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Is It True That "Everyone Has Won and All Must Have Prizes"?
Lester Luborsky, PhD; Barton Singer, PhD; Lise Luborsky, MA
Tallies were made of outcomes of all reasonably controlled com- in the clinical sense where we believe a great deal is
parisons of psychotherapies with each other and with other treat- known, but in the controlled research sense where we be¬
ments. For comparisons of psychotherapy with each other, most lieve we are just beginning. We "know," for example, that
studies found insignificant differences in proportions of patients psychoanalysis works better with patients who have high
who improved (though most patients benefited). This "tie score ef-
fect" did not apply to psychotherapies vs psychopharmacotherapies ego-strength, but we can find only a little research evi¬
dence for this of the kind considered in this review.
compared singly\p=m-\psychopharmacotherapiesdid better. Combined
treatments often did better than single treatments. Among the com- Comparative studies of psychotherapies is not an area
parisons, only two specially beneficial matches between type of pa- where one or two decisive experiments can be telling—one
tient and type of treatment were found. must rely on the verdict of a series of at least passably
Our explanations for the usual tie score effect emphasize the com- controlled studies. Ideally, one would want to have an im¬
mon components among psychotherapies, especially the helping re- peccable definitive study that would settle the question of
lationship with a therapist. However, we believe the research does comparative worth once and for all, but it is not possible,
not justify the conclusion that we should randomly assign patients since every study has some uniqueness of sample charac¬
to treatments\p=m-\researchresults are usually based on amount of im- teristics measuring instruments, and other less easily de¬
provement; "amount" may not disclose differences in quality of im- fined aspects. A consensus of many studies is what we
provement from each treatment. must hope for.
The subtitle
in Wonderland-it
you will
recognize
the dodo bird
was
issince it
from Alice
who handed
The best way to summarize the studies is to consider
them separately for each of the main types of comparisons
down this happyverdict after judging the race. It was also that have been done; eg, group vs individual psychother¬
the subtitle of that classical paper by Saul Rosenzweig,1 apy, time-limited vs unlimited psychotherapy, client cen¬
"Some implicit common factors in diverse methods of psy¬ tered vs other traditional psychotherapies, and behavior
chotherapy." Our title implies what many of us believe- therapy vs psychotherapy. For each type of comparison, a
that all the psychotherapies produce some benefits for convenient "box score" is given with the number of stud¬
some patients. What we do not know is whether or not ies in which the treatments were significantly better or
there are psychotherapies that produce substantially bet¬ worse, or "tie score"—our term for not significantly differ¬
ter results and are especially suited to certain patients. entstatistically.
Here, when we use the word "know," we are not using it Only studies in which some attention was paid to the
main criteria of controlled comparative research were in¬
Accepted for publication Jan 3, 1975. cluded. The research quality of each study was scored ac¬
From the Department of Psychiatry, University of Pennsylvania (Drs.
Luborsky and Singer); the Eastern Pennsylvania Psychiatric Institute (Dr.
cording to 12 criteria (see Criteria). Each departure from
Luborsky); Philadelphia Veterans Hospital (Dr. Singer); and Villanova each criterion was scored —1, somtimes —V2. Many of these
University (Ms. Luborsky). criteria were derived from those of Fiske et al.2 These 12
Read in part before the third annual meeting of the Society for Psycho- criteria were only to be considered as guidelines, since the
therapy Research, Nashville, Tenn, June 16,1972. A short version was pre- sum of the weights cannot be matched point for point
sented to the American Psychopathological Association meeting, Boston,
March 5,1974. The present version was read as the presidential address to with the validity of the study. In fact, for a particular
the Society for Psychotherapy Research, Denver, June 14, 1974.
