The Primary Finding of Hans Eysencks 1952 Review of Psychotherapy Outcome Studies Was That
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[Classics Editor's note: The 1 footnote in this article has been enclosed in curly brackets, to distinguish it from the reference notes, which are enclosed in square brackets, as in the original.]
The recommendation of the Committee on Training in Clinical Psychology of the American Psychological Association regarding the training of clinical psychologists in the field of psychotherapy has been criticized by the writer in a serial of papers [10, xi, 12]. Of the arguments presented in favor of the policy advocated by the Committee, the nearly cogent 1 is mayhap that which refers to the social need for the skills possessed by the psychotherapist. In view of the importance of the bug involved, it seemed worth while to examine the evidence relating to the actual effects of psychotherapy, in an try to seek clarification on a point of fact.
Landis realized quite clearly that in club to evaluate the effectiveness of any form of therapy, data from a control group of nontreated patients would be required in lodge to compare the effects of therapy with the spontaneous remission rate. In the absenteeism of anything better, he used the amelioration rate in land mental hospitals for patients diagnosed under the heading of "neuroses." As he points out:
There are several objections to the use of the consolidated amelioration charge per unit . . . of the . . . state hospitals . . . as a base rate for spontaneous recovery. The fact that psychoneurotic cases are non usually committed to state hospitals unless in a very bad status; the relatively small number of voluntary patients in the group; the fact that such patients do become some degree of psychotherapy specially in the reception hospitals; and the probably quite different economic, educational, and social condition of the State Hospital group compared to the patients reported from each of the other hospitals - all argue against the acceptance of [this] figure . . . every bit a truly satisfactory base of operations line, simply in the absence of whatever other better effigy this must serve [26, p. 168].
Really the various figures quoted by Landis agree very well. The percentage of neurotic patients discharged annually as recovered or improved from New York country hospitals is 70 (for the years 1925-1934); for the U.s.a. as a whole it is 68 (for the years 1926 to 1933). The per centum of neurotics discharged equally recovered or improved within one twelvemonth of admission is 66 for the U.s.a. (1933) and 68 for New York (1914). The consolidated amelioration charge per unit of New York land hospitals, 1917-1934, is 72 per cent. Equally this is the effigy called past Landis, nosotros may accept it in preference to the other very similar ones quoted. Past and large, we may thus say that of astringent neurotics receiving in the main custodial care, and very little if any psychotherapy, over ii-thirds recovered or improved to a considerable extent. "Although this is not, strictly speaking, a bones figure for 'spontaneous' recovery, notwithstanding any therapeutic method must show an appreciably greater size than this to be seriously considered" [26, p. 160].
Another judge of the required "base line" is provided by Denker:
[p. 320] Five hundred consecutive disability claims due to psychoneurosis, treated by general practitioners throughout the state, and not by accredited specialists or sanatoria, were reviewed. All types of neurosis were included, and no attempt fabricated to differentiate the neurasthenic, anxiety, compulsive, hysteric, or other states, simply the greatest intendance was taken to eliminate the true psychotic or organic lesions which in the early on states of affliction so frequently simulate neurosis. These cases were taken consecutively from the files of the Equitable Life Assurance Lodge of the United states, were from all parts of the country, and all had been ill of a neurosis for at to the lowest degree three months earlier claims were submitted. They, therefore, could exist fairly called "severe," since they had been totally disabled for at least a 3 months' period, and rendered unable to carry on with any "occupation for remuneration or profit" for at to the lowest degree that time [9, p. 2164].
These patients were regularly seen and treated by their ain physicians with sedatives, tonics, proposition, and reassurance, only in no case was whatsoever attempt made at anything simply this most superficial type of "psychotherapy" which has always been the stock-in-trade of the general practitioner. Repeated statements, every three months or so by their physicians, as well as contained investigations by the insurance company, confirmed the fact that these people actually were not engaged in productive piece of work during the period of their illness. During their disablement, these cases received disability benefits. As Denker points out, "It is appreciated that this fact of disability income may have actually prolonged the total period of disability and acted as a bulwark to incentive for recovery. One would, therefore, not expect the therapeutic results in such a group of cases to be as favorable as in other groups where the economic gene might human activity every bit an important spur in helping the sick patient adjust to his neurotic conflict and illness" [9, p. 2165].
