Health: What's so special about psychotherapy?

It may be good to talk - but it makes no difference who's listening, a new study shows. Jeremy Laurence reports.

These are difficult times for psychotherapists. They may be feeling in need of a little post-traumatic stress disorder counselling. For research is accumulating showing that the talking cures they peddle are no better than traditional GP care.

The evidence is far from conclusive and there are good reasons why, instead of being downcast, therapists should take heart. But the findings are significant, they are a set back and they cannot be ignored. Too many counsellors and therapists are inclined to dismiss criticism as evidence of professional rivalry or deep-seated hostility rather than taking a clear-eyed look at the way forward.

The latest study, by psychiatrists at the Royal Free Hospital, London, suggests that the success of the talking cure lies in the talking - not in who you talk to.

They compared two groups of about 70 patients, most with depression, who were given either up to 12 sessions of psychotherapy or routine GP care. They all improved significantly over nine months but there were no differences between the groups. Psychotherapy, in other words, is no more effective than chatting with your GP.

At least a third of general practices offer counselling or therapy to help patients with emotional difficulties and thousands of therapists offer their services privately. The number of organisations offering training for counsellors has risen from 76 in 1990 to 545 in 1997, and the number of trained counsellors is estimated to run into tens of thousands. More than 100,000 people are estimated to be "in therapy" of one kind or another but the boom has happened in the absence of hard evidence that it works.

In a commentary on the findings of the latest study, published in The Lancet last week, Dr Andre Tylee, a GP and lecturer on mental health at the Institute of Psychiatry, says that the study provides "compelling evidence" that the psychotherapy offered by a counsellor is no better than the sympathetic ear offered by the GP.

This was the broad conclusion of a controversial report by the NHS Centre for Reviews and Dissemination at the University of York in August which concluded that counselling of the sort offered to people undergoing divorce, bereavement or redundancy was useless when practised on its own.

That report was based on a review of existing research and was sent round the NHS by the centre, which is funded by the health department, to encourage best practice. It said the technique "has not been shown to produce sustained benefit in a variety of groups at risk". The finding was immediately challenged by the British Association of Counsellors who said it was "unduly negative".

An earlier review by the Australian psychiatrist, Professor Gavin Andrews, published in the British Journal of Psychiatry in 1993, reached similar conclusions. It said no trial had shown psychotherapy to be better than placebo in effecting recovery and the treatment was more expensive and carried greater risks than ordinary GP care. There is an important caveat to be added to this catalogue of gloom. Whatever the results of therapy, patients like it. It is hugely popular.

Professor Michael King and colleagues, who conducted the study at the Royal Free Hospital, noted that although patients treated by psychotherapists did no better than the rest, they were happier with their treatment. This suggests that were it provided privately, patients might still be prepared to pay for it, despite the lack of evidence of efficacy.

GPs like it, too - and for the same reasons. As one doctor put it: "I know there is no evidence that it works but my patients want it, there is nothing I can do for them, it is relatively cheap to provide and it's harmless."

There is a further caveat. If psychotherapy and counselling as presently practised work no better than traditional forms of care, it may be possible to refine them so that they do. The NHS Centre for Reviews report says: "More attention needs to be given to the content and effectiveness of specific forms of counselling and the skills of counsellors before this approach is extended too widely."

There is a parallel here with the development of drug treatments. Several decades ago, the dried and powdered leaves of the wild foxglove were found to be an effective treatment for heart trouble. But the effect was not consistent - some patients got better and others did not. Only when the active constituent, digoxin, was isolated and prescribed did doctors begin to get consistent results.

Similar efforts are being made to refine and develop aspects of psychotherapy to improve results. One promising avenue has been the development of cognitive therapy - the training technique that seeks to correct destructive ways of thinking - for which there is evidence of efficacy. But as the latest research shows, there is much still to be done.