of the placebo effect. This alone increases the measured difference in effectiveness between the treatment and comparison groups.

Another twist to make an impression with statistics: Anyone who leaves early is simply not counted. Only those who stick with the ball until the end and are willing to give feedback are included. This means that at least one in five people falls under the table. (10) Treatment terminations can have several reasons: money becomes scarce, you move, the route to another professional is shorter, and a physical illness comes in the way. Sometimes, the person being treated feels so much better that they consider further sessions unnecessary. But most often, those seeking help do not continue because the “chemistry” between them and the therapist is not correct, his efforts are of no use, or their condition even worsens.

But that’s not all: a majority of studies do not even record delayed failures – deteriorations that occur beyond the observation period. What is a big patient compliment worth at the end of the very last session if the person concerned feels miserable again soon afterward? (11) Follow-up studies only partially resolve the shortcoming: Who still wants to be interviewed extensively by scientists several months later? Those who have remained stable are more likely than those who continue to feel miserable, if not more depressed than ever.

Significant generational effect

The ice becomes even thinner as soon as you compare older effect studies on individual psychotherapies with more recent ones. Norwegian therapy researchers Tom Johnsen and Oddgeir Friborg from the University of Oslo undertook this effort. The two examined 70 studies on the supposed benefits of cognitive behavioral therapy that had appeared since the late 1970s. (12) In the first investigations, the process shined – at least on paper. But from then on, it went downhill quickly, and now it only helps half as much.

For what reason? The earliest studies were carried out less rigorously, and unpleasant results tended to be swept under the carpet. The therapists involved were part of the “first generation”: they had helped develop the therapy or were taught it by the intellectual authors. In their spirit of optimism, euphoria, and often missionary zeal, they were consistently more committed, enthusiastic, and devoted. On the other hand, their successors were likelier to stick to the methodological guidelines that the founding generation had instilled in them – at the expense of intuition, spontaneity, creativity, flexibility, authenticity, and empathy.

That being said, today’s patients know, thanks to Dr. Google, a lot more about the limitations and weaknesses of psychotherapy. As a result, their trust and their belief in the effectiveness and benefits of what is offered often suffer. It rightly suffers.

As poor as psychotherapy actually performs as soon as research shows it to be effective, its claimed successes look even worse in everyday practice. The vast majority of examinations take place at university hospitals and university institutes, where patients are carefully pre-selected. Multimorbid people – those who suffer from several disorders at the same time – are usually not even allowed to take part. In practice, they are the norm; therapeutically, they represent nuts that are much harder to crack.

Is essential, what helps save?

How can you doubt scientific psychotherapy when it helps you save money? This is what Jürgen Margraf, professor at the University of Basel, argues after evaluating 54 studies with a total of over 13,000 patients that were published in the first decade of the 21st century on the costs and benefits of outpatient psychotherapy. (13) “In this regard,” he found, “a significant cost reduction through psychotherapy was found in 95% of the relevant studies, and 86% also showed a net saving,” i.e., a “positive cost-benefit ratio after deducting the costs Psychotherapy costs.” In 76% of the studies considered, “psychotherapy was superior to medication-based strategies.”

All of this is gratifying and commendable, but it leaves one outrageous question unanswered: Would 54 studies of the costs and benefits of self-help groups for the mentally ill have yielded significantly lower percentages?

Deceptive poll numbers

All in all, the “scientifically proven” effectiveness of psychotherapy is not far off. As meta-analyses of existing clinical studies consistently show, in 30 to 50 percent of patients, the symptoms do not improve at all while they receive psychotherapy, and even fewer if it has already been a few weeks. In five to ten percent, their condition worsens while they are still being treated. (14) Although hundreds of new therapeutic procedures have been added in the past decades, these deplorable conditions have not changed.

In such a dilemma, experts prefer to refer to flattering surveys among patients. Ultimately, what matters is what those seeking help think of psychotherapy after they have committed themselves to it. When your suffering subsides or even evaporates: Isn’t that what ultimately counts – how you feel, much more than any other finding?

At first glance, the figures presented really make an impression. At the beginning of 2012, in a survey of 2,129 former or current psychotherapy patients aged 14 and over, more than two-thirds said that the treatment would help them cope with their problems better. Another 13 percent said their difficulties had even disappeared completely. (15)

Of all those who undergo psychotherapy, 70 to 80 percent say they do better than those who do nothing – an impressive rate, says clinical psychologist Sven Barnow, professor at the University of Heidelberg. After all, it exceeds the success rates of chemotherapy for breast cancer (11 percent) and aspirin for preventing heart attacks (7 percent). “Psychotherapy works very well,” he concludes. (16)

In a 2011 survey by the University of Leipzig, among 1,212 adults who received psychotherapy on an outpatient basis – i.e., not in a day clinic or an inpatient setting – the clear majority were also extremely satisfied: 70 percent have been able to deal with stress better since then, 74 percent feel more joy in life, 69 percent rate their self-esteem as strengthened, and 67 percent also feel physically better. One in two people say that thanks to psychotherapy, they are more able to cope with professional demands again. (17) Two months after completion, the improvement rate is still close to 50 percent. (18) Possibly even higher? A whopping “80 percent of patients experience significant relief from their symptoms,” says the President of the German Psychological Society (DGPs). (19) Pretty remarkable, isn’t it?

As with survey results, a thorough data check is also worthwhile here. What was the question exactly? How was the questioning conducted? How was it evaluated? The Federal Chamber of Psychotherapists uses a 2011 survey by Stiftung Warentest with almost 4,000 participants as a model study. (20) According to this, 77 percent of mentally ill people classify their level of suffering as “very great” or “great” before they begin psychotherapy; after treatment is completed, it is only 13 percent. 61 percent say they have been able to cope with everyday stress more easily since then. 53 percent say they have become more productive at work. Almost one in four people are “satisfied” or “very satisfied” with their psychotherapist. (21) How fine.

