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Mental Health: Does therapy help?

Among our findings
Who went for help
The results: therapy work
Whom should you see?
What about doctors?  
The power of groups
Drugs, pro and con
How long will it take?

Coping with this serious physical illnesses hard enough. But if you're suffering from emotional or mental distress, it's particularly difficult to know where to get help. You may have some basic doubts about whether therapy will help at all. And even if you do decide to enter therapy, your health insurance may not cover it--or cover it well.

As a result, millions of Americans who might benefit from psychotherapy never even give it a try. More than 50 million American adults suffer from mental or addictive disorders and any given time. But a recent government survey showed that fewer than one-third of them get professional help.

That's a shame. The results of a candid, in-depth survey of CONSUMER REPORTS subscribers--the largest survey ever to query people on mental health care--provide convincing evidence that therapy can make an important difference. Four thousand of our readers who responded had sought help from a doctor for psychological problems, or had joined a self-help group. The majority were highly satisfied with the care they received. Most had made strides toward resolving the problems that lead to treatment, and almost all said life had become more manageable. This is true for all the conditions we ask about, even among the people who had felt the worst at the beginning.

Among our findings

  • People were just as satisfy and reported similar progress whether they saw a social worker, a psychologist, or psychiatrist. Those who consulted a marriage counselor, however, were somewhat less likely to feel they had been helped.
  • Readers who sought help from their family doctor tended to do well. But people who saw a mental health specialists for more than six months did much better.
  • Psychotherapy alone worked as well as psychotherapy combined with medication, like Prozac were Xanax. Most people who took drugs like those did feel they were helpful but they often reported negative side effects.
  • The longer people stayed in therapy, the more they improved. This suggest that limited mental health insurance coverage, and a new trend and health plans-emphasizing short-term therapy--may be misguided.
  • Most people who went to a self-help group were very satisfied with the experience and said they got better. People were especially grateful to Alcoholics Anonymous, and very loyal to that organization.

Our survey adds an important dimension to existing research in mental health. Most studies have started with people who have very specific, well-defined problems, who have been randomly assigned to a treatment or control group, and who have received carefully scripted therapy. Such studies have shown which techniques can help which problems but they aren't a realistic reflection of most patients' experiences.

Our survey, in contrast, is a unique look at what happens in real life, where problems are diverse and less well defined, and where some therapists try one technique after another until something works. The success of therapy under these real-life conditions has never before been well studied, says Martin Seligman, a former director of clinical training in psychology at the University of Pennsylvania and past president of the American Psychological Association's Division of clinical psychology.

Seligman, a consultant to our project, believes our readers' experiences send "a message of hope " for other people dealing with emotional problems.

Like other surveys, ours has several built-in limitations. Few of the people responding had a chronic, disabling conditions such as schizophrenia or manic depression. We asked readers about their past experiences, which can be less reliable than asking about the present. We may have sampled an unusually large number of people in long-term treatment. Finally our data comes from the reader's own perceptions, rather than from a clinicians assessment. However, other studies have shown that such self reports frequently agree with professionals clinical judgments.

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Who went for help

And in our 1994 Annual questionnaire, we asked readers about their experiences with emotional problems and their encounters with health-care providers and groups during the years 1991 to 1994. Like the average American outpatient client, the 4000 readers who said they had sought professional help were mostly well educated. Their median age was 46, and about half were women. However, they may be more amenable to therapy than most.

Many who went to a mental health specialists were in considerable pain at the time they enter treatment. Forty-three percent said their emotional state was either very poor (" I barely managed to deal with things ") or fairly poor (" life was usually pretty tough ").

Their reasons for seeking therapy included several classic emotional illnesses: depression, anxiety, panic, and phobias. Among the other reasons our readers' sought therapy: marriage or sexual problems, frequent low moods, problems with children, problems with jobs, grief, stress related ailments, and alcohol or drug-related problems.

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The results: therapy work

Our survey showed that therapy for mental health problems can have a substantial effect. Forty-four percent of people whose emotional state was " very poor" at the start of treatment said they now feel good. Another 43 percent who started out " fairly poor " also improved significantly, though somewhat less. Of course, some people probably would have gotten better without treatment, but the vast majority specifically said that therapy helped.

Most people reported they were helped with the specific problems that brought them to therapy, even when those problems were quite severe. Of those who started out as " very poor, " 54 percent said that treatment " made things a lot better, " while another one-third said it helped their problems to some extent. The same pattern of improvement held for just about every condition.

Overall, almost everyone who sought help experience some relief-- improvements that made them less troubled and their lives more pleasant. People who started out feeling the worst reported the most progress. Among people no longer in treatment, two-thirds said they'd left because their problems had been resolved or were easier to deal with.

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Whom should you see?

In this vast field of mental health, psychiatrists, psychologists, and clinical social workers have long fought for turf. Only psychiatrists, who are medical doctors, can prescribe drugs and have the training to detect medical problems that can affect a person's mental state. Otherwise, each of these professionals is trained to understand human behavior, to recognize problems, and to provide therapy.

