Proof of efficacy is no proof of validity in psychotherapy

PSYCHOTHERAPY IS ENTRUSTED with the ingrate mission to fight an enigmatic and demanding scourge of humanity—mental illnesses—with all its emotional suffering and personal distress, let alone their behavioral, physiological, interpersonal and societal consequences–and if this would not be enough a challenge, psychotherapists are left alone to their own devices, which is nothing more than words and wisdom. Thus, the feat to achieve clinically relevant sustainable changes and reductions in face of these demands and possibilities can hardly be overrated. It might be reasoned that this is made possible by the constant evolvement and refinement of psychological models and methods, which underlie, stimulate and steer personal insight and change. But does the same apply to psychotherapy itself? Doubts about psychotherapy's ability to self-reflect and change accordingly have been raised as early as 1936, when Saul Rosenzweig hung psychotherapy's sword of Damocles with his now infamous, "Everybody has one, all must have prizes"—Dodo verdict, only that this was not fastened by a single strand of horsehair, but through the claim that "diverse methods of psychotherapy" act through "some implicit common factors" (citation taken from the title of Rosenzweig, 1936). In the same vein, although less provocative, Rogers postulated that "the techniques of the various therapies are relatively unimportant" (cited from Rogers, 1957, p. 247). Mind, these perspectives are far from being fringe science, but rather in the heart of the "great psychotherapy debate" (Wampold & Imel, 2015). Here, Jerome Frank defined during the 1960s what has become the antagonist of the mainstream, that is, a medical understanding of psychotherapy, which focuses on the specific trinity of etiology, diagnosis and method. In his contextual understanding of psychotherapy, he instead postulated that "all therapeutic rituals and procedures, irrespective of differences in specific content, combat demoralization by strengthening the patient-therapist relationship" (cited from Frank, 1986, p. 342). Interestingly and noteworthy in the context of this commentary on Sahanika Ratnayake's article, Frank proposed a hermeneutic understanding of "truth" for psychotherapy as "the only criterion for the 'truth' … is its plausibility: thus the 'truest' interpretation would be the one which is most satisfying or makes the most sense to persons [End Page 95] whose judgment one accepts. In psychotherapy the ultimate criterion of the truth of an interpretation is the extent to which the patient is convinced by it" (cited from Frank, 1986, 344). While Frank (and other proponents of a contextual understanding of psychotherapy) mainly seems to be interested in the understanding of what constitutes the therapeutic factors in psychotherapy, others have identified serious epistemic and ethical problems (Blease, 2015; Jopling, 2001; Trachsel & Gaab, 2016). Psychotherapy's impressive achievements should not be considered as proof for its validity of its means but rather as a call to proof that this has all has been achieved thorough valid means. For this quest, simply relying on the gold standard in intervention science—randomized placebo-controlled trials—does not help as control placebo-control conditions in psychotherapy research are so rife with theoretical as well as pragmatic problems that is has been reasoned that "in evaluating the efficacy of psychotherapy, the placebo effect cannot and should not be controlled" (cited from Kirsch, Wampold, & Kelley, 2016). Furthermore, the placebo itself is so effective that it is difficult to differentiate it from even highly effective psychotherapies, which in turn poses the dilemma to choose between effectiveness and ethics (McNally, 1999) or as the Society of Clinical Psychology (Division 12, American Psychological Association, 2018) put it in the case of eye movement and desensitization reprocessing (EMDR): "If EMDR is indeed simply exposure therapy with a superfluous addition, it brings to question whether the dissemination of EMDR is beneficial for patients and the field." To further complicate matters, placebos even work when provided with a psychological rationale (Gaab, Kossowsky, Ehlert, & Locher, 2019), thus the aim is not to show the benefits of psychotherapy over placebo but to prove that psychotherapy is not nothing more than a placebo. In psychotherapy, this is near impossible on empirical or theoretical grounds alone (Gaab, Blease, Locher, & Gerger, 2016), so other approaches are needed. [Excerpt]

Journal

English

Jens Gaab

Gaab, J. (2022, June). Proof of efficacy is no proof of validity in psychotherapy. Philosophy, Psychiatry, & Psychology, 29(2), 95-96. doi:10.1353/ppp.2022.0015