Recent evidence suggests its benefits are real but may be short-lived
Robin Bailey is a licensed counselor, cognitive behavioral psychotherapist, and senior lecturer at Britain’s University of Central Lancashire.
Mental health issues are a huge global problem.
The World Health Organization estimates that between 35% and 50% of people in developed countries suffer from anxiety or depression in any given year.
And the annual worldwide cost of treating these conditions is enormous — about 2 trillion dollars — so knowing what works and what doesn’t is critical.
Counseling goes under the microscope
Counseling is one of the most popular treatments for mental health problems.
The approach focuses on how patients view themselves, rather than — as in Freudian psychotherapy — how a therapist interprets their unconscious thoughts.
And — rather than telling them what to do, like an advice columnist — the counselor should help the patient find suitable personal solutions to their own problems.
This “humanistic” form of therapy emerged in the 1940s and is now one of the three most commonly used mental health treatments, along with cognitive behavioral therapy (CBT) and psychodynamic therapy.
However — despite its popularity and consistent evidence of its short-term efficacy for many people — counseling may not make them better in the long term.
Before getting to the results of recent studies, let’s set the background and define some terms.
What are counseling, CBT, and psychodynamic therapy?
There’s a good deal of confusion about the differences between various psychological “talk” therapies.
Broadly speaking, the most commonly used types appear comparably effective — but some aren't well suited to some conditions, making such mismatches of little value and/or potentially harmful.
And the effectiveness of a given therapy appears to depend on several factors:
- The patient's relationship with the therapist, which researchers call the "therapeutic" alliance".
- The patient's specific psychological problem, genetic profile, personality, health and nutrition status, and family history.
Sadly, diet/nutrition and physical fitness are often overlooked, despite being necessary therapeutic factors — although not typically sufficient, absent appropriate therapeutic interventions.
In fact, there’s ample evidence that omega-3 fatty acids (EPA and DHA), B vitamins, and other nutrients provide important — even critical — support for achieving optimal mental and mood health. (See the Omega-3s & Brain Health and the Foods & Brain Health sections of our news archive.)
Types of talk therapy run into the hundreds, but only four are widely used or prescribed:
- Behavior therapy — altering unhealthy behaviors.
- Cognitive-behavior therapy — altering maladaptive ways of thinking.
- Psychodynamic therapy — resolving unconscious conflicts and adverse childhood experiences).
- Interpersonal therapy — remedying unhealthy ways of interacting with others and helping clients to find their own solutions to problems.
Licensed counselors in these fields can also help detect more severe psychological problems and refer patients to psychiatrists, neurologists, and other specialists as needed.
Currently, Behavior Therapy and CBT enjoy modestly better clinical evidence of efficacy versus the two other, less commonly used forms — and they’re more widely covered by health insurance.
Let's look at how the top three therapies — whose goals and methods overlap — are typically defined:
Counseling focuses on how people function both personally and in their relationships.
A licensed psychological counselor helps patients address their emotional, social, work, school and physical health concerns, focusing on life stresses and more severe issues.
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy helps reveal inaccurate or negative thinking so that patients can view their circumstances and feelings more clearly and respond to them more effectively.
CBT can help treat depression, post-traumatic stress disorder (PTSD) or eating disorders — and help anyone better manage stressful life situations.
In psychodynamic psychotherapy — which grew out of classic Freudian psychotherapy — a therapist tries to help a patient view and understand their past and present relationships with others objectively and consider new ways to relate to people.
Mounting evidence finds counseling only effective in the short term
It appears that counseling may only be a short-term strategy for tackling mental health issues.
After nearly 80 years, only a small number of empirically robust studies exist, and findings indicate that long-term effectiveness is no better than a non-mental health-based intervention, such as seeing a GP.
Often researchers and practitioners of counseling argue that randomized control trials are too rigid and don’t truly reflect what happens in counseling practice.
That said, a UK study of 26,527 people with depression found that 53% showed no clinically significant improvement after receiving a course of counseling — although there was no long-term follow-up to see whether the minority who improved enjoyed sustained benefits.
