The World Health Organization estimated that today over 350 million people worldwide suffer from depression alone which is about 5% of the global population. At its worst, depression can lead to suicide. Suicide results in an estimated one million deaths every year.[i] In most countries the number of people who would suffer from depression during their lives falls within an 8–12% range.[ii] Worldwide, in most countries, more than one in three people fulfill all diagnostic criteria for at least one mental disorder at some point in their lives.[iii] If we take these numbers into account, we can draw only two logical conclusions. First, we are dealing with a pandemic of mental illness on an unprecedented scale in the history of the human race. By comparison, the Spanish flu, which may have been the biggest pandemic ever, claimed merely 50-100 million lives. If we decide to treat these incidence and growth rates seriously, we would have to conclude that the entire human race is going mad. The second conclusion is that we are dealing with incredibly efficient marketing. As a scientist, I believe that the more probable scenario is likely to be true. Let us, therefore, take a closer look at this second possibility and analyze the mechanisms of psychomarketing.
One of the chief contributions in this respect was made by Martin Seligman, who in 1995 published a paper in American Psychologist about the results of a survey conducted by Consumer Reports among clients of psychotherapists.[iv] The article entitled: The Effectiveness of Psychotherapy is one of the most frequently cited articles devoted to psychotherapy effectiveness. According to Google Scholar in December 2014 it has been cited 1,899 times, on average 99.95 times per year. It makes it a classical psychological work and the second most often cited article from all those written by Seligman.
It seems that he found the solution for the pandemia of mental ilnessess, as he brings: “a message of hope for people dealing with emotional problems”. The first pages of the paper feature a sort of confession by Seligman:
But my belief has changed about what counts as a “gold standard.” And it was a study by Consumer Reports (1995, November) that singlehandedly shook my belief. I came to see that deciding whether one treatment, under highly controlled conditions, works better than another treatment or a control group is a different question from deciding what works in the field (Muñoz, Hollon, McGrath, Rehm, and VandenBos, 1994). I no longer believe that efficacy studies are the only, or even the best, way of finding out what treatments actually work in the field. I have come to believe that the “effectiveness” study of how patients fare under the actual conditions of treatment in the field, can yield useful and credible “empirical validation” of psychotherapy and medication. This is the method that Consumer Reports pioneered.[v]
What was so groundbreaking in this research that it shook the belief of the future APA president? While carrying out a survey about people’s satisfaction with cars they owned, Consumer Reports asked 180,000 subscribers about their satisfaction with psychotherapy. Readers were asked to respond “if at any time over the past three years [they had] experienced stress or other emotional problems for which [they] sought help from any of the following: friends, relatives, or a member of the clergy; a mental-health professional like a psychologist, counselor, or psychiatrist; your family doctor; or a support group.” As Tana Dineen in her devastating critique of this survey wrotes:
In the usual style of CR, it was a consumer-satisfaction survey. It did not ask respondents objective, factual questions such as how much alcohol they drank, how often they fought with their spouse or considered suicide before going for help as compared to after. Nor did it seek independent verification of the self-reports. Instead it asked readers how much better they felt and how much they thought therapy had helped them. From these responses came the “convincing evidence that therapy can make an important difference.”
The response rate for the survey was very low. From thepopulation of 180,000 subscribers only 7,000 (3.9 per cent) responded to the mental-health survey; of these, 4,000 (2.2 per cent) reported seeing a mental-health professional, family doctor or attending a support group; the remaining 3,000 (1.6 per cent) had talked to a friend, relative or cleric. What is interesting is that CR ignored the experience of this latter comparison group of 3,000, and attended to only the 4,000, with particular emphasis on the 2,900 (1.6 per cent) who consulted mental-health professionals. That is why there were no control groups, no randomization (the sample, which consisted mostly of middle-class, well-educated and predominantly female individuals with a median age of forty-six, was not at all representative of the general population). There were no objective indicators – only subjective evaluations. It was like they were measuring customers’ satisfaction with a washing machine. Yet despite so many methodological flaws (I have only pointed to some of them), Consumer Reports concluded that: “our groundbreaking survey shows that psychotherapy usually works. … Longer psychotherapy was associated with better outcomes.”[vi] Morover, as Tana Dineen wrotes:
Both the CR article and the subsequent marketing material from APA claim that nine out of ten people were helped by psychotherapy. But for psychotherapy to work, one needs people with problems. Such is not the case here. Over half of the respondents (58.2 per cent) said that they felt “so-so,” “quite good” or even “very good” before treatment. Seligman apparently doesn’t scratch his head at this point and wonder whether these people are “therapy junkies.” Rather he assesses them as “being sick” and not knowing it, referring to them as “‘sub-clinical’ in their problems” and falling “one symptom short of a full-blown ‘disorder’.” However, from a common-sense, non-psychologized perspective, these people might be considered normal, okay or even in great shape. Perhaps, for them, psychotherapy was more recreational than therapeutic. And, if so, how does one really know whether treatment is even appropriate, let alone whether it works?
To add further to the confusion over effectiveness, Seligman states that 64 per cent of those receiving six months or less of therapy reported that their problems were resolved. However, his own chart indicates that, when averaged across disciplines, only 30 per cent of the people reported that treatment “made things a lot better” with respect to their specific problems. One is left wondering how it is possible that 64 per cent reported that their problems were resolved when only 30 per cent said that their problems were improved. Both numbers are far below those claimed by APA and CR when they say that psychotherapy helps nine out of ten people, leaving one wondering about the extent of inaccuracies and misinformation.
Why did a recognized researcher, one of the 30 most influential psychologist in the world still working today published a paean of praise for some marketing analysts from Consumer Reports? Was it only because he was the main consultant of the team conducting the poll? We can only guess what the correct answer is. Even though the source article and its discussion by Seligman have been subjected to devastating criticism,[vii] it seems that the disgraceful aim of introducing subjective indices into research on effectiveness of psychotherapy was achieved. Unfortunately, today not only therapists and patients, but also many researchers commonly use this approach. The “gold standard” has been established.
[i] World Health Organization, “Depression. Fact sheet N°369,” (October 2012): http://www.who.int/mediacentre/factsheets/fs369/en/
[ii] L. Andrade and A. Caraveo, “Epidemiology of major depressive episodes: Results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys,” Internation Journal of Methods in Psychiatric Research, 12 (2003): 3–21.
[iii] “Cross-national comparisons of the prevalences and correlates of mental disorders. WHO International Consortium in Psychiatric Epidemiology,” Bulletin of the World Health Organization, 78 (2000): 413–26.
[iv] Consumer Reports, “Mental Health: Does Therapy Help?” (Novemeber, 1995), 734-739.
[v] Seligman, M. E. P. (1995). The effectiveness of psychotherapy. American Psychologist, 50, 965–974, p. 966.
[vi] Consumer Reports, “Mental Health,” 734.