Why does therapy for mental illness work?
Psychoanalysis. Cognitive behavioural therapy. Compassion-based therapy. People use countless forms of therapy for mental illness. Why do they all work equally well?
Mental disorders – such as anxiety, depression and phobias – are very common. In the course of a year, about one in five people experience a disorder like this.
The most common forms of treatment are medications like antidepressants and therapy. Therapy is available in many versions, based on various theories about the human mind.
Psychoanalysis is a classic type of therapy founded by Sigmund Freud. It is based on the idea that conflicts and perceptions from childhood affect us, often without us being aware of it.
The therapy involves approaching and understanding these unconscious processes through frequent, free-flowing conversations over a long period of time.
Towards the other end of the spectrum we find cognitive behavioural therapy. Here your childhood remains in the past. Treatment concentrates on the here and now. The therapy involves breaking negative thought patterns and developing techniques for dealing with difficult situations in everyday life.
Chance determines form of therapy
You might think that the health services would employ one type of therapy for certain disorders or patients and a different approach for other groups.
But this isn’t always the case.
“When you see a mental health care specialist, how he or she has been educated can be more or less random,” says Jan Ivar Røssberg, a professor at the University of Oslo and chief psychiatric physician at Oslo University Hospital.
Chance plays a part in deciding who receives what therapy. There's no process to develop a clear idea of what is best for which patient.
The fact is that we know surprisingly little about how the varied types of therapy affect different people and disorders.
All the methods work equally well
A lot of research shows that therapy helps people suffering from mental illness.
“Compared to receiving no treatment, therapy has a positive effect,” says Røssberg.
But when we compare one type of therapy to another, it’s difficult to find any difference. As unbelievable as it may seem, most therapies seem to work equally well, despite the fact that what's being done can be very different.
KariAnne Vrabel, head of the research institute at Modum Bad Psychiatric Center in Norway, confirms this.
“Here at Modum Bad we have a long tradition of doing studies where we compare therapies. What we’ve found is that there’s usually little difference in the efficacy of the therapies,” she says.
Does this mean that therapy doesn't actually work, and the people going through it just experience a placebo effect?
Not just a placebo effect
Røssberg says no.
As in many other treatments for physical and mental ailments, the placebo effect plays a role. But the therapy provides something more.
“Quite a few studies compare a treatment method with a psychological placebo, like someone just being there and supporting you,” says Røssberg.
In comparisons like these, therapy often turns out to be more effective.
The interesting question is perhaps not whether the treatment works, but how and for whom.
What treatment for which patients?
Although therapy has proven to be effective, not all variants work for everyone. A person with depression or an eating disorder may improve significantly from a certain type of treatment, while another patient shows no improvement.
“The questions we’re asking today have changed,” says Vrabel.
“We need to investigate whether there’s a difference in what therapy works for a given person.”
Vrabel is involved in studies to find answers to this question, as is Røssberg.
“We have to try to individualize treatment,” he says.
Individualizing treatment involves finding out if some treatments work better to address certain diagnoses. But the researchers also need to examine the significance of other factors.
“Treatment efficacy can depend on personality, age, gender, education and whether patients have had many previous illness episodes,” says Røssberg.
Four different therapies tested
Røssberg is now leading a study focused on trying to find out more on this question.
He has started a large study with three other therapists covering four different forms of therapy, looking at how patients change as they receive different forms of therapy. They are now recruiting patients with depression, who are randomly assigned to either cognitive therapy or psychodynamic therapy.
At the same time, the researchers gather as much information as possible about the patients and their medical history. The aim is to find out which factors characterize patients who have a positive outcomes from the two forms of treatment.
“We can imagine, for example, that women with a certain personality structure, a university education and several depressive episodes might experience the best results from cognitive behavioural therapy,” says Røssberg.
After the survey, the researchers will test the system. They will accept new patients, survey them and give them the treatment that should work according to their research calculations. Eventually, the researchers will be able to see if patients are better off with the treatment they receive – that is, if more patients than usual are helped by the therapy.
Not everyone has trauma
Personalized treatment is a hot topic in both medicine and psychology.
Research in recent years has shown that human beings are very different from each other, and that the same disease can often be triggered and manifest differently in different people. Treatment can be affected if we let ourselves be blinded by stereotypes.
Trauma has held a special place in the treatment of mental disorders. Many people with mental illness have experienced traumatic events, such as abuse, death or an upsetting marital breakdown.
For these patients, it may be necessary to address such painful experiences. But not everyone with mental illness carries such a traumatic history.
“A lot of people I talk to haven’t experienced trauma,” says Røssberg.
Some cases may primarily be related to unfortunate genes and biological disorders. For such patients, digging into one’s childhood doesn’t necessarily serve any helpful purpose. Instead, antidepressants could offer a significant beneficial effect.
Vrabel confirms these major differences in patients.
“Sometimes there may be a greater difference between two patients with the same diagnosis than between patients with different disorders,” she says.
Relationship is always important
We need more knowledge on the most basic questions: What mechanisms are involved when people develop mental illness? And what happens in therapy for a treatment to work?
“So far we know far too little,” says Røssberg.
But one thing is certain.
A lot of research shows that the relationship between the patient and the therapist is essential in all forms of therapy. This means that both therapist and patient share a common understanding of the problem and the way forward, and that they trust each other.
“But the question is, how do you make the shift from a good therapeutic alliance to the patient no longer having depressive symptoms?” Røssberg asks.
“Is it that patients gain more insight? Have fewer negative thoughts? Do they interpret situations differently? Do they learn new ways to handle situations? I think it's so exciting to try to figure that out!” he says.
But Røssberg does not believe that a therapeutic alliance is the only thing that matters for the treatment to work.
“You also need techniques for change and a common goal,” he says.
Structure and goals for change
Vrabel is also interested in this issue. She believes structure is an essential component for treatment. Having structure creates an important distinction between therapy and conversations with grandma, the priest or a good friend.
Vrabel points to an interesting study done in Copenhagen.
Patients with eating disorders either received psychoanalysis for two years or 20 weeks of cognitive therapy. The results showed that the psychoanalysis had no effect, and that cognitive therapy was very effective.
But the study had used unstructured psychoanalysis.
Shortly afterwards, the results from another study emerged, in which the researchers had compared cognitive therapy with a structured and focused variant of psychoanalysis.
This study indicated that both therapies worked equally well.
“It’s essential for the therapist to have a clear idea of what is going to happen and a goal for what kind of change is desired,” says Vrabel.
Identifying what changes
In Røssberg's ongoing study, researchers will also be investigating what is changing in the course of therapy.
Different therapies often aim to bring about different changes. Cognitive therapy may focus on challenging automatic negative thoughts, whereas psychodynamic therapy is more concerned with patients’ relationships with other people.
But in this study, the researchers will use forms of measurement that are adapted to all the different approaches, in order to enable the researchers to evaluate how the treatment works.
“It's exciting! Maybe we’ll find out that the negative automatic thoughts actually change with psychodynamic therapy,” says Røssberg.
Everyone thinks they’re right
You might ask why this hasn’t been studied before.
Røssberg thinks part of the reason is that the supporters of the various methods have not been talking to each other.
“These different directions each have their own theory about how problems arise, what sustains them and what makes patients better,” he says.
“I think there’s been a bit of “My way is best.” You’ve been trained in a certain method, and then you continue to fight for that way of doing things.
“But our project includes people with completely different backgrounds. We have very exciting discussions because of that,” says Røssberg. “And that’s how I think it should be!”
Translated by: Ingrid Nuse.