How Do We Know When to Switch to a Different Psychotherapy Technique?

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Two commentaries in The Lancet Psychiatry discuss whether the evidence base for psychotherapies is really any better than it is for psychiatric medications, and what we know and don’t know about what patients should do when a specific type of psychotherapy doesn’t help them. What evidence base is there to guide switching from one type of treatment to another?

The Lancet Psychiatry. “Do We Need to Talk?” The Lancet Psychiatry 2, no. 2 (n.d.): 111. Accessed February 1, 2015. doi:10.1016/S2215-0366(15)00015-2. (Full text)

Markowitz, John C, and Barbara L Milrod. “What to Do When a Psychotherapy Fails.” The Lancet Psychiatry 2, no. 2 (February 2015): 186–90. doi:10.1016/S2215-0366(14)00119-9. (Excerpt)

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2 COMMENTS

  1. My guess: there is no better evidence base (how on Earth do you design “placebo” for this one or standarise it) and from all the evidence I’ve seen it seems clear that if you’re lucky and get to know a nice, friendly therapist with empathy and brains then you may benefit. Otherwise it’s just as useless. Nonetheless I still think psychotherapy, even though not without risks, is far better than drugs. Solely on less harm basis.

    • Agree 100%. The “side effect” profile from at least decent therapy is much lower and of shorter duration if you decide to stop. The question of an evidence base for ‘switching techniques’ is a red herring, in my opinion. The time to switch techniques is when the ones you are using aren’t having a positive effect from the client’s viewpoint. If a therapist is in good communication with his/her client, and is committed to empowering the client to gain more control and agency in his/her life, it will be obvious if they are being successful or not and that it may be time to change the approach.

      Bottom line, good therapy is not about techniques, but it’s about being present and emotionally available and creative and responsive to the needs of your client. There is no real training for that, except perhaps experiencing quality therapy yourself.

      I also agree that the odds of finding such a therapist on the first go round are very small. Folks need to shop around for a person who works well with them and with whom they feel comfortable. I’d say three quarters of the therapists out there are mediocre to poor, so don’t give up if the first one isn’t great, but don’t put up with half-assed therapy, either. It’s definitely “caveat emptor” in the psychotherapy realm, but luckily it doesn’t usually result in permanent brain damage. (Unless they refer you to a psychiatrist, of course, at which point it’s time to run!)

      — Steve