Reprint requests to the Department of Psychiatry, University of Penn- study a single criterion may be absolutely crucial in deter¬
sylvania, 207 Piersol Bldg, University Hospital, 3400 Spruce St, Phila- mining its validity; for example, the use of random as¬
delphia, PA 19104 (Dr. Luborsky). signment in a study may have produced significantly dif-
Table 1.—List of Treatments Compared List of Treatments Compared (Continued)
Qua I- Out- Refer¬ Qual- Out- Refer¬
Treatment ity* comet ences Treatment ity* comet ences
Group vs individual psycho¬ D- Time-limited & short-term B— + Muench22
therapy groups improved more 1965
Decreasing order of Baehr' than long-term samples
effectiveness from group 1954 (on Rotter Test & Maslow
& individual therapy, Security-Insecurity
to individual therapy, Inventory)
to group therapy Time-limited client-centered Shlien23
Similarities of results of Barron & treatment compared 1957
group & individual Leary'0 favorably with longer,
generally greater than 1955 unlimited treatment, on
differences most outcome measures
Changes on discomfort & Imber et al" Time-limited treatment (20 Shlien
social ineffectiveness 1957 sessions) vs unlimited et al2"
scales were independent treatment (median: 37 1962
of type of therapy sessions)
Little difference in Haimowitz & 70% of patients treated Frank
effectiveness Haimowitz12 for 6 mo vs 74% who et al"
1952 dropped out in the first 1959
No difference in effectiveness month showed decrease
Thorley & in discomfort
Craske"
1950 'Ideal" long-term treatment, Pascal &
Group therapy, better + O'Brien brief supportive treat¬ Zax2«
adjustment ratings et al" ment, & environmental 1956
Rehospitalization rates did 1972 manipulation produced
not differ 0 high but not different
level of change
Slightly less improvement in Gelder
group than individual etal'5 Time-limited patients Reid &
therapy in rapidity of 1967 (maximum of 8 sessions) Schyne27
change (rating by patients improved more than those 1969
on main phobia, ratings
in long-term treatment
by psychiatrists on Client centered ("Rogerian")
anxiety & depression) vs other traditional psycho¬
No difference in general Peck" therapies
improvement or in separate 1949 Client centered vs psycho¬ Cart-
areas (adjustment & analytic: no difference wright28
in degree of experiencing 1953
symptoms) & level of self-observation
No differences between Slawson17
Client centered vs psycho¬ Heine29
psychodrama added to 1965
individual plus routine analytic vs Adlerian 1953
treatment vs "controls" psychotherapy: patients
receiving individual reported no difference in
amount of change
plus routine treatment
Little difference between Boe et alls Client centered ("Reflec¬ Baker30
regular hospital treat¬ 1966 tive") vs "leading" therapy 1960
ment with individual vs ("Neo-Freudian"): no
difference
regular hospital treatment
with group treatment Client centered ("Reflec¬ Ashby
Patients treated by brief or B+ + Pearl" tive") yielded lower et al3'
Intensive group therapy 1955 improvement ratings than 1957
showed more reduction "leading" therapy
in California ethnocen- Client centered vs Adlerian Shlien
trism scale than patients et al2"
treated by individual 1962
psychotherapy Psychotherapy vs behavior
Group with diazepam, Covi therapy
imipramine hydrochloride, et al»! Results of behavior therapy Cooper
or placebo vs brief 1974 vs matched psychother¬ et al32·33
individual supportive apy controls 1965,
therapy with diazepam, 29 severeagoraphobias 1963
imipramine, or placebo with behavior therapy,
no difference from
Time-limited vs time-unlim¬
ited treatment matched psychotherapy
Compared to patients in controls
Henry & 12 limited "other phobias"
long unlimited treatment, Shlienîi
patients in brief time- 1958 improved more with
limited treatment showed behavior therapy than
severe decline in affect matched sample with
differentiation (on TAT), psychotherapy +
but no difference on At 1-yr follow-up, the 12
"other phobias" no
therapist rating, difference between
behavioral index, and
Q-sort behavior therapy &
psychotherapy
Table 1.—List of Treatments Compared (Continued) List of Treatments Compared (Continued)
Qua I- Out- Refer¬ Qual¬ Out- Refer¬
Treatment ity* comet ences Treatment ity* comet ences
10 behavior therapy vs 10 Gelder & 13 behavior therapy vs 13 Zitrin et al
conventional psycho¬ Marks3" supportive psychotherapy 1974
therapy (all severe 1966 (unpub¬
agoraphobics) lished
At the end of 1 yr, not data)
different (all severe Psychopharmacotherapy alone
agoraphobics) vs psychotherapy alone
17 students (who went to Crighton & Phenothiazine and/or group C + Gorham"2
health services spon¬ Jehu" psychotherapy (schizophrenics) 1964
taneously) desensitization 1969 Stelazine vs psychotherapy, + May &
vs group therapy on length of hospital Turna43""
Both treatments improved stay, release rate, & 1964 &
but no difference in supplemental treatment 1965
improvement feelings
on
(schizophrenics)
about exams, sleep
Trifluoperazine vs group + Evangela-
disturbance, or grades psychotherapy- kis«
16 desensitization, 16 group, B+ Gelder adjunctive therapy 1961
10 individual at end of 6 et al« + Lorr
mo desensitization did best 1967
Chlordiazepoxide vs
psychotherapy et al"
(severe agoraphobics in 1963
sample did poorly) +
Overall &
At end of 2-yr follow-up, Psychopharmacotherapy alone vs +
differences
no 0 psychotherapy alone Tupín"7
Penothiazine & 1969