Historically, social workers have been the underdogs and have had to fight for state laws requiring insurance companies to cover their services. But many of today's budget minded insurances favor social workers--and psychiatric nurses--because they offer relatively low-cost services.

In our survey, almost three-quarters of those seeking professional help went to mental health specialists. Their experiences suggest that any of these therapists can be very helpful. Psychiatrists, psychologists, and social workers received equally high marks and were praised for being supportive, insightful, and easy to confided in. That remained true even when we statistically controlled for the seriousness and type of the problem and the length of treatment.

Those who went to marriage counselors didn't do quite as well, and gave their counselors low grades for competence. One reason may be that working with a fractured couple is difficult. Also, almost anyone can hang out a shingle as a marriage counselor. In some states the title " marriage and family therapist " is restricted to those with the appropriate training. But anyone can use other words to say they do marriage therapy, and in most places the title " marriage counselor " is up for grabs.

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What about doctors?

Many people are more comfortable taking their problems to their family doctor then to a psychologist or psychiatrist. That may work well for some people, but our data suggest that many and would be better off with a psychotherapist.

Readers who exclusively saw their family doctor for emotional problems--about 14 percent of those in our survey--had a very different experience from those who consulted a mental health specialist. Treatment tended to be shorter; more than half of those whose care was complete had been treated for less than two months. People who went to family doctors were much more likely to get psychiatric drugs--83 percent of them did, compared with 20 percent of those who went to mental health specialists. And almost half the people whose doctors gave them drugs received medication without the benefit of much counseling.

The people who relied on their family doctors for help were less distraught at the outset than those who saw mental health providers; people with severe emotional problems apparently get themselves to a specialist. Even so, only half were highly satisfied with their family doctors treatment (compared with 62 percent who were highly satisfied with their mental health provider.) A significant minority felt their doctor had neither the time nor temperament to address emotional issues. In general, family doctors did help people get back on their feet--but long-term treatment with a specialist was more effective.

However, if you begin treatment with your family doctor, that's where you're likely to stay. Family doctors referred their patients to a mental health specialists in only one out of four cases, even when psychotherapy might have made a big difference. Only half of those who were severely distressed were sent on, and 60 percent of patients with panic disorder or phobias were never referred, even
though specific therapies are known to work for those problems.

Other research has shown that many family doctors have a poor track record when it comes to mental health. The failed to diagnose some 50 to 80 percent of psychological problems, and sometimes prescribed psychiatric drugs for too short a time or at doses too low to work.

The power of groups

He it was 60 years ago that the businessman and a physician, both struggling with alcoholism, realize they could stay sober by talking to one another. They talked to other Alcoholics, too, and eventually worked out the system of long-term recovery known as Alcoholics Anonymous, or AA. Today there are over a million active a AA members in the U.S., and attending an AA group is often
recommended as part of professional treatment. The format has also been adopted by dozens of other self-help groups representing a wide spectrum of dysfunctional behavior, from Gamblers Anonymous to Sex and Love addicts Anon. Support groups also bring together people who are dealing with medical
illness or other trials.

One-third of our survey respondents went to a group, often in addition to individual psychotherapy.

Do overall, they told us, the groups seemed to help.

Readers who went to AA voiced overwhelming approval. Virtually all endorsed AA's approach to treatment, and most said their struggle with addiction had been largely successful. In keeping with AA's principle that recovery is a lifelong process, three-quarters of our readers had been in the group for more than
two years, and most were still attending. Most of those who had dropped out said they'd moved on because their problems had improved.

Certainly, not everyone who goes to AA does as well; our sampling method probably over represented a long-term, and thus successful, AA members. Aa's own survey suggest that about half of those who come to the program were gone within 3 months. Studies that follow people who have undergone treatment for alcoholism find that AA is no more or less effective than other programs: A year after entering treatment, about half the participants are still in trouble.

Nevertheless, AA has several components that may maximize the chance of success. In general, most Alcoholics do well while they are being actively treated. In AA, members are supposed to attend 90 meetings in the first 90 days, followed by three meetings a week for life.

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Drugs, pro and con

for decades, drug therapy to treat problems such as depression and carried a raft of unpleasant, sometimes dangerous side effects. Then came Prozac (flouxetine), launched in 1988. Safer and easier to take than previous anti-depressant, Prozac and other drugs in its class--including sertraline (Zoloft) and paroxetine (Paxil)--have radically change the treatment of depression. Along the way, people have claimed that Prozac seems to relieve a growing list of other complaints--from eating disorders and shyness to, most recently, pre-menstral syndrome.

In our survey, 40 percent of readers who sought professional help received psychiatric drugs. And overall, about 60 percent of readers who took drugs said the medication help a lot.

