Psychotherapy: Gaps in Our Knowledge

Our understanding of psychotherapy is as fragmented and distorted as the proverbial blind men’s understanding of the elephant. For one thing, we lack reliable data about how many people practise psychotherapy, let alone how they practise it. The World Health Organisation collects survey data on the numbers of mental health practitioners, but does not ask respondents to specify whether they practice psychotherapy. Some countries, including Germany, Sweden and Australia, collect data on the number of people who practise psychotherapy within their national health care programmes, but not on those with private psychotherapy practices. Some countries collect data only on psychotherapy services that are reimbursed by insurance—which are only a small fraction of the services provided. And many countries collect no data at all. For example, in Poland, a country of 38 million people, no one has even an approximate idea of how many people are currently practising psychotherapy.

Furthermore, there is an enormous variety of practices that people define as psychotherapy. In a 2018 paper, researchers identified at least 600 different modalities. New approaches are constantly emerging, and modalities that have been discredited often re-emerge under new names. Only about a dozen approaches have been systematically tested for their effectiveness, and most of those have been tested only with respect to a small subset of psychological problems.

In many parts of the world, although psychologists and psychiatrists must be licensed, the practice of psychotherapy is completely unregulated: anyone can call herself a psychotherapist. Some branches of psychotherapy do require credentials, but the amount of training they demand varies wildly depending on the modality—from a few dozen hours of online coursework to several years of intensive training. And, after being credentialed, some therapists are subjected to ongoing supervision and quality controls; some are not.

In addition, therapists’ and patients’ reports are influenced by a host of confounding variables, making them no more reliable than those of the blind men describing the elephant. Some patients are delighted with their therapy, and some are not, but there is no way to evaluate the extent to which this is affected by the type of modality used, the quality of the therapist herself or the patient’s specific circumstances.

It is thus impossible to accurately estimate how many people have undergone (or are undergoing) psychotherapy, impossible to compile reliable statistics on patient experiences and impossible to assess the overall quality, efficacy or harmfulness of particular psychotherapy services. Personal opinions of psychotherapy are therefore necessarily based on individual encounters with the field and on the anecdotal experiences of a miniscule fraction of patients, each of whom, like the blind men in the parable, has touched only a fragment of reality. As things currently stand, our assessments of psychotherapy simply cannot be complete, and the surer people are of their assessments, the more sceptical of those assessments we should be.

There has, of course, been some objective research in this area, but it has usually raised more questions than it has resolved. Amid the flood of publications reporting on the effectiveness of individual therapeutic modalities, there have been occasional comprehensive reviews and meta-analyses—and these tend to cast doubt on the accuracy and reliability of the individual studies. For example, a 2017 meta-analysis looked at over 5,000 studies on the effectiveness of psychotherapy, selected because they met the highest methodological standards. While most of the study reports spoke favourably of psychotherapy, only 7% of them contained results that confirmed the effectiveness of the modality or modalities studied.

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