Behavior therapy ("operant- King antidepressants vs
¡nterpersonal" therapy) + et al36
psychotherapy
did best (hospitalized 1960
schizophrenics) vs Drug groups (meprobamate, 0 Koegler &
prochlorperazine, Brill"8
verbal therapy, recre¬
1967
therapy,
ational & no phénobarbital) vs
therapy psychotherapy
Group desensitization vs Lazarus37 Amitriptyline hydrochloride + Klerman
vs psychotherapy et al"'.5o
group interpretation 1961
(plus relaxation) for 1974,
matched pairs of 1973
agoraphobics &claustro- Chlorpromazine vs + Hogarty &
phibics psychotherapy Goldbergs'
Group desensitization vs 1973
group psychotherapy for Psychotherapy plus
all patients psychopharmacotherapy vs
10 implosive therapy vs 20 Levis & psychopharmacotherapy alone
conventional therapy vs Carrera38 Chlorpromazine, alone & as + Cowden
10 no treatment; implo¬ 1967 adjunct to group et al"
sive therapy showed shift psychotherapy 1956
from pathology, conven¬ Chlorpromazine & group therapy King*3
tional therapy not more (hospitalized chronic 1958
effective than on waiting schizophrenics)
list 3 mo
Phenothiazine and/or group Gorham
7 systematic desensitization, McReyn- psychotherapy et al"2
7 insight-oriented olds3» (schizophrenics) 1964
psychotherapy, & 14 1969
Stelazine & psychotherapy vs May &
relaxation therapy Turna"3 ""
stelazine on length of
20 behavior therapy (4.1 Marks & hospital stay, release rate, & 1964 &
sessions per week) vs Gelder"» supplemental treatment 1965
20 controls in psycho¬ 1965 (schizophrenics)
therapy (2.4 sessions Chlorpromazine & group King«
per week) (all phobies)
psychotherapy 1963
58 behavior therapy patients Patterson (schizophrenics)
treated (in first 5 mo) et al"'
Trifluoperazine hydrochloride Evangela-
improved more than 69 1971 & group psychotherapy- kis"5
others in psychoanalytic adjunctive therapy 1961
psychotherapy
Patients in both samples Psychotherapy plus drug vs Overall &
in second period improved drug alone Tu in47
equally (inexperienced 1969
therapists did better with Chlordiazepoxide used with Lorr
behavior therapy; with psychotherapy et al"6
experience, effectiveness 1963
of both treatments Antidepressants (amitriptyline) 0 Klerman
equal) and psychotherapy (relapse + et al"».5o
31 behavior therapy vs 30 B+ Sloan rate) (social adjustment) 1974,
insight-oriented therapy; et al 1973
at 4 mo, no difference; 1974 -f
Chlorpromazine & sociotherapy Hogarty &
at 1 yr, no difference (unpub¬ Goldberg5'
lished 1973
data)
Table 1.—List of Treatments Compared (Continued) List of Treatments Compared (Continued)
Qual¬ Out- Refer¬ Qual¬ Out- Refer¬
Treatment ity* comet ences Treatment ity* comet ences
Psychotherapy plus Peptic ulcer: 32 medication, Chappell &
pharmacotherapy vs diet, & group psychological Stevenson66
psychotherapy alone training vs 22 medication & diet 1936
Phenothiazine & group Gorham Ulcerative colitis: 34 Grace
psychotherapy vs group et al"2 superficial psychotherapy et al67
therapy (schizophrenics) 1964 & diet & medication vs 34 1954
Stelazine &psychotherapy + May& diet & medication
vs psychotherapy effect Turna"3·"" Duodenal ulcer (augmented B- Glen68
on length of hospital stay, 1964, histamine test): 21 medical 1968
release rate, & supple¬ 1965 therapy vs 24 psychotherapy
mental treatment
Bronchial asthma: 33 group Groen &
(schizophrenics) psychotherapy & medication Pelser6'
Reserpine alone &as + Cowden vs inhalants & medication 1960
adjunct to psychotherapy et al» vs inhalants
(schizophrenics) 1956
Recovery from heart attack: + Gruen
Psychotherapy & B+ Grinspoon psychotherapy plus medical 1974
phenothiazine pharmaco¬ et a|55,5' regimen vs medical regimen (unpub¬
therapy (chronic 1967, lished
schizophrenics) 1968 data)
Shader
et al*7
Asthma: hypnosis & relaxation -I- Maher-
1969 vs drugs Loughman
et al7»
Psychotherapy plus Gibbs 1962
chlorpromazine vs et al*8
Ulceratitie-colitis: 57 + O'Conner
psychotherapy 1957
psychotherapy & drugs et al7'
(schizophrenics) vs 57 drugs alone 1964
Chlordiazepoxide used with + Lorr
Sinclair-
Warts (subjects who had failed
psychotherapy vs et al«
with physical treatment): Gieban
psychotherapy (outpatients) 1963
7 hypnosis therapy & 14 et al72
Meprobamate & Lorr suggestion applied on only 1959
chlorpromazine with et ais' one side of the body
psychotherapy (outpatients) 1961
Hypertension: group D- Titchener
Psychotherapy and drug Rickels psychotherapy & medical —
et al73
(meprobamate) vs psycho¬ et al«8 management vs medical 1959
therapy (neurotic 1966 management§
outpatients) Dermatoses: hypnotherapy + Zhukov7"
Psychotherapy & imipramine + Daneman61 & resort treatment vs 1961
vs psychotherapy (depressive 1961 resort treatment
reactions) (neurotics) Psychotherapy vs control Grace
Diazepam, phénobarbital, & Hesbacher 34 superficial psychotherapy et al67
placebo: combined et al« vs 34 (matched) treated 1954
treatment better than psycho¬ 1970 with diet & medication
therapy & placebo (neurotics) (patients in hospital with
Trifluoperazine-group + Evangela- ulcerative colitis)
psychotherapy-adjunctive kis« 44 individual psychotherapy Morton75
therapy vs group therapy 1961 matched in pairs with 44 1955
(mixed inpatients) (90 days no treatment)
Psychotherapy plus C + Overall & 10 group therapy, 10 no + Tucker76
phenothiazine & Tupin"7 treatment (chronic hospital 1956
antidepressants vs 1969 soiling behavior)
psychotherapy (mixed inpatients) Group therapy vs no Coons77
