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You need your head examined

Despite the huge growth in the number of psychotherapist, you’d be better off talking to an intelligent friend, says Raj Persaud

Fifty years ago, psychotherapy was dealt a major blow with the first scientific paper to question seriously whether it worked, and whether therapy might sometimes do more harm than good.? The study triggered a debate that has raged for half a century and which some say has failed to generate an adequate response from practitioners. It started when a young German psychologist, Hans Eysenck, analysed the first proper clinical trials of therapy at the Maudsley Hospital, London. Eysenck, who went on to become the most famous psychologist in the world, compared the improvement rate of thousands of people undergoing psychotherapy with a control group who had similar psychological problems, but who merely remained on a waiting list

While an encouraging 64 per cent of patients receiving psychotherapy improved after two years from their breakdown, 72 per cent of the control group made a similar recovery with no psychotherapeutic assistance. Of those having the most rigorous and intensive therapy of all, full blown Freudian psychoanalysis, only 44 per cent recovered.

When Allen Bergin, a psychologist at Brigham Young University, looked closely at this kind of research, he found the data were hiding an even more peculiar story. The ?scatter ? of measured change plotted on graphs for patients having therapy was much greater than the scatter for those receiving no treatment.

In other words, those that had psychotherapy either did fairly well, or often actually pretty badly. They tended to lie in extremes of the distribution, compared with those who had no therapy, who all improved by more or less the same amount.

Bergin had uncovered a result that has dogged the field since.? Therapy not only does good, but also harm. Further analysis found the greatest potential for harm was when therapists stuck rigidly to particular schools of training, rather than adapting to the patient.

Therapy has splintered into so many differing and often opposing schools ? Freudians, Jungians, transactional analysis and a host of others ? that it resembles the plethora of small Left-wing political groupings of the Seventies, often more united by a hatred for each other than the natural enemy, which, in the case of therapy, is science. Contrary to the research evidence that sticking rigidly to a particular therapeutic orientation is bad for patients, these schools tend to emphasise vigorously why they are better than all the others, in order to survive.

But unlike factionalised Left-wing politics, therapy proved enormously successful and is growing at an incredible rate.? The British Association of Counselling had just a few hundred members by the mid-Seventies but has now grown more than twelve fold to 16,000 members.? The Department for Employment estimates that 2 ?5 million workers in Britain today deliver some form of counselling as part of their jobs.

This dramatic growth has occurred despite the fact that scientific research continues to question the assumptions on which much therapy is based. A key scientific blow to the therapy empire came in 1975 when Lester Luborsky, professor of psychology at the University of Pennsylvania, published a landmark paper with the title ??Everyone has won and all must have prizes ??, known famously as the Dodo bird verdict, which comes from Alice ?s Adventures in Wonderland .The title Is an ironic twist to Eysenck?s early habit

He found that it didn?t seem to matter what particular psychotherapy you had ? everyone benefits more or less to exactly the same extent.

Given that many schools of therapy are based on fundamentally opposing theories of human nature, this is an incredible result.? It appears to be irrelevant whether you have full blown Freudian psychoanalysis, an hour a day for five days a week for several years to probe your unconscious deeply, or just a few sessions of behavioral therapy, where it is assumed that your unconscious and your conscious do not exist.

This finding suggested that what gets you better are the effects of talking to someone who encourages you and activates hope.

This suggestion was confirmed by another major study conducted by psychologists Hans Strupp and Suzanne Hadley of Vanderbilt University in the United States in 1979.? They found that depressed patients treated by a group of untrained people did just as well as those treated by trained and experienced psychotherapists.

15 separate major scientific attempts to pool all the research done into the effects of therapist experience and training on patient outcome, only one ever found a significant positive association between years of therapist experience and patient benefit.

Yet another scientific nail in the therapy coffin was the extensive study conducted by Dr William Piper of the University of Alberta in 1991.? He analysed 22,500 therapist interventions from audiotapes of sessions, and found the more interpretations the therapist made, the worse the patient got.

All this welter of scientific evidence points to the fact that much of the benefit you can get from therapy is practically indistinguishable from what you might obtain from confiding in a reliable, understanding and intelligent friend.

The dramatic growth of therapy, despite Eysenck?s paper 50 years ago, and all the scientific data since, may be telling us something about the break- down of relationships in our society, and the decline of conventional coping mechanisms, such as religion and the nuclear family.

On the other hand, the American Handbook of Psychiatrydefends therapy by arguing: ?Perhaps its effectiveness can never be shown by scientific methods.? Perhaps the experience of analysis is like that of beauty, of mysticism, of love ?self-evident and world-shaking to him, who knows it,but quite incommunicable to another who does not.?

This kind of defense of therapy suggests that the rise of counselling is telling us something more worrying, about the continued retreat of scientific and rational thinking in the modern age, in the face of the new primacy of personal anecdotal experience. Only in such an increasingly Alice in on-Wonderland world can ?everyone win and all must have prizes ?.

Dr Raj Pesaud is a consultant psychiatrist at the Maudsley Hospital in south London.

