Psychotherapy is likely to be most effective

Historically mental illness has been ‘treated’ in a host of dangerous and sometimes horrifying ways.

Around 7000 years ago trepanation was the treatment de jour. It was thought that mental illness was caused by evil spirits and could be cured by drilling small holes into the brain.

While trepanation and other surgical methods such as lobotomies have unsurprisingly fallen out of favor, there is another approach – one that has been both celebrated and scorned over the last century: Psychotherapy.

Talking as a way to treat mental distress is as old as the story of humanity. In 300 BC, Socrates engaged his students through philosophical group discussions. Now known as the Socratic or dialectic method, these group discussions were used to help people better understand their universe and their purpose therein.

Contemporary psychotherapy works from a conceptual framework that links knowledge of the mind and knowledge of the brain. When undertaken by a trained clinician, psychotherapy can provide modes of describing personal experience through conversation, creating ways of understanding the self and treating mental health conditions.

The following article will explore the research and benefits of psychotherapy, and how you can maximize those benefits in order to improve psychotherapeutic outcomes.

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Table of Contents

What are the Benefits of Psychotherapy?

Meta-analyses of psychodynamic psychotherapy studies indicated that short-term treatment improved symptoms of depression, anxiety, and anorexia nervosa. When patients were reassessed nine months after treatment, the effect size of psychodynamic therapy had increased. An indication of lasting psychological changes that yielded further benefits as time passed (Busch, Rudden, & Shapiro, 2004).
Ongoing anger and stress are major contributors to high blood pressure and a number of related health issues. Linden & Moseley (2006) found that psychotherapy produced the same level of systolic blood pressure reductions as anti-hypertension medication.
Psychotherapeutic counseling in the treatment of heroin addiction has been shown to improve the attendance of subjects while undertaking detoxification treatment. When compared to those receiving detoxification alone, subjects receiving both treatments simultaneously were more likely to enter long-term treatment following the initial program (Rawson, Mann, Tennant, & Clabough, 1983).
Meaning-centered group psychotherapy has been shown to reduce psychological distress and improve spiritual well-being in patients with advanced or terminal cancer (Breitbart, 2015).
Psychotherapy can improve symptoms of depression, general anxiety disorder, social anxiety, bipolar disorder, OCD, phobias, and panic disorders when used as either the sole treatment or in conjunction with pharmacological treatments (Hunsley, Elliott & Therrien, 2013).
A growing body of evidence indicates that psychotherapy decreases the use of psychiatric hospitalization and reduces the use of other medical and surgical services. Successful integration of psychotherapy into primary care may reduce medical costs by 20-30% (Cummings, et al., 2003).
Psychotherapy in conjunction with pharmaceutical treatment has been shown to be more enduring and effective in the long-term than medication alone. Hollon, DeRubeis, Shelton (2005) found that relapses of anxiety and mild to moderate depression occurred in 76.2% of those who had received medication. The relapse rate was 30.8% among those who had received medication and psychotherapy simultaneously.

A Look at the Research

Psychotherapy has been studied in a variety of clinical and real-life settings, most commonly by assessing changes in symptoms and cognition from pre- to post-therapy (Kwon & Oei 2003).

Freud is generally credited with establishing psychotherapy as an autonomous branch and his psychoanalytic approach assumed that humans have an unconscious mind where feelings that are too painful to face are often hidden (NICE Clinical Guidelines, 2014).

At the end of the First World War, Freud conversed with soldiers who had been traumatized by their experiences: these dialogues served as a precursor to contemporary psychodynamic psychotherapy (Gaztambide, 2012).

During the Second World War, psychiatrists and psychologists drew on ideas from psychoanalysis and social psychology in order to return battle casualties to active duty, or at the very least to productive employment as civilians (Jones, 2004).

The introduction of clinical services during wartime was a significant catalyst for change and innovation, creating opportunities to develop and advance a number of group and individual therapies.

The decades that followed saw an increase in the number and quality of studies used to evaluate the outcome of psychotherapy. Meta-analytic reviews of research undertaken during the 1970s and 1980s indicated that patients who underwent treatment fared substantially better than untreated individuals (Lambert & Barley, 2001).

By the 1990s – the decade of the brain – the clinical interest in psychotherapeutic interventions and brain research led to rapid advances in neuroimaging. This technology allowed researchers to examine the relationship between psychotherapeutic interventions and changes in brain function post-therapy.

A number of studies have shown that psychotherapy induces structural changes to the brain and can alter activity in areas involved in self-referential thoughts, executive control, emotion, and fear (Luders et al., 2011).

For instance, CBT treatment of psychosis was assessed using a threatening facial expression task (Kumari et al., 2011). After treatment, patients exhibited decreased activation of the inferior frontal, insula, thalamus, putamen, and occipital – the network of brain regions involved in processing negative facial expressions.