Amitriptyline & + Klerman treatment, (mainly 1957
psychotherapy vs et al"' hospitalized schizophrenics)
psychotherapy 1974
Group therapy (2 times a Jensen78
Psychotherapy plus B- + Podobnikar63 week, 13 weeks) vs 1 group 1961
chlordiazapoxide 1971 no therapy, but consultation
hydrochloride (Librium) with nurses, vs 1 group no
vs psychotherapy with placebo therapy, no consultation
Psychotherapy plus Karon & (44 closed-ward women)
pharmacotherapy vs Vandenbos6" 1 sample with psychiatrist < Sheldon7'
psychotherapy for 1970 (outpatient department) 1964
inexperienced therapists vs 1 sample with nurse
(schizophrenics) (day care center) vs 1
Psychotherapy plus sample with general
pharmacotherapy vs practitioners (psychiatric
psychotherapy alone for aftercare, schizophrenic women)
experienced therapists 37 group treatment with + Shattan
Psychological therapy (combined psychiatrist & social et al8°
usually with medical regimen) worker vs 23 no systematic 1966
vsmedical regimen alone (for psychotherapy: better
psychosomatic conditions) rehospitalization rates &
Eczema: dermatological & B- + Brown & highly significant difference
psychiatric treatment vs Bettley« in number granted absolute
dermatological treatment 1971 discharge (mostly schizophrenics)
Table 1.—List of Treatments Compared (Continued) List of Treatments Compared (Continued)
ferent patient samples to be compared. grading system was not to provide highly reliable subdivi¬
All studies were graded according to how well they fit sions of grading so much as it was to weed out the worst
the criteria of controlled comparative studies on a scale studies. Nevertheless, it was reassuring to find that the in¬
from A to E. An A indicates the main criteria of search dependent grading judgments on the scale by two of us
design were mainly satisfied; B, one or two were partially (L.L. and B.S.) on 16 randomly selected studies yielded a
deficient; C, three or four were partially deficient; D, three correlation of .84.
or four were partially deficient and one was seriously
deficient; and E, the deficiencies were sufficiently serious Criteria
so that the results were not worth considering and the 1. Controlled assignment of patients to each group: Regardless
study, therefore, was not included. (The grades for each of which methods was used, the aim was to achieve comparability
study are noted in Table 1.) The primary purpose of our of the groups on the important dimensions. (For psychotherapy
studies, one crucial dimension is initial severity of the patient's vanee to the problems of practitioners than studies of non-
illness.) patients, this review will consider only research in which
(a) Random assignment: This is a risky way to assign patients, bona fide patients were in bona fide treatment—excluded
despite its use in most studies. Unless the groups are then checked were role-playing studies and those using student volun¬
for comparability (as in b), random assignment gives little assur¬ teers.
ance of comparability.
Within these limits, the present review is more com¬
(b) Matching of total groups: A fairly adequate method. than any; it combines many of the studies of the
(c) Matching in pairs: This is the most powerful way of assign¬ plete
three most complete reviews: Bergin,4 Meltzoff and Korn¬
ing patients.
No difference in composition of the groups by the end of therapy reich,5 and Luborsky et al,6 with additional types of com¬
by virtue of different amount of kind of dropouts. parisons that have not been reviewed before. The diffi¬
2. Real patients were used. This is important enough so that culties encountered in locating and evaluating the rele¬
our present review only includes those with real patients. vant research are impressive. Therefore, it is not
3. Therapists for each group were equally competent. Very few surprising that some previous reviewers have presented
studies give information on which to judge this, although most biased conclusions about the verdict of this research liter¬
studies probably try to take this obvious factor into account. ature on the relative value of certain forms of psychother¬
4. Therapists were not inexperienced. A high percentage of the
studies used inexperienced therapists, since it is easier to get apy (eg, two replies to one of these reviewers, Luborsky7·8).
Since we tried to do a complete review—within the lim¬
inexperienced therapists to agree to carry out one's study. How¬ its noted—we can now complete our introduction with an
ever, the research is to be considered moderately impaired when
only inexperienced therapists were used. historical perspective. From a tabulation of the publica¬
5. Treatments were equally valued. This is a crucial criterion. It tion dates of the studies (Table 1), we learn that the entire
is violated routinely when a treatment was compared with a con¬ field of controlled comparative treatment research got its
trol in which no treatment wasoffered. However, even when two start only in the middle and late 1950s: the bulk of the
treatments were compared in studies, the treatments were
some studies were done in the last two decades. Within this pe¬
often presented in ways that create different impressions of the
extent to which they were valued-either to the therapists or pa¬
riod, each type of comparison had its special era. Group vs
individual treatment comparisons started as far back as
tients in each form of treatment.