If no long-term gains are made, patients will repeatedly relapse and require more rounds of treatment. Not only does this drain healthcare resources, it also diminishes patient hope.
And since there’s little evidence that counseling significantly improves patients’ work and family relationships, costly failure has wider personal and economic implications.
In 2003, British researchers reviewed clinical trials that had compared counseling with “usual care”: routine visits to a general practitioner (GP), cognitive behavioral therapy (CBT) and antidepressant drugs.
They concluded that, compared with “usual care”, counseling provides short-term, modest improvements in reducing anxiety and depression — but no long-term improvements (Bower P et al. 2003).
A more recent review from some of the same British researchers — who used the rigorous analytical standards of the Cochrane Collaboration — investigated whether counseling was effective for mental health and “psychosocial” problems or “problems in living” (Bower P et al. 2011).
Their analysis of nine trials showed that, in the short term (one to six months), counseling was more effective than “usual care”.
However, they concluded that, in the long term (seven to 36 months), counseling was no longer more effective than “usual care”.
They also concluded that counseling failed to improve patients’ short or long-term work, leisure activity, or family relationships.
Finally, the authors of the 2011 review found that counseling did not reduce overall health costs, and in some instances may have increased them.
The picture is the same for younger age groups. School children who received counseling for psychological distress fared better at six weeks than those on a waiting list for treatment. But at 12 weeks there was no real difference between the groups (Pybis J et al. 2017).
The "therapeutic alliance" matters to efficacy
Counseling works on the premise that the therapist must provide key conditions for a patient to achieve personality change: empathy, genuineness, and unconditional acceptance.
And there's good evidence that the personal connection between therapist and patient — the so-called "therapeutic alliance" matters more than the specific type of talk therapy.
For example, an analysis published in 2001 concluded that the strength of the bond between therapist and client accounts for about 7 percent of therapeutic effectiveness, while the specific type of talk therapy accounts for only about 1 percent.
They attributed most of the remaining 92 percent to other factors, including — possibly critically — the personalities of the therapist and client.
And earlier this year, an international research team experience in the field published an evidence review to confirm the results of several prior ones which found that the "alliance" or bond between therapist and patient is more important than the mode of talk therapy (Flückiger C et al. 2018).
The placebo effect is potent
As with drugs, the placebo effect of psychotherapy can be very substantial.
Several years ago, an international team reviewed the clinical evidence and came to this conclusion:
"For psychological disorders, particularly depression, it has been shown that pill placebos are nearly as effective as active medications whereas psychotherapies are more effective than psychological placebos. However, it is shown that when properly designed, psychological placebos are as effective as accepted psychotherapies." (Wampold BE et al. 2005)
Acupuncture versus counseling
A large randomized trial (755 participants) published five years ago compared acupuncture with counseling in the treatment of depression (MacPherson H et al. 2013).
Consistent with previous findings, both counseling and acupuncture showed small to moderate levels of effectiveness compared with usual care, up to six months after treatment.
But the effects of both treatments were no better than usual care at seven months and beyond.
A final note: Crisis debriefing looks worse than useless
The post-traumatic counseling that survivors of violence often get offered or seek is called crisis debriefing.
In such sessions, therapists urge survivors to recall their experience and the associated feelings soon after it.
But the available evidence suggests that crisis debriefing does more harm than good, as we reported in Post-Trauma Counseling? Thanks, but No Thanks.
More recently, Harvard University psychologists conducted a review of the evidence surrounding crisis debriefing intended to prevent or reduce post-traumatic stress symptoms.
And they concluded that crisis debriefing is at best ineffective and possibly damaging — probably because it upsets natural healing processes and more deeply embeds traumatic events in memory.
To learn about some potential dietary aids to blunting and/or easing PTSD, see Omega-3s May Ease Post-Traumatic Stress and Curcumin May Curb the Fearful Memories that Fuel PTSD.
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