Psychotherapy: Art or science?
(December 2004 Issue)

“There’s the perception that the connections between symptoms and causes are better understood by medical than mental health professionals” says Daniel Abrahamson, Ph.D., director of professional affairs at the Connecticut Psychological Association. (photo by Tom Croke)

By Ami Albernaz

Is psychotherapy more intuitive art - a give-and-take process through which patients gradually learn effective emotional management skills - or empirical science, a set of clear-cut methods which, once discerned, will enable patients to gain these skills more quickly? This question, posed by a New York Times magazine article over the summer, has been the focus of a longstanding, steadily intensifying debate in the field, with fervor on both sides perhaps never running so high as it is now.

On one side of the debate are those - including some managed care companies - pushing for short-term, standardized therapies that hold up to scientific testing and can be packaged in treatment manuals. On the other side are those who say that relying on prescribed quick fixes leaves little room for clinical wisdom and that patients are not best served by short, circumscribed relationships with therapists.

New England Psychologist spoke to a few practitioners about the issue, and found it is no less a hot button topic in this region as it is anywhere else. Yet there are calls for reconciliation and a search for a middle ground. "When debates are polarized, it's dangerous. We need to be cautious," says Michael Constantino, Ph.D., an assistant professor in the graduate clinical psychology program at the University of Massachusetts Amherst.

Constantino notes that although research into psychotherapy techniques is fairly young, practice is already based on a scientific model that is enhanced and altered as seen fit. "I can't imagine what would be if scientific data weren't behind therapies," he says. "Many of us are scientists searching for the most effective treatments. Still, we should never overlook clinical wisdom. Administering therapies should allow room for both science and intuition."

Empirical research has resulted in effective guidelines for the treatment of conditions such as panic disorder, Constantino says. "But it would be unfortunate if therapists were told, 'You must use this manual for this condition,'" he adds. "Therapists should be allowed to rely on clinical wisdom and experience and choose a certain method of treatment."

Clinical expertise is considered in the guidelines of an American Psychological Association (APA) task force on the issue, convened by new APA President Ronald Levant, Ed.D. According to a task force document, the concept of "evidence-based practice" has focused largely on empirical research, even though it can be interpreted to also incorporate clinical expertise and patient values. The task force, composed of 21 practitioners and academics within the psychology, psychiatry and public health fields, is charged with finding an appropriate definition of evidence-based practice and will make recommendations to the APA and health care decision-makers.

The focus on empirical evidence in judging psychotherapies, to some psychologists, is plainly unfair. Daniel Abrahamson, Ph.D., director of professional affairs at the Connecticut Psychological Association and a practicing psychologist, says the psychotherapy discussion is rooted in a misperception of psychotherapy as being less based on precision than is physiological care.

"There's the perception that the connections between symptoms and causes are better understood by medical than mental health professionals," he says. "Much of the discussion starts with that false assumption. If you think about it, so many antibiotics are prescribed each year, based on an intuitive understanding of physicians of what might be helpful. Sure, there are some clear treatment protocols and there are in the mental health arena as well."

Medical and mental health practitioners follow similar steps, he continues. First, data is collected in order from the patient: what the problems are and when they occur, if there are emotional symptoms that overlap with physical ones or vice-versa. For treatment, both physicians and psychologists might recommend similar courses of action: lifestyle changes, medication or perhaps simply time, to wait and see if symptoms worsen or fade. The practitioner may choose to treat the patient or may refer the patient to a specialist.

"There's not a huge difference in approach between physical and psychological treatments," Abrahamson says. "So my question is, why do we hold psychological treatments to different standards than medical treatments?"

Just as medical doctors try to understand why courses of treatment work for their patients, it is valid to try to understand why certain psychotherapies are helpful, says Jeffrey Winseman, M.D., a psychiatrist at Bennington College in Vermont and director of student psychological services at Albany Medical College in New York. "As practitioners provide to someone who wants to be healed, it's appropriate to wonder if what's being given is effective, and why," he says, then adds: "But in the field of psychotherapy and in neuroscience, we can't always say why what we do helps people."

The danger in insurance companies mandating short-term, manualized therapies, Winseman says, is that it is perhaps the quality of the client-therapist relationship that matters more than the method of treatment. "Numerous studies have shown the effectiveness of both short-term CBT and longer-term, insight-oriented therapy," he says. "Not that one is better than other, but it's more the depth of relationship, how it's handled. If someone coming in for cognitive therapy has a year of treatment, that person will get more done than if he or she were to come in for eight sessions. The evidence says that a longer the therapy is, the better and more lasting the changes are."

To Abrahamson, insurance pressures to keep psychotherapy short are not only misguided, but discriminatory. "If a company was to tell a person with chronic diabetes, 'you can only have six sessions,' the person would die," he says. "A practitioner has to make constant adjustments. For someone with complex emotional problems - including child abuse, neglect, lack of ability to function emotionally - we would expect as much treatment as is necessary to help work through problems and dysfunctions."

What is needed, Abrahamson adds, is a move toward genuine parity between medical and mental health coverage. "Calling for evidence-based practice [in psychotherapy] is nothing more than an effort to decrease access to mental health care," he says. "It's problematic because we've been trying to treat medical and psychological treatments as equal. We now have the technology to know that many psychological conditions have physiological causes. Yet we wouldn't set limits for patients with arthritis, cancer or cardiac conditions."

Yet at a time when managed care considerations are a reality, mental health practitioners must figure out how best to proceed, Winseman says. "There are corporate interests in keeping therapy brief, to keep costs down. People want more for less money," he says. "That corporations are tied up in psychological care is a central problem, and we in the field haven't been able to find a way to divest ourselves of that."

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