What the chamber wisely kept quiet: The survey was anything but representative; it took place online. Those who are most likely to take part in such uprisings are those who are particularly motivated to do so – and these are highly satisfied people who believe they are freed from severe suffering and are extremely grateful to their saviors, certainly more than those for whom nothing noteworthy has happened.

All in all, surveys in everyday therapeutic practice reveal an even more embarrassing picture of psychotherapy than clinical studies suggest. This sobering finding was confirmed when a research team from Berlin’s Humboldt University led by psychologist Jenny Wagner followed more than 4,000 schoolchildren and students for four years. Almost 300 of them had undergone psychotherapy during this time.

Wagner was surprised: “They have described that since then, they have become more emotionally unstable, have more anxiety in their everyday lives, and are less able to get involved with other people. So those were really negative effects that we saw. We have also seen an increase in depression, for example, and a decrease in life satisfaction.”

Because these results seemed unbelievable, Wagner’s team also examined how psychotherapy works on another group: older Americans. But “we also saw these negative effects on personality development.” (22)

Lots of fanfare, hardly any substance

The psychotherapy industry is throwing a lot of fanfare around “the largest psychotherapy study ever conducted,” carried out in 2015. (23) A British-American research team recorded no fewer than 26,430 patients between the ages of 16 and 95 who had been treated by 1,400 British psychotherapists over the course of twelve years. Most commonly, they suffered from anxiety (56%) and depression (39%), conflict in their relationships (39%) and at work (23%), low self-esteem (34%), severe loss (23%), or trauma, such as after sexual abuse (15%). On average, eight therapy sessions took place. How did they help?

To find out, the “CORE-OM” was used (24): a 34-part questionnaire for self-assessment relating to the areas of subjective well-being, psychological symptoms, functioning in general, and particularly in social relationships; a risk assessment was also required. (To what extent does the patient pose a danger to themselves and others?) The results were fantastic: no less than 60 percent of those surveyed felt “significantly better” at the end of therapy, and another 23 percent felt at least a little better. Only 19 percent were still in bad shape. Only 1.3 percent had their mental health worsen.

Such figures shine – as long as the composition of the study sample remains unquestioned. To do this, the research team used a database set up in 1993, the CORE National Research Database. In a first step, they selected around 105,000 patients whose psychotherapists had submitted an assessment form between 1999 and 2011. All such patients should complete the CORE-OM questionnaire at the start and immediately after completion of their therapy.

If they failed to do this, they were not even included in the evaluation – almost every second person, almost 50,000. However, this preselection distorts the overall picture enormously: If someone does not provide data as requested at the end of therapy, it is because they did not wait for it. However, those who leave prematurely usually do so because the treatment has had a disappointing effect of little or nothing at all. If you take these dropouts into account, the impressive 60 percent improvement rate suddenly shrinks to a relatively meager half.

After all, 30 to 50 percent of satisfied people still represent impressive performance, doesn’t it? Rather no. If every third or second person receiving psychotherapy feels better after two months, the other half, if not two-thirds, continue to feel just as bad or even worse than at the beginning. Since only one in five of those presumably in need of treatment actually get involved with professional spiritual helpers, the fate of the remaining 80 percent raises pressing questions.

What will become of them when they so urgently need to be taken into professional care? Will they sink into a black hole for the rest of their miserable existence? Is their psychological torment prolonged indefinitely because they ignorantly, stubbornly, and foolishly spurn the blessings of modern mental health? Resistance to improvement occurs inside and outside of practices and clinics, probably a little more often outside than inside, but certainly not in excessive numbers. Those who are left untreated can generally expect one of three disease progressions: In the first group, the oppression will resolve itself at some point after just waiting.

Others benefit from the character mentioned above trait that psychologists call resilience: psychological robustness that involves learned skills to overcome crises despite difficult conditions. They help you to pull yourself together, not to let yourself go, to grit your teeth, to get through a depression bravely and confidently. A third group benefits from the support of trusted laypeople in their immediate social environment who provide therapy with great skill and empathy without knowing it or calling it that.

Does such a “successful” healing method want to be a serious part of the medical profession? What would a psychotherapist think of his orthopedic surgeon if his track record for problems with the musculoskeletal system looked like this: out of a hundred patients affected at his practice location, only twenty confided in him. He can only help seven to ten people: some a little, others a little.

In ten to thirteen others, the condition remains partly unchanged and partly worsens: spines become even more crooked, rheumatic joints become even more deformed, and bone fractures and ligament and tendon tears become even more severe. The remaining eighty patients avoid him from the start because, for the vast majority, such problems disappear either on their own or, through self-treatment or with help from family or friends. How valuable, unalterable, and indispensable would such an orthopedist seem to the psychotherapist?

“But I see that I can help!” protests the professional spiritual helper angrily.

He could have been struck with operational blindness. Psychotherapists often simply cannot admit that their patient is not making any progress, that he is getting worse, or that he is considering stopping the treatment. In less than three percent of all cases, they do not want to admit that the condition has worsened. (25)

The widespread perception disorders among professionals as to the effectiveness and benefits of their efforts probably stem from the all-too-human need to look as good as possible to oneself: Not a single psychotherapist surveyed considers his own performance to be worse than average, whereas over 96 percent do above average. It, therefore, grossly overestimates what the guild is actually capable of. (26)

(Harald Wiesendanger)

This text is a revised excerpt from H. Wiesendanger: Psycholügen, Volume 3: Deep in the soul: a case for professionals?, Schönbrunn 1st edition 2017.