However, many of our readers did well with psychotherapy alone; in fact, people who received only psychotherapy improved as much as those who got therapy plus drugs. For many people, having the option of talk therapy is important because every psychiatric drug has potential side effects that some individuals find hard to tolerate. Almost half of all our respondents on medication reported problems with the drug. Drowsiness and a feeling of disorientation were the most common complaints, especially among people taking the older anti-depressants such as amitriptyline (Elavil).

although the problems associated with psychiatric drugs are well known, 20 percent of readers said their provider never discussed with them--a disturbing lapse in communication. Equally disturbing was the findings of that 40 percent of the people taking antianxiety drugs had done so for more than a year--25%
for more than two years--even though long-term use results in habituation, requiring larger and larger doses.

Antianxiety medication such as Xanax and Valium can provide relief if used for a short time during a particularly stressful period, such as the death of a parent. But they have not been well tested for generalized anxiety--a kind of chronic, excessive worrying combined with physical and emotional symptoms--and therapists have found them only erratically effective.

Xanax is approved by the U.S. Food and Drug Administration for panic disorder, which causes repeated bouts of unbearable anxiety; studies show that it acts quickly to reduce panic attack. But after two months, Xanax apparently performs little better than a placebo. (see a Consumer Reports, January 1993.)
the reason many people take and anxiety drugs for so long is that they're extremely hard to kick; if the drug is stopped, symptoms return in full force.

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How long will it take?

Did when a person needs psychotherapy, how much do they need? That has become a critical question--both for clinicians and for the insurers that pay for therapy. And its a hard one to answer.

Nationally, most people who get therapy go for a relatively short time--an average of four to eight sessions. It's not clear, however, whether people stop going because they have been helped a enough, because they don't think that therapy is working, or because they've run out of money. Controlled studies of specific kinds of therapy in usually cover only 12 to 20 visits. While brief therapy often helps, there is no way to tell from such studies whether 30 or 40 sessions, or even more, would be the even more effective.

For the people in our survey, longer psychotherapy was associated with better outcomes. Among people who entered therapy with similar levels of emotional distress, those who stayed in treatment for more men than six months reported greater gains than those who left earlier. Our data suggest that for many people, even a year's worth of therapy with a mental health specialists may be very worthwhile. People who stayed in treatment for more than two years reported the best outcomes of all. However, these people tended to have started out with more serious problems.

we also found that people got better in three distinct ways, and that all three kinds of improvements increased with additional treatment.  First, therapy eased the problems that brought people to treatment. Second, it helped them to function better, improving their ability to relate well to others, to be productive at work, and to cope with everyday stress. And it enhanced what can be called " personal growth." People in therapy had more confidence and self-esteem, understood themselves better, and enjoyed life more.

Despite the potential benefit of long-term therapy, many insurance plans will limit mental health coverage to " medically necessary " Services--which typically means short-term treatment aimed at symptom relief. If you want to stay in therapy longer you may have to pay for it yourself.

Our findings complement recent work by psychologist Kenneth Howard of Northwestern University. By following the progress of 854 psychotherapy patients, Howard and his associates found that recovery followed a " dose-response " curve, with the greatest response occurring early on. On average, 50 percent of people recovered after 11 weekly therapy sessions, and 75% got better after about a year.

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emotional distress may not always require professional help. But when problems threaten to become overwhelming or interfere with everyday life, there is no need to feel defeated.

Our survey shows there's real help available from every quarter--family doctors, psychotherapists, and self-help groups. Both talk therapy and medication, when warranted, can bring relief to people with a wide range of problems and deep despair.

With such clear benefits to be had, the strict limits on insurance coverage for mental health care are cause for concern. As the debate over health care continues, we believe that improving mental health coverage is important.

If you want to see a therapist, you should approach therapy as an active consumer. In our survey, the more diligently a person " shopped " for a therapist--consulting with several candidates, checking their experience and qualifications, in speaking to previous clients--the more they ultimately improved. once in treatment, those who formed a real partnership with their therapists--by being open, even with painful subjects, and by working on issues between sessions--were more likely to progress.

When you look for a therapist, competence and personal chemistry should be your priorities. You'll be sharing your most intimate thought and feeling, so it's important to choose someone who puts you at ease.

Many people first consult their family doctor, who has already won their confidence and trust. If you decide to stay with your physician for treatment, bear in mind that the approach will probably be medically base of and relatively short.

If you would prefer to work with a therapist, ask your doctor for a referral.
Other good referral sources are national professional associations or their local or state chapters. For information or referral you can call the American Psychiatric Association, at 202 682-6220; the American Psychological Association, 202 336-5800; the National Association of Social Workers, 800 638-8799, extension 291; the American Association for Marriage and Family therapy, 800 374-2638; and the American Psychiatric Nurses Association, 202 857-1133. Also contact local universities, hospitals, and psychotherapy and psychoanalytic training institutes. For general information on mental illness, called the National Alliance for the Mentally Ill, 800 950-6264.

Family and friends may also know of reputable therapists; try to get several names to consider. Our readers who located therapists through personal or professional references felt better served than those who relied on adds, their managed-care company's roster, or local clinics.




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