1949 and continued to the present, but most of them were
6. The outcome measures took into account the target goals of
the treatment. Few studies did this explicitly. Probably all studies done in the decade of the 1950s. The time-limited vs time-
that use a therapist- or patient-rating of outcome take this into unlimited comparison was done mostly in the late 1950s
account as a matter of course (weight -%). and early 1960s. The client centered vs other psychother¬
7. Treatment outcome was evaluated by independent measures. apy comparisons began in the 1950s and extended to the
Most studies used the therapist as the main source of outcome in¬ first half of the 1960s. The psychotherapy vs behavior
formation. Some also used the patient; only a few used more inde¬ therapy comparisons only began in 1960, with most stud¬
pendent outcome measures. Because of the difficulty of making a ies being done in the late 1960s and some continuing to
judgment about which outcome measures are inherently best, it is the present. The psychotherapy vs pharmacotherapy com¬
difficult to weight this criterion very highly (see Luborsky3 on sug¬
gested independent clinical measures). parisons were represented by three studies done in the
late 1950s, with most of them being done in the 1960s and
8. Information was obtained about other concurrent treat¬
ments, both formal and informal, and these are not unequal in the continuing until the present. The psychotherapy vs medi¬
compared treatments. The most frequent instance in which this is cal regimen for psychosomatic illnesses covers the longest
important is the patient's taking of a variety of prescribed and time span, beginning in 1936, although studies are sparse
unprescribed drugs during comparative treatment studies. When in the entire period. The psychotherapy vs no psychother¬
there is no information on this (as is often the case) and when the apy comparison started in the 1950s and was well repre¬
compared treatments were associated with different amounts of sented then, but the vogue was over by the first half of the
the incidental, concurrent treatments, the study is impaired 1960s.
(weight lk). It would have been of special interest to compare quan¬
9. Samples of each of the compared treatments were indepen¬
—
lations (eg, prisoners). elusion about the comparison with other psychotherapies:
Twenty (or about 60%) of the comparisons significantly client-centered psychotherapy and behavior therapies.
favored psychotherapy, but 13 showed a tie, meaning that The preponderance of nonsignificant differences between
the psychotherapy was not significantly better than the treatments should gain in impressiveness when one con¬
nonpsychotherapy in almost a third of the comparisons. siders that researchers as well as editors of journals may
None of the comparisons favored the control group. tend to hesitate about publishing results of studies with
We considered, in searching for explanations, whether nonsignificant differences. Also, many of these compari¬
or not the 13 comparisons showing a tie might have in¬ sons are studied by partisans of one treatment or the
cluded more chronic inpatients. Hardly any trend in this other.
direction was found—of 19 comparisons for schizophrenic It is natural to question whether or not, despite care in the de¬
patients, eight were a "tie"; of 14 comparisons for non- sign, the therapeutic allegience of the experimenters might in
schizophrenic patients, five were a "tie." Two more appli¬ some way influence the results, since the comparisons are often
cable explanations might be that the nonspecific ingredi¬ not double-blind and not impeccable in other ways. We, therefore,
ents are often powerful for both the psychotherapy and examined the list of authors and asked some of their peers about
their therapeutic allegiences.
the "control groups" (cf, Frank,97 and Sloane et al), and
It appears to be a meaningful question only for those forms of
the treatment effects often are not powerful enough to treatment where a strong allegience is present. Only two of these
produce significant advantage over the beneficial forces clearly qualify: that is, behavior therapy vs other psychotherapies
activated by nonspecific factors. and client centered therapy vs other psychotherapies. For the
Schizophrenic Nonschizophrenic rest, affiliations tend to be less strong.
Box Score Patients Patients For the behavior therapy vs psychotherapy comparison, one ob¬
vious conclusion is that it is partisans of a form of treatment who
Psychotherapy do the studies of it. We could identify the affiliation of all but two
better 20 11 9
Tie
was
8
authorships and all of these were partisans of behavior therapy.
13 5 The same kind of observation occurs for the client centered vs
Control group other psychotherapies comparison—almost all of these are affili¬
was better 0 0 0 ated with client centered psychotherapy. This probably should
have been expected. Who else but a partisan would take the time
Conclusions and Implications
and energy to do a comparative treatment study? Since almost all
1. Most comparative studies ofdifferent forms ofpsycho¬ are partisans in various degrees, it is difficult to draw any conclu¬
sion about the role of partisanship in the results.
therapy found insignificant differences in proportions of
patients who improved by the end of psychotherapy. It is 2. The controlled comparative studies indicate that a
both because of this and because all psychotherapies pro¬ high percentage of patients who go through any of these
duce a high percentage of benefit (see conclusion 2) that psychotherapies gain from them. Meltzoff and Korn¬
we can reach a "dodo bird verdict"—it is usually true that reich,5""781 for example, basing their conclusions on the
"everybody has won and all must have prizes." This pre¬ controlled comparative studies, estimate that for both in¬
dominance of tie scores appears when different forms of dividual and group therapy about 80% of the studies show
psychotherapy are compared with each other; that is, it ap¬ mainly positive results. The same can be said for the other
plies to the first four comparisons: group vs individual psy¬ kinds of treatment that were compared. Even a fair per¬
chotherapy, time-limited vs time-unlimited psychother¬ centage of patients who go through minimal treatment
apy, client centered vs other traditional psychotherapies, seem to make some gains (as pointed out by Sloane et al
and behavior therapy vs other psychotherapies. Only the and others). This may have contributed to our surprising
last two comparisons involved "schools" of psychotherapy. finding that approximately a third of the comparisons of
It is noteworthy that in the 25 or 30 years of comparative psychotherapy with control groups do not show significant
treatment studies, only two schools of treatment have a differences. This general benefit effect may contribute to
sufficient number of comparative studies to permit a con- the high frequency of tie scores—if a very high percentage
of all patients receive benefits, it is, therefore, more diffi¬ cial kind of conditioning for delinquency developed by
cult to achieve a significant difference between different Gerald Patterson, PhD.
