David Kay
Hypnotherapist & Anxiety Specialist

On this page you will learn what the evidence is for most of the major types of psychotherapy, and also drug treatments, for anxiety, depression, and most kinds of emotional problems that cause people to seek help. Note: This is a general article, if you are interested in our own success rates click here.


Psychotherapy

Did you know that for much of the 20th Century debate raged, first as to whether psychotherapy worked at all, and then as to which types of therapy were best? The contest was on between psychodynamic styles of therapy, and therapies based on learning theory:

• Psychodynamic therapies treat the subconscious as a real mind with a life of its own. They look for the underlying emotional causes of symptoms, usually in your childhood. They aim to treat these causes by making them fully conscious. Most styles of counselling, hypno-analysis, regression and abreaction fall into this category.

• Therapies based on learning theory treat the subconscious more as a programmable machine. They look for the cause of problems in learned behaviour and negative thinking. Treatments are aimed at changing these patterns directly without sifting through your childhood or looking into your emotions. Cognitive therapy, behavioural therapy, solution-focused therapy, non-analytical hypnotherapy and NLP fall into this category.

Unfortunately, researchers tended to select only studies that rather suited their position!

The debate was settled between 1977 and 1997, starting with a very good analysis that included all published and unpublished studies to date that compared psychotherapy with a control (no treatment) group, or that compared different styles of treatment. 375 studies were used in total. The results were clear-cut: The average patient receiving therapy would be better off than 75% of untreated patients. And the success rate for psychotherapy was 66% compared to only 34% for the control group.(1)

A second analysis carried out using an improved method and 475 studies confirmed even more positively the benefits of psychotherapy: The average patient receiving therapy would be better off than 80% of untreated patients. And the success rate for psychotherapy was 70% compared to only 30% for the control group.(2)

Subsequently it was demonstrated that these figures hold true even when studies of patients without chronic and disabling disorders are excluded.(3) In studies that compared different styles of treatment, no evidence was found that any one treatment is better than any other.(4)

BOTTOM LINE: ALL TREATMENTS WORK, AND ALL APPEAR TO WORK EQUALLY WELL


The Medical Model

The 1950s saw the discovery of modern psychiatric drugs to treat a whole range of mental diseases, and that generally seem to work.

• The medical model treats anxiety, depression and other disorders as flaws in biological functioning. Drugs are used to correct neurochemical imbalances and bring about a resolution of symptoms.

Drugs are far more strictly regulated than either psychotherapies or alternative medicines. In order to pass regulations for human use, drug companies have to produce two clinical trials that demonstrate the efficacy of a new drug. Generally the following criteria must be met:

• Subjects are selected with a specific diagnosis, and proper ways of measuring any change are in place.

• The number of subjects is large enough (1,000-3,000).

• The trial is placebo controlled – the drug is compared with a placebo (a pill with no active ingredients).

• Subjects are randomly assigned either the drug or the placebo.

• Double blind – neither the subjects nor the administrators know who is receiving the placebo.

• Statistical analysis of the results must show that the drug is significantly better than the placebo (the probability of the results occurring by chance is less than 1%).

Against this somewhat reassuring list must be weighed the fact that pharmaceutical companies often carry out more than two trials. Trials that do not support the use of the drug do not get published.

Many studies have independently verified the effectiveness of available drugs. There is a general consensus that 60-70% of anxious patients improve on either antidepressants or benzodiazepines, and 60-70% of depressed patients improve on almost any type of antidepressant.

Obsessive disorders and certain emotional states are a little different - only certain antidepressants (ones that increase serotonin) will help.

The Placebo Effect

Did you know that the placebo response in anxious and depressed patients has also been extensively studied?

The proportion of anxious or depressed patients that respond to a placebo is rather variable. One study looked at 75 trials carried out between 1981 and 2000 for major depression. The average proportion of patients in the placebo group who responded was 29.7%.(5) One good study of more than 500 patients with panic disorder reported a response rate of 32%, but there has been some difficulty assessing the placebo response to anxiety disorders because patients on the placebo often drop out – requesting proper treatment!(6)

Again, obsessive compulsive disorder is a little different - the rate of response to placebo is much lower compared to anxiety or depression.(7)

BOTTOM LINE: MEDICATIONS WORK AND HELP ABOUT TWICE AS MANY PEOPLE FEEL BETTER THAN PLACEBOS.


Individual Patients

This really is the most important piece of information to take away with you. What we have talked about so far only describes the 'statistical' or average patient. The figures are useful for gaining perspective, but they do not tell us what will be best for any one individual. And we are all so different!

What the research does tell us is that there are basically two things that work: psychotherapy (including hypnotherapy when used in conjunction with psychotherapy), and medication.

What about other approaches? Other approaches (e.g. natural remedies) can be helpful in milder types of anxiety or depression, but there is not much evidence that they can be used alone for a more severe illness. If you have a severe illness natural approaches, such as diet, supplements and herbs, exercise and meditation need to be viewed as complementary to orthodox treatments - at least until you are feeling better. Having said that, there are obviously many anecdotal reports of success using only natural means. These may be a placebo response, spontaneous recovery (especially with first episode depression), or genuine.

Now some patients respond almost miraculously to a psychodynamic therapy, such as hypnoanalysis, while others remain untouched. Some personalities are simply more suited to an intellectual undertaking, such as cognitive therapy. Hypnotherapy has proved extremely helpful for many patients, and yet there are some who benefit more from fully conscious 'talk' sessions. A few patients have a frustrating time with therapy until they get onto a good medication - then they progress well. Others come to us already on a medication that doesn't seem to be working - a good therapy helps the medication work better for them. And of course, there are those 30% or so who will improve whatever we do - via the placebo effect.

BOTTOM LINE: A GOOD THERAPY IS ONE THAT IS SUITED TO THE TYPE OF PROBLEM AND THE PERSONALITY OF THE PATIENT.

This is where a multi-perspective or eclectic approach comes in. To attempt to treat everyone with a single one-size-fits-all approach could be compared to a doctor who only ever prescribed one drug. Let's say he prescribed Prozac to everyone who came through the door. Many would be helped, of course, but many would not, and some would be harmed. Therefore, to help the maximum number of people, either the practitioner should offer a variety of different approaches, or (like the statutory mental health teams) there will be a team of professionals each with their own particular area of skill.