The Consumer Reports Study
Martin E. P. Seligman
University of Pennsylvania
Abstract. Consumer Reports (1995, November) published an article which concluded that patients benefited very substantially from psychotherapy, that long-term treatment did considerably better than short-term treatment, and that psychotherapy alone did not differ in effectiveness from medication plus psychotherapy. Furthermore, no specific modality of psychotherapy did better than any other for any disorder; psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters; and all did better than marriage counselors and long-term family doctoring. Patients whose length of therapy or choice of therapist was limited by insurance or managed care did worse. The methodological virtues and drawbacks of this large-scale survey are examined and contrasted with the more traditional efficacy study, in which patients are randomized into a manualized, fixed duration treatment or into control groups. I conclude that the Consumer Reports survey complements the efficacy method, and that the best features of these two methods can be combined into a more ideal method that will best provide empirical validation of psychotherapy.
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There were a number of clear-cut results, among them:
- Treatment by a mental health professional usually worked. Most respondents got a lot better.
- Averaged over all mental health professionals, of the 426 people who were feeling very poor when they began therapy, 87% were feeling very good, good, or at least so-so by the time of the survey. Of the 786 people who were feeling fairly poor at the outset, 92% were feeling very good, good, or at least so-so by the time of the survey. These findings converge with meta-analyses of efficacy (Lipsey & Wilson, 1993; Shapiro & Shapiro, 1982; Smith, Miller, & Glass, 1980).
- Long-term therapy produced more improvement than short-term therapy. This result was very robust, and held up over all statistical models. Figure 1 plots the overall rating (on the 0–300 scale defined above) of improvement as a function of length of treatment. This "dose–response curve" held for patients in both psychotherapy alone and in psychotherapy plus medication (see Howard, Kopta, Krause, & Orlinsky, 1986, for parallel dose–response findings for psychotherapy).
- There was no difference between psychotherapy alone and psychotherapy plus medication for any disorder (very few respondents reported that they had medication with no psychotherapy at all).
- While all mental health professionals appeared to help their patients, psychologists, psychiatrists, and social workers did equally well and better than marriage counselors. Their patients' overall improvement scores (0–300 scale) were 220, 226, 225 (not significantly different from each other), and 208 (significantly worse than the first three), respectively.
- Family doctors did just as well as mental health professionals in the short term, but worse in the long term. Some patients saw both family doctors and mental health professionals, and those who saw both had more severe problems. For patients who relied solely on family doctors, their overall improvement scores when treated for up to six months was 213, and it remained at that level (212) for those treated longer than six months. In contrast, the overall improvement scores for patients of mental health professionals was 211 up to six months, but climbed to 232 when treatment went on for more than six months. The advantages of long-term treatment by a mental health professional held not only for the specific problems that led to treatment, but for a variety of general functioning scores as well: ability to relate to others, coping with everyday stress, enjoying life more, personal growth and understanding, self-esteem and confidence.
- Alcoholics Anonymous (AA) did especially well, with an average improvement score of 251, significantly bettering mental health professionals. People who went to non-AA groups had less severe problems and did not do as well as those who went to AA (average score = 215).
- Active shoppers and active clients did better in treatment than passive recipients (determined by responses to "Was it mostly your idea to seek therapy? When choosing this therapist, did you discuss qualifications, therapist's experience, discuss frequency, duration, and cost, speak to someone who was treated by this therapist, check out other therapists? During therapy, did you try to be as open as possible, ask for explanation of diagnosis and unclear terms, do homework, not cancel sessions often, discuss negative feelings toward therapist?").
- No specific modality of psychotherapy did any better than any other for any problem. These results confirm the "dodo bird" hypothesis, that all forms of psychotherapies do about equally well (Luborsky, Singer, & Luborsky, 1975). They come as a rude shock to efficacy researchers, since the main theme of efficacy studies has been the demonstration of the usefulness of specific techniques for specific disorders.
- Respondents whose choice of therapist or duration of care was limited by their insurance coverage did worse, as presented in Table 1 (determined by responses to "Did limitations on your insurance coverage affect any of the following choices you made? Type of therapist I chose; How often I met with my therapist; How long I stayed in therapy").
These findings are obviously important, and some of them could not be included in the original CR article because of space limitations. Some of these findings were quite contrary to what I expected, but it is not my intention to discuss their substance here. Rather, I want to explore the methodological adequacy of this survey. My underlying questions are "Should we believe the findings?" and "Can the method be improved to give more authoritative answers?"
http://horan.asu.edu/cpy702readings/seligman/seligman.html
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