forms of treatment. Could the conclusions be artifacts of poor research? Defi¬
3. The "dodo bird verdict" does not apply when one ven¬ ciencies in the research designs and other artifactual
tures beyond comparisons of psychotherapies with each problems (Fiske et al2 and Rosenthal and Rosnow98) proba¬
other; ie, to comparisons ofpsychotherapy with other forms bly do not account for our main conclusion concerning sim¬
of treatment. (1) A preponderance of tie scores does not ilar improvement rates for the different forms of psycho¬
apply when psychotherapy vs other types of treatment therapy, because of the following:
such as pharmacotherapy are compared singly—In the (a) The criterion in the majority of these studies is the
available studies, pharmacotherapy produces significantly usual criterion—that is, therapist's judgment of improve¬
higher numbers of patients judged as benefiting. (2) It ment. (Some rely on independent clinical judges and some—
does not apply to combined treatments vs single treat¬ especially those using inpatients—utilize discharge rates
ments. The advantage for combined treatment is striking and readmission rates.) Although this criterion (like any
in that it appears for all three of the box scores deal¬ criterion) has its own vantage point (the therapist's opin¬
ing with combinations: for psychotherapy plus pharmaco¬ ion), nevertheless those studies using other criteria show a
therapy vs psychotherapy alone; for psychotherapy plus similar trend (in terms of comparative percentages of pa¬
pharmacotherapy vs pharmacotherapy alone; and for psy¬ tients benefiting) to those using only the therapist's judg¬
chotherapy plus a medical regimen vs a medical regimen ment as a criterion. One could argue that if we improved
alone (for psychosomatic illnesses). A combination of the quality of our outcome measures, we might find a
treatments may represent more than an additive effect of higher percentage of significant differences among psy¬
two treatments—a "getting more for one's money"—there chotherapies. While this possibility must be admitted, we
may also be some mutually facultative interactive bene¬ have no evidence so far to support it.
fits for the combined treatments. (3) It does not apply (6) Compared to many studies of psychotherapeutic re¬
to comparisons of psychotherapy vs "control groups" (eg, sults, especially those of three or four decades ago, these
absence of or minimal psychotherapy)-more than half of in our review are relatively well controlled—although only
these comparisons favor psychotherapy. a few of them come up to all of the recommendations for
4. There are only a few especially beneficial matches of comparison of treatments listed by Fiske et al.2 Further¬
type of treatment and type of patient-which is to be ex¬ more, despite deficiencies in the quality of the research in
pected since conclusion 1 is the dominant trend: (1) The the studies selected for the box scores the best designed do
most impressive match for the alleviation of a variety of not show a very different trend from those that are less well
psychosomatic symptoms is psychotherapy (and related designed.
psychological treatments) added to appropriate medical One direct way to illustrate this is to dichotomize the
treatment in comparison with a medical regimen alone. studies into two groups; those receiving a quality rating
(2) Behavior therapy may be especially suited for treat¬ of A or vs those receiving C or D. In general, the sub¬
ment of circumscribed phobias. groups show the same main trends. One possible excep¬
But it is, nevertheless, amazing in view of the large tion, however, is that five out of six of the comparisons in
clinical literature on matching patient and treatment that which behavior therapy is shown to be better than psycho¬
in our review we have come upon only two especially bene¬ therapy are in the poor quality category.
ficial matches between type of treatment and type of pa¬ It may also be of interest to note the overall research
tient. There are some other good candidates but these are quality for each type of comparative study. Here the larg¬
supported by only single studies rather than by the mass¬ est number of poor studies are to be found in the compari¬
ing of studies that we require for our present review. son of psychotherapy plus psychopharmacological agents
A symposium at the 1973 Society for Psychotherapy Re¬ vs psychopharmacological agents alone. Also for psycho¬
search meeting was focused on these, evaluating two logical treatment plus a medical regimen vs a medical
matches and attempting to locate others. This symposium, regimen alone, five out of the nine studies have D or D—
titled "Therapeutic technology: Effects of specific tech¬ ratings.
niques on specific disorders," discussing the advantage for What are the main ways ofimproving these comparative
psychosomatic symptoms of psychotherapy plus a medical treatment studies? Through the experience of evaluating
regimen vs a medical regimen alone (senior author); Ar¬ the quality of these studies, we have evolved a system for
nold Goldstein, PhD, presenting research on modifications judging them according to a list of 12 criteria partly based
of psychotherapy for lower class socioeconomic patients on Fiske et al.2 We will highlight here only those four cri¬
with special focus on prescriptive and modeling tech¬ teria on which most of the research is in need of improve¬
niques; Peter E. Nathan, PhD, reviewing behavior therapy ment.