Positron emission tomography studies indicated that psychotherapy can cause changes to the frontal-subcortical brain circuitry and assists in the mediation of obsessive-compulsive disorder. Porto et al, (2009) suggested that psychotherapy allows patients to experience a change in the affective value that they assign to stimuli, thus extinguishing responses to stimuli that had previously brought on compulsive behavior.

7 Interesting Facts and Statistics

The relationship between client and clinician has a significant impact on psychotherapy effectiveness. Research into the factors associated with therapeutic outcomes suggested that the therapeutic alliance explains 25-30% of the variance in psychotherapy outcomes (Horvath, Del Re, Flückiger, & Symonds, 2011).
Not all psychotherapy is created equally – there are over 550 treatments in use for children and adolescents alone (Kazdin, 2000). The majority of these have not been subjected to controlled investigation to ensure they can be applied to clinical practice.
Individuals who wait less than three months from assessment to treatment are almost 5 times more likely to report that psychotherapy was beneficial when compared to those waiting twelve months or longer (Mind, 2010).
Psychotherapy delivered in a routine care setting is generally as effective as psychotherapy delivered in clinical trials (Minami, Wampold, Serlin, Hamilton, Brown, & Kircher, 2008).
Krause & Orlinsky (1986) found that between 60-65% of people experienced significant symptomatic relief within one to seven psychotherapy sessions. This number increased to 70-75% after six months, and 85% at one year.
While psychotherapy primarily involves mutual discussion between a therapist and client, other methods may be used, for example, art, music, drama, and movement.
Cognitive behavioral therapy for depression was found to cause fewer adverse side effects such as insomnia, fatigue, restlessness than antidepressants (Kamenov, Twomey, Cabello, Prina, & Ayuso-Mateos, 2017).

How Can Touch Be Beneficial in Psychotherapy?

Therapeutic touch was first described by Willison & Masson (1986) as physical contact between the therapist and the hands, shoulders, legs, arms or upper back of their client. Although touch has been shown to be important for development and relationships, within psychotherapy it has the potential to both harm and heal.

Leijssen (2006) emphasized that therapeutic touch must always be for the client’s sake; what is desired by one may not be desired by another. For some, human-to-human contact is within their personal and cultural boundaries of what is acceptable and helps to create a connection with a therapist, for others touch is outside a therapist’s remit (Ford, 1993).

According to Nordmarken & Zur (2004), there are six types of touch frequently used in psychotherapy:

Ritualistic, socially accepted gestures for greeting or departure.
Consolation touch.
Reassuring touch.
Grounding or reorienting touch.
Touch intended to prevent a client from hurting self or others.
Corrective experience.

While therapeutic touch should be carefully considered, in the right context it can be hugely beneficial. Within the practice of body-oriented psychotherapy (BOP), for instance, different forms of touch are applied professionally as a method of re-shaping somatic memories and releasing associated psychological constraints (Totton, 2003).

With practice-based clinical evidence and a number of empirical studies pointing towards the efficacy of non-verbal intervention strategies, therapeutic touch provides a range of unique contributions to the treatment of mental disorders.

While touch in BOP is particularly suited to those with body-related psychopathologies, it is also relevant for disorders with limited treatment response to traditional psychotherapies, for instance, PTSD, anorexia nervosa or chronic schizophrenia (Rohricht, 2009).
Interpersonal touch has been found to alleviate existential concerns among individuals with low self-esteem while improving psychological well-being and confidence (Nuszbaum, Voss, & Klauer, 2014).
Therapeutic touch is linked to the release of neurochemicals that support bonding and reduce the experience of pain (Dunbar, 2010).
Touch can provide clients with a sense of safety. Eyckmans (2009) indicated that close proximity such as placing a hand on the arm of a client can be reassuring and soothing whilst also grounding them in the present moment.
Touch can encourage a sense of empowerment. Berensden (2017) suggested that for some clients a sense of control in defining and defending their personal boundaries has been thwarted in the wake of trauma. If unwanted touch had been imposed upon them in the past, being able to say ’no’ to a therapist’s invitation for touch without the negative consequences of punishment or rejection can in itself be reparative.

The Benefits of Psychotherapy for Depression

Neuroimaging, neuropsychiatric and brain stimulation studies of depression indicate the location of depression lies in multiple brain regions (Pandya, Altinay, Malone, & Anand, 2012).

It has been suggested that corticolimbic connectivity abnormalities are a primary cause of a number of psychiatric illnesses including depression and that psychotherapy can assist in the modulation of dysfunctional networks within the corticolimbic system (Leisman & Melillo, 2013).

The corticolimbic system consists of several brain regions that include:

The anterior cingulate cortex – processes emotional experiences at the conscious level and selective attentional responses. The anterior cingulate cortex is divided anatomically into dorsal (cognition) and ventral (emotion) components.

The ventromedial prefrontal cortex – plays a role in the inhibition of emotional responses, decision-making, and the processing of risk and fear.