The cases were all followed upward for at least a 5-yr catamenia, and often equally long as 10 years after the period of inability had begun. The criteria of "recovery" used by Denker were every bit follows: (a) return to work, and ability to comport on well in economic adjustments for at to the lowest degree a five-twelvemonth period; (b) complaint of no further or very slight difficulties; (c) making of successful social adjustments. Using these criteria, which are very similar to those usually used by psychiatrists, Denker establish that 45 per cent of the patients recovered after one twelvemonth, another 27 per cent afterward ii years, making 72 per cent in all. Another 10 per cent, 5 per cent, and 4 per cent recovered during the 3rd, 4th, and fifth years, respectively, making a total of 90 per cent recoveries after five years.
This sample contrasts in many ways with that used by Landis. The cases on which Denker reports were probably non quite every bit severe as those summarized past Landis; they were all voluntary, nonhospitalized patients, and came from a much higher socioeconomic stratum. The majority of Denker's patients were clerical workers, executives, teachers, and professional men. In spite of these differences, the recovery figures for the 2 samples are almost identical. The most suitable figure to choose from those given past Denker is probably that for the two-year recovery rate, as follow-upward studies seldom get beyond two years and the higher figures for three-, four-, and v-year follow-up would overestimate the efficiency of this "base of operations line" procedure. Using, therefore, the 2-yr recovery figure of 72 per cent, we notice that Denker'south figure agrees exactly with that given by Landis. We may, therefore, conclude with some confidence that our estimate of some 2-thirds of severe neurotics showing recovery or considerable improvement without the benefit of systematic psychotherapy is not likely to be very far out.
A number of studies have been excluded because of such factors equally excessive inadequacy of follow-up, fractional duplication of cases with others included in our tabular array, failure to indicate type of treatment used, and other reasons which fabricated the results useless from our bespeak of view. Papers thus rejected are those by Thorley & Craske [37], Bennett and Semrad [p. 322] [2], H. I. Harris [19], Hardcastle [17], A. Harris [18], Jacobson and Wright [21], Friess and Nelson [14], Comroe [5], Wenger [38], Orbison [33], Coon and Raymond [half dozen], Denker [8], and Bond and Braceland [iii]. Their inclusion would not have contradistinct our conclusions to whatsoever considerable degree, although, as Miles et al. point out: "When the diverse studies are compared in terms of thoroughness, careful planning, strictness of criteria and objectivity, at that place is often an inverse correlation between these factors and the percentage of successful results reported" [31, p. 88].
Certain difficulties accept arisen from the inability of some writers to make their column figures agree with their totals, or to calculate percentages accurately. Again, the writer has exercised his judgment equally to which figures to accept. In certain cases, writers have given figures of cases where there was a recurrence of the disorder after credible cure or improvement, without indicating how many patients were affected in these ii groups respectively. All recurrences of this kind take been subtracted from the "cured" and "improved" totals, taking one-half from each. The total number of cases involved in all these adjustments is quite pocket-size. Another investigator making all decisions exactly in the reverse direction to the present author's would inappreciably alter the concluding percentage figures by more 1 or 2 per cent.
Nosotros may now turn to the figures as presented. Patients treated by means of psychoanalysis amend to the extent of 44 per cent; patients treated eclectically improve to the extent of 64 per cent; patients treated only custodially or by general practitioners meliorate to the extent of 72 per cent. There thus appears to exist an inverse correlation betwixt recovery and psychotherapy; the more psychotherapy, the smaller the recovery rate. This conclusion requires certain qualifications.