in the treatment of phobias both circumscribed and gener¬ With regard to criterion 1, the patients should be de¬
alized; and Albert Stunkard, MD, discussing his research scribed, especially on certain crucial dimensions. This will
with Sydnor Penick, MD, on group behavior therapy for permit something better than random assignment of the
obesity. Some other candidates for special patient-treat¬ patients to the treatments. Composing groups by match¬
ment matches were considered briefly; one of them was a ing pairs of patients on crucial dimensions, such as sever¬
special form of conditioning for enuresis provided in the ity of illness, is highly desirable but very few of the stud¬
context of complete environmental control (particularly ies did this. Adequate description of the sample will also
the work of John Atthowe, PhD), and another was a spe- permit additional exploration of specific interactions of
type of treatment with type of patient. This last recom¬ various forms of psychotherapy probably should not be
mendation for improving experimental designs could lead taken to imply that the quality of the improvement is nec¬
to the confirmation of special patient-treatment matches essarily similar. The patient who has improved via group
and the discovery of new ones. Also, the lead provided in therapy or individual therapy may have gained something
the O'Brien et al14 study that group therapy may be espe¬ different in his conception of himself or in his capacity for
cially suitable for schizophrenics should be explored in reflecting from one who has improved via behavior ther¬
new studies; similarly more replications of Penick et al99 apy or chlordiazepoxide hydrochloride (Librium). There is
and Stunkard1™ should be done. only a little evidence for this supposition; eg, Heine,29
With regard to criterion 5, in many studies insufficient Klerman et al,50 and Dudek101; much more research needs
effort was made to present the treatments to the patients to be done on this.
as equally valued. Then, in addition, the patients in some Malan102 makes this the centerpiece in the conclusions to
studies may have known which therapies were most valued his review of outcome research problems, ie, "The failure
by the therapists or by the experimenters. to design outcome criteria and do justice to the complex¬
With regard to criterion 7, this criterion emphasizes the ity of the human personality." Malan has in mind develop¬
importance of evaluating the treatment outcome by inde¬ ing better measures that rely on clinical judgment to esti¬
pendent measures. Since treatments have a variety of im¬ mate the quality of the outcome. Comparative studies of
pacts, it is also important to include the main types in the educational treatments (Messick103) are also becoming
outcome criteria. The two main types of outcome that more concerned with learning the possible outcomes, not
must be evaluated are those related to specific symptoms just the intended outcomes, and with the interaction of
and those related to general adjustment. Different ther¬ the treatment conditions and individual differences in the
apies may produce different proportions of these. For ex¬ students.
ample, the behavior therapies and the pharmacotherapies 2. As noted earlier, the studies we reviewed are almost
may have more influence on the symptom-outcome mea¬ entirely limited to relatively short-term treatment; that
sures while the long-term, intensive psychoanalytically is, about 2 to 12 months. This is a glaring omission in the
oriented psychotherapies may have more influence on the research literature. We do not know enough about what
general adjustment measures. conclusions would be reached for long-term intensive
With regard to criterion 9, usually there was no evi¬ treatment.
dence offered that the treatment given actually fits the in¬ 3. Our conclusions apply to the results of comparative
tended form of treatment. The simplest and most direct studies of several forms of treatment. As indicated above,
way of doing this is rarely done: taking samples of the ad¬ usually no step is taken to show how well the designation
ministered treatment and having them judged indepen¬ fits. Even beyond this problem, it is very likely that cer¬
dently. Judging samples in this way will also do much to tain ingredients of the treatment that apply across treat¬
permit comparisons across treatments in different studies, ment labels are the main influencers of outcome. The ther¬
since there are so many varieties of treatment designated apist, for example, can be supportive, warm, and empathie
"psychotherapy"—eg, the "psychotherapy" provided for in a variety of differently designated forms of treatment,
schizophrenia may be quite different from the "psycho¬ and this may be a powerful influence on the outcome of
therapy" provided for neurotic patients. treatment.
Another aspect of criterion 9 is equally important. The 4. As we have noted in conclusion 4, there are a couple
length of the treatment and the length of the follow-up of especially promising matches of a type of patient and a
must be such as to be considered reasonable examples of type of treatment, and others may be soon established.
the designated form of treatment. Some forms of treat¬ In sum, for these reasons (and for other more general
ment exert their effects early (probably behavior ther¬ ones noted in Luborsky104 we should not yet consider our¬
apy, pharmacotherapy, time-limited therapy, and directive selves ready to make assignments on a random basis.
therapies); some may have a slower course and more long- How do we interpret the main finding in conclusion 1?
