“I have been working for several years now as a psychotherapist, and I find it important to work on the basis of the latest scientific evidence. But it happens quite often that I do an evidence-based treatment and the patient still does not improve. How is that possible with an evidence-based therapy? Maybe I am not such a good therapist after all?”
A widespread misunderstanding
It is a widespread misunderstanding among clinicians that evidence-based therapies should work in every patient. That is not only the case in mental health, but also in the broader biomedical field. The assumption is that when a therapy is evidence-based, it should in principle work for all, or almost all, patients.
If a patient does not improve, the clinician thinks that the therapy was not done as it should have been, that the manual was not followed properly. Or the therapist thinks that she or he did not follow the procedures well, or did not manage to make it work in the patient. It also happens a lot that when a therapy does not work, the therapist thinks the diagnosis was wrong, and that the whole diagnostic procedure should be started all over again. Maybe the wrong diagnosis was made, or an important comorbidity was missed.
The fact that a therapy is “evidence-based” certainly does not mean that all patients who get it recover.
What “evidence-based” actually means
Evidence-based just means that the effects of a therapy have been shown in well-designed effect studies, the so-called randomized controlled trials. In such studies, patients who receive a specific type of therapy are compared to patients who do not receive the therapy, or who receive an alternative therapy. If these studies show that patients receiving the therapy are substantially better off than those not receiving it, then this therapy is called “evidence-based”.
That certainly does not imply that every patient should get better from therapy. In fact, the number of patients who do not get better from evidence-based therapies is substantial.
How many patients actually respond?
One outcome measure that is often used in research is “response”. Response can be defined as a 50% reduction in symptoms from the start of therapy to the end. In a large study integrating the results of more than 400 randomized controlled trials, it was found that the response rate was 42% for people receiving an evidence-based therapy for depression. The rate for anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder was between 30 and 40%. In the control conditions, these percentages were much lower — between 5 and 19%, depending on the disorder.
These data show that evidence-based therapies certainly work, and that patients receiving therapy are much better off than those who did not get it.
However, there is also a large group who do not benefit, or not enough. And the therapies are still evidence-based.
What this means in practice
This has some important implications. First, it is important to be open with patients that therapies are helpful in many, but not all, cases. Patients can be lucky and get better during that first treatment. However, many patients will need another treatment, an extension of the current treatment, maybe they need medication in addition to therapy, or maybe they need to switch to another therapist. It is important that patients are aware of this reality, and that it is not because of them or the complexity of their case that a therapy may not work.
The other important implication is that when a patient does not respond to therapy, that is not because you are a bad therapist, did not do the therapy well, or because there is a mismatch between you and the patient. Of course that is always possible, but the fact that a patient does not respond is not evidence for it. The same is true of the diagnosis: it may be wrong, but it is more likely that the therapy simply did not work for this patient.
It is also important for you as a clinician to keep in mind that many patients will not respond to therapy, and that you need to consider next-step therapies, extension of therapies, or the addition of medication in such cases.
Pim Cuijpers is professor emeritus of clinical psychology and scientific director of Metapsy. He has been involved in more than 1,100 scientific studies, mostly on psychological treatments of mental health problems. This is one of a series of evidence summaries in which Prof. Cuijpers tries to answer questions from patients and clinicians, based on what is known in science about treatments. The knowledge is mostly drawn from collective work of the Metapsy collaboration of at least 15 years. Do you have other questions you would like Prof. Cuijpers to discuss? Feel free to contact us.
Literature
- Cuijpers P, Miguel C, Ciharova M, Harrer M, Basic D, Cristea IA, de Ponti N, Driessen E, Hamblen J, Larsen SE, Matbouriahi M, Papola D, Pauley D, Plessen CY, Pfund RA, Setkowski K, Schnurr PP, van Ballegooijen W, Wang Y, Riper H, van Straten A, Sijbrandij M, Furukawa TA, Karyotaki E. (2024). Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis. World Psychiatry, 23, 267–275. https://doi.org/10.1002/wps.21203
- Cuijpers P, Karyotaki E, Ciharova M, Miguel C, Noma H, Furukawa TA. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 144, 288–299. https://doi.org/10.1111/acps.13335