The dorsolateral prefrontal cortex – involved in higher cognitive functions such as working memory, abstract reasoning, and inhibiting inappropriate responses

The amygdala – processes and regulates emotional responses to stimuli so that an individual may recognize similar events in the future.

The hippocampus – involved in spatial learning, memory, and behavioral regulation.

One potential cause for many of the core symptoms of depression – particularly those associated with negative emotional experiences – is inefficient cortical control over brain regions that respond to emotional stimuli. Psychotherapy has broadly been hypothesized to remediate these neural abnormalities and reduce symptoms by strengthening the cortical emotion regulatory processes.

Improved prefrontal cortex and cortical function lead to enhanced regulation over limbic regions, thereby constricting emotional reactions to negative stimuli (Pandya, Altinay, Malone, & Anand, 2012).

Goldapple et al, (2004) used functional neuroimaging in order to measure changes in limbic and paralimbic activity after CBT treatment in depressive patients. When compared to pharmaceutical treatment they found that patients who underwent CBT showed elevated activity in their hippocampus, parahippocampus, and dorsal cingulate – areas that play key roles in learning, memory, and cognition.

Conversely, those who received only pharmaceutical treatment showed less elevated activity in the same regions.

The neural mechanisms of psychodynamic psychotherapy (PDT) in relieving the symptoms of depression have also been indicated through neuroimaging. The metabolic activities within the amygdala, hippocampus, and dorsal prefrontal cortex in depressive patients after PDT become similar to that of ‘healthy’ people when patients are exposed to attachment-related stimuli (Buchheim et al, 2012).

A large and growing body of research implicates the ventromedial and dorsolateral sectors of the prefrontal cortex as key neural substrates underlying depression (Koenigs & Grafman, 2009).

The use of MRI technology to compare levels of brain activity in depressive individuals pre- and post-CBT identified increased activity within the dorsolateral prefrontal cortex, and decreased activity in the limbic system, particularly the amygdala (Höﬂich et al., 2012).

How Can We Go About Maximizing the Benefits?

Client-focused research has endeavored to improve psychotherapy outcomes, maximize the benefits and share this information to clinicians so as to better guide ongoing treatment.

Methods and clinical support tools have been developed to monitor progress and enhance the outcome for those receiving treatment, effectively bridging the gap between research and clinical practice (Lambert, 2001). So, how can we go about maximizing the benefits of psychotherapy?

Client Feedback

Client feedback serves as a method of monitoring progress during the therapeutic practice. Incorporating feedback may help to enhance practitioners’ decision‐making and allow for the adaptation of treatment plans. Feedback of this nature is especially useful in helping to identify potential deficiencies in ongoing treatment (Lambert, 2001).

Client feedback has demonstrated reductions in premature withdrawal from psychotherapy and improved outcomes. Results from a randomized clinical trial indicated that individuals in client feedback conditions demonstrated significantly more improvement compared to those receiving no feedback and that improvement occurred more rapidly (Reese, Toland, Slone, & Norsworthy, 2010).

The Therapeutic Working Alliance

The therapeutic alliance is more than the relationship between therapist and client. The quality of the client-therapist alliance is a reliable predictor of positive clinical outcome independent of psychotherapeutic approaches and outcome measures (Ardito & Rabellino, 2011).

Optimal therapeutic alliance is achieved when the client and clinician have a relationship of confidence and high regard. A client must believe in the abilities of the practitioner and the practitioner must be confident in the commitment of clients to achieving agreed objectives.

Bordin (1979) suggested that the alliance influences outcomes, not because it is healing in its own right, but as an element that enables the client to accept and believe in the treatment.

Goal Setting

Goal setting within psychotherapy will vary from client to client. At the onset of treatment, it is essential for the client to have a good understanding of what they are working towards and what to expect throughout the process (Fenn & Byrne, 2013).

A goal for a client with obsessive-compulsive disorder may be to reduce the time spent washing their hands from 5 hours per day to 1 hour per day by the end of three weeks of therapy. The practitioner can then help the client to prioritize these goals by breaking down a problem and creating a hierarchy of smaller goals (Fenn & Byrne, 2013).

Latham & Locke (1991) suggested that successful goal setting should adhere to key principles; these can also be applied to a therapeutic setting.

Both client and practitioner should be committed to attaining the goal
The goal should be specific
The goal should be challenging yet attainable
Feedback should be immediate and unambiguous

A Take-Home Message

Not all psychotherapeutic treatments are comparable in terms of proficiency and performance. However, when appropriate diagnoses are made and empirically supported treatments are undertaken, psychotherapy can be enormously beneficial in the treatment of a diverse range of psychological and physiological health issues.

While it’s no simple fix, psychotherapy can often bring clarity and peace of mind to those distressed by difficult events in their lives.

Exploring negative thoughts and emotions through psychotherapy and understanding the potential impacts they have on psychological health, can help reframe thoughts and behavior in order to improve mental health conditions.