In our tabulation of psychoanalytic results, we take classed those who stopped treatment together with those non improved. This appears to exist reasonable; a patient who fails to finish his handling, and is not improved, is surely a therapeutic failure. The aforementioned rule has been followed with the data summarized under "eclectic" handling, except when the patient who did not finish treatment was definitely classified every bit "improved" by the therapist. All the same, in view of the peculiarities of Freudian procedures it may appear to some readers to be more just to course those cases separately, and bargain only with the percent of completed treatments which are successful. Approximately one-tertiary of the psychoanalytic patients listed broke off treatment, and so that the percent of successful treatments of patients who finished their course must be put at approximately 66 per cent. It would announced, so, that when we discount the adventure the patient runs of stopping treatment altogether, his chances of improvement nether psychoanalysis are approximately equal to his chances of improvement nether eclectic treatment, and slightly worse than his chances under a general practitioner or custodial treatment.
Two further points require clarification: (a) Are patients in our "control" groups (Landis and Denker) as seriously ill as those in our "experimental" groups? (b) Are standards of recovery maybe less stringent in our "control" than in our "experimental" groups? It is hard to answer these questions definitely, in view of the great divergence of opinion between psychiatrists. From a shut scrutiny of the literature information technology appears that the "control" patients were probably at least equally seriously sick as the "experimental" patients, and perhaps more than and then. As regards standards of recovery, those in Denker'due south written report are as stringent as virtually of those used by psychoanalysts and eclectic psychiatrists, but those used by the State Hospitals whose figures Landis quotes are very probably more lenient. In the absenteeism of agreed standards of severity of illness, or of extent of recovery, it is not possible to go further.
In full general, certain conclusions are possible from these data. They neglect to testify that psychotherapy, Freudian or otherwise, facilitates the recovery of neurotic patients. They bear witness that roughly two-thirds of a group of neurotic patients will recover or improve to a marked extent inside about ii years of the onset of their disease, whether they are treated by means of psychotherapy or not. This figure appears to be remarkably stable from one investigation to another, regardless of blazon of patient treated, standard of recovery employed, or method of [p. 323] therapy used. From the bespeak of view of the neurotic, these figures are encouraging; from the point of view of the psychotherapist, they tin can inappreciably be called very favorable to his claims.
The figures quoted do non necessarily disprove the possibility of therapeutic effectiveness. There are obvious shortcomings in whatever actuarial comparison and these shortcomings are especially serious when at that place is so petty agreement among psychiatrists relating even to the about cardinal concepts and definitions. Definite proof would require a special investigation, carefully planned and methodologically more adequate than these ad hoc comparisons. Merely even the much more pocket-sized conclusions that the figures fail to evidence whatsoever favorable effects of psychotherapy should give pause to those who would wish to give an of import part in the grooming of clinical psychologists to a skill the existence and effectiveness of which is all the same unsupported by any scientifically acceptable bear witness.
These results and conclusions will no dubiety contradict the strong feeling of usefulness and therapeutic success which many psychiatrists and clinical psychologists concord. While it is true that subjective feelings of this type have no identify in science, they are likely to prevent an easy acceptance of the full general argument presented hither. This contradiction between objective fact and subjective certainty has been remarked on in other connections by Kelly and Fiske, who found that "I aspect of our findings is almost disconcerting to us: the inverse human relationship betwixt the conviction of staff members at the time of making a prediction and the measured validity of that prediction. Why is is, for case, that our staff members tended to make their best predictions at a time when they subjectively felt relatively unacquainted with the candidate, when they had constructed no systematic picture of his personality structure? Or conversely, why is information technology that with increasing confidence in clinical judgment . . . nosotros find decreasing validities of predictions?" [23, p. 406].
In the absence of agreement between fact and conventionalities, there is urgent need for a decrease in the strength of belief, and for an increase in the number of facts bachelor. Until such facts as may be discovered in a process of rigorous analysis back up the prevalent belief in therapeutic effectiveness of psychological handling, it seems premature to insist on the inclusion of grooming in such handling in the curriculum of the clinical psychologist.
Received January 23, 1952 [sic].
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