From the Edge of the Couch by Raj Persaud (Bantam Press) is available for ?11.99 plus ?1.99 p&p.? To orde please call Telegraph Books Direct on

Freudian psychoanalysis

Based on Freudian ideas that unconscious processes explain most self-defeating behavior. The unconscious can only be illuminated by techniques such as dream analysis and interpreting slips of the tongue.? The therapist says little and classically sits behind the patient who lies on a couch and projects fantasies about parents.

Scientific validity rating:**

Jungian analytical psychology

Jung was a contemporary of Freud and similarly used dream analysis to get to the unconscious.? He placed much less emphasis on childhood and sex as being at the heart of patients ? conflicts.? Compared with Freudian therapists, Jungian analysts believe in a more collaborative relationship with the patient.

Scientific validity rating **

Rebirthing

A therapy that enables people to re-experience their own birth in order to free themselves from the constraining beliefs and experiences associated with birthing.? The thesis is that trauma associated with birth forms the basis of all anxiety.? Two Denver rebirthing therapists were found guilty of child abuse resulting in death in 2001 when a 10-year-old client died from suffocation during a rebirthing that involved being buried in cushions and blankets.

Scientific validity rating *

Primal scream

A psychologically violent defence-shattering method which aims through catharsis to unblock repressed painful feelings about one?s unmet needs as an unborn child. The theory is that the pain of the trauma experienced before, during and in the early months of birth is kept from conscious awareness, but at the cost of neurotic symptoms and psychological disorders later in life.

Scientific validity rating *

Cognitive behavioral therapy

An argumentative approach where the patient?s ideas are challenged and all self-defeating behaviour is put down to negative and irrational beliefs.? The therapy remains strictly in the here and now, and the past is considered irrelevant to the present.? Requires clients to embrace strict rationality and to take responsibility for their own attitudes and is, therefore, less popular with patients than other much less scientifically valid therapies.

Scientific validity rating *****

Kinds of therapist

Psychiatrist: medically trained, available on NHS but long waiting times are a problem and they are more trained in treatment of psychosis than more common problems such as anxiety.? Should be a member of the Royal College of Psychiatrists.? Can prescribe medication.

Psychologist: no medical training but a degree in psychology from a university, so is unable to prescribe medication.? However, is usually better at treatment of problems such as anxiety than psychiatrists.? Tends to provide scientifically validated therapies like cognitive behavioural therapy but, again, there are long waiting lists on NHS. Should be a member of the British Psychological Society.

Psychotherapist: should be on register of United Kingdom Council for Psychotherapy or the British Confederation of Psychotherapists. Not usually qualified at university level in psychology or psychiatry, but will usually have completed a fairly rigorous training lasting several years.? Will tend to use interpretations and be less active in sessions in terms of offering straightforward advice.

Counsellor: should be member of a major counselling organisation such as the British Association of Counselling. Will tend to have had a rigorous training that relied less on instilling techniques involving development of deep or intense relationship with client.? Tends to use more short-term and time limited approaches to working with a client. However, the distinction between therapy and counselling is blurred.

Friend: according to majority of scientific evidence just as effective as any of the above for mild to moderate psychological problems, but can get fed up if approached regularly for advice and tends to be less forgiving of obvious self-defeating behaviour. No charge, usually, but likes being taken out for a drink or a meal in exchange for regular burden sharing. Might gossip about you if not completely trustworthy. No opportunity to sue for compensation if negligent.

CIVILIAN counsellors can do more harm than good when trying to help soldiers in the aftermath of battle, many military experts believe. Instead, good training combined with a ?buddy system ? for debriefing gives the vast majority of Servicemen protection against long-term pyschological damage, they say.

According to Prof Simon Wessely, director of the Gulf War Research Unit at King?s College, London, between one and three percent of troops who took part in the last Gulf war suffered post-traumatic stress ? the extreme, long-lasting pyschological damage caused by distressing and often life- threatening events ? a far lower number than is often claimed.

Although psychological damage is as much part of war as physical damage, he believes British troops are well prepared to cope with the stress of conflict.? ?I don?t think they are more psychologically stressed from seeing terrible things than doctors or nurses.?

The risks of post-traumatic stress disorder are far higher if Servicemen and women do not trust their equipment, are younger, come from lower socioeconomic backgrounds and have past trauma.

But a key factor appears to be the level of support from their peers and friends.? Six years ago, the Royal Navy and Royal Marin s developed a ?buddy ? scheme called trauma risk management, or Trim, designed to give support to troops.? Senior officers meet after any major incident and assess whether it could have caused psychological harm.? If they consider someone to be at risk, a train d colleague is asked to assess him or her.

Lieutenant Commander Neil Grenbury, a psychiatrist with the Royal Navy, said hundreds of people had been trained. ?We are trying to get people returning from operations to talk to their buddies and talk to their friends. ?We?re doing our best to get the ones who are a little bit wobbly, rather than going in and trying to make everyone better and ending up with hundreds of psychologists and counsellors and soldiers spending lots of time in therapy with no positive output.??

David Derbyshire

12 march 2003