lasting effects (probably the insight-oriented psycho¬ Essentially, three factors are involved in accounting for
therapies and particularly psychoanalysis). The insight- the main finding that the studies do not produce any clear-
oriented psychotherapies are poorly represented in most cut winners when psychotherapies are compared with each
of these comparative studies—treatment lengths were other. To start with the least of the three first: (1) Since all
rarely more than one year and usually much, much less, forms of psychotherapy tend to achieve a high percentage
and follow-ups were either absent or too brief to catch the of improved patients (our conclusion 2), it is difficult (sta¬
assumed long-term benefits of the insight-oriented psy¬ tistically) for any single form of psychotherapy to show a
chotherapies. significant advantage over any other form—the higher
Is there a practical application of our conclusions in these percentages, the less room at the top for significant
terms of the assignment of patients to different forms of differences between treatments. A survey of the distribu¬
treatment? Taken at face value, our conclusions seem to tion of improvement ratings reported by different studies
dictate that from now on we should stop paying attention supports our assertion (J. Mintz, PhD, Lester Luborsky,
to the form of the treatment in referring patients for psy¬ unpublished data). (2) Although each form of psychother¬
chotherapy. Yet there are several reasons why we should apy differs in some elements of its philosophy, each offers
hesitate to recommend such a drastic departure from all to provide the patient with a plausible system of explana¬
the clinical wisdom: tions for his difficulties and also with principles that may
1. Similarities in numbers of patients benefiting from guide his future behavior. Such an organized explanatory
and guidance system may be one of the common elements not, however, covered the huge literature specifically on habit dis¬
that facilitates the benefits from all forms of psychother¬ orders (eg, addiction and bed wetting)—behavior therapy might be
apy (as was suggested by Rosenzweig1). (3) The most po¬ better for them—and we have not included many studies with stu¬
tent explanatory factor is that the different forms of dent volunteers rather than genuine patients.
Response of some skeptics about the efficacy of any form of psy¬
psychotherapy have major common elements—a helping chotherapy: "See, you can't show that one kind of psychotherapy
relationship with a therapist is present in all of them, is better than another, or, at times, even better than minimal or
along with the other related, nonspecific effects such as nonpsychotherapy groups. This is consistent with the lack of evi¬
suggestion and abreaction. This explanation is stressed by dence that psychotherapy does any good."
Rosenzweig,1 by Frank,97 by Strupp,105 and many others. Our answer: As we mentioned, the nonsignificant differences
This is exactly where more research needs to be done—on between treatments do not relate to the question of their bene¬
the components of a helping relationship (eg, in Strupp's fits—a high percentage of patients appear to benefit by any of the
comparison of trained vs untrained helpers Strupp105. psychotherapies or by the control procedures.
When differences among treatments do appear in some Response of some balanced psychotherapy researchers of any
orientation: "Before I ask my question, I first want to say that I
studies, they might then be explicable in terms of the pro¬ am pleased to see a careful review of comparative psychotherapy
portions of these components. studies with research quality considered. I hadn't realized, even
These common ingredients of psychotherapies may be
though I know the literature very well, that there were so many
so much more potent than the specific ones that it is controlled comparative studies, and that the trends you found
wrong to lump them together in the sense of giving them emerge so clearly. I was especially surprised about group psycho¬
equal weight. It is like making horse and canary pie by the therapy since I thought it was significantly less effective than in¬
Spanish recipe—horse and canary in equal proportions, one dividual psychotherapy, and I was surprised about behavior ther¬
horse and one canary. apy which I thought had more comparative treatment studies
with general patient populations which showed its superiority.
COMMENT And finally, I hadn't realized the advantages for combined treat¬
ments. Now for my question: Would we not learn more in future
It is not entirely fair and (and it may even be unther-
studies if we constructed the studies to investigate specific treat¬
apeutic) to present a report that arouses strong responses ments for specific types of patients?"
in many readers without giving them some chance to be Our answer: We couldn't agree with you more. But we should
heard. We, therefore, give a few of these responses based underline what has been found so far in the review, that the
on a small prepublication pretest sampling of opinion. breakdowns in terms of types of patients and types of treatments
Response of some psychoanalysts: "This doesn't adequately rep¬ have yielded little in terms of specific matches of type of patient
particularly psychoanalytic
resent long-term, intensive treatment, and form of treatment, with the possible exception of limited
treatment." phobias treated by behavior therapy and psychosomatic patients
Our answer: It is completely true, unfortunately. It is time treated by medical regimen plus psychotherapy.
there were some of such studies to include. This investigation was supported in part by Public Health Service Re¬
Response of some behavior therapists: "Behavior therapy is bet¬ search grant MH-15442 and Research Scientist Award MH-40710.
ter. You must not have looked at the right studies or included all Charles O'Brien, MD, PhD (for the group therapy section), Hans Strupp,
of them." MD, John Paul Brady, MD, Karl Rickels, MD (for the psychopharmacology
section), Bruce Sloane, MD, Peter E. Nathan, PhD (for the behavior ther¬
Our answer: For the general run of patient samples who seek apy section), Marjorie Cohen, and Freda Greene assisted in the preparation
psychotherapy, we have included all that could be found. We have of this report.
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CORRECTION
Reprints Available; Word Omitted.\p=m-\Twoerrors occurred in
the article "Narcissism and the Readiness for Psychotherapy
Termination," published in the June ARCHIVES (32:695-699,
1975). On page 695, the last footnote (column 1) should read
"Reprintrequeststo30NMichiganAve,Chicago,IL60602(Dr
Goldberg)." And on page 696, in column 1, the second sentence
in the paragraph preceding the centerhead should read "They
are not in analysis. ." As published, the word "not" was
..
omitted.