Preserving Access to Evidence-Based Therapy

At Psychotherapy Action Network, we applaud the effort of the World Health Organization (WHO) to broaden access to evidence-based psychotherapy. However, we are concerned that the WHO’s new Psychological Interventions Implementation Manual includes recommendations that predominantly endorse behavior therapy (BT) and cognitive-behavior therapy (CBT) techniques, for both adults and young people. This overlooks the significant evidence supporting other therapeutic approaches, including but not limited to psychodynamic therapy. It's likely that these guidelines will restrict access to those approaches by giving insurers, clinics, and policy makers a justification for denying coverage for all but the mostly short-term, structured and symptom-focused treatments.

With this letter, we ask the WHO to reconsider its guidelines approach and help preserve:

• Patients' right to choose a form of therapy that’s most useful to them.

• Clinicians' right to provide the form of therapy that’s most appropriate for each client and their unique circumstances.

• Evidence-based practice.

Evidence Showing the Efficacy of Psychodynamic Psychotherapy

There is strong evidence available showing support for psychodynamic therapy – see the summary below, and more complete details in this letter written by an international group of psychotherapy outcome researchers. We support the researchers in stating that a diversity of treatment options should be represented in WHO guidelines. This diversity of treatment options is necessary to treat a diversity of people around the globe: there is no one-size-fits-all across individuals, cultures, geographies. Moreover, there is strong evidence that psychodynamic therapy can lead to lasting results.

Summary of evidence for psychodynamic therapy:

• Strong recommendation for treatment of depressive, anxiety, somatoform, and personality disorders, both relieving symptoms and improving functioning, per the American Psychological Association’s updated criteria for empirically supported treatments;

• Superior efficacy of short-term psychodynamic therapy over CBT for the treatment of chronic pain;

• Efficacy for patients who did not respond to other treatments, including those suffering from treatment-resistant or chronic depression

• Reduction of suicide attempts and self-harm in both adults and adolescents;

• Treatment of childhood depression, per inclusion in the UK guidelines on childhood depression;

• PTSD, with particular focus on patients with severe personality disorders, who typically show a high prevalence of traumatic experiences.

Questions about Strength of Evidence for Behavior Therapy and Cognitive Behavior Therapy

Behavior therapy (BT) and cognitive-behavior therapy (CBT) should not be represented as the sole effective treatments for mental health disorders. While they unquestionably are effective for some patients, a number of independent analyses and meta-analyses of BT/CBT studies have raised significant questions about the strength of the evidence for these approaches which argue against their being represented as a “gold standard.”

In brief,

• There are fewer high-quality studies than previously presumed;

• Some treatments rated as having “strong” evidence do not show superior efficacy compared to those with “modest” evidence;The replicability and power estimates of many BT/CBT methods in the American Psychological Association’s database were found to be low;

• The effects of CBT in depressive and anxiety disorders are uncertain, with only a 50% success rate, and even lower remission rates; 

• High drop-out rates and low remission rates for PTSD:

  • 38.5% of Veterans treated in the American VA system with the recommended Exposure and Cognitive Processing therapy dropped out

  • Of those who completed treatment, only 31% recovered or improved.

  • Growing evidence suggests that non-exposure-based approaches may be at least as effective.

Our Recommendations

We strongly endorse the recommendation of the psychotherapy researchers, namely that:

• WHO should include psychodynamic therapies in its guidelines.

• WHO should add psychodynamic researchers and experts to its guidelines development group.

We ask that WHO adopt a more encompassing approach to its guidelines that includes evidence-based psychodynamically informed therapies among those it recommends. By embracing a broader array of empirically supported therapeutic methods, WHO can more effectively elevate the overall quality and efficacy of global mental health care.

Psychotherapy Action Network (PsiAN)

Linda L. Michaels, PsyD MBA
CoFounder, Chair
lindamichaels@psian.org

Janice R. Muhr, PhD
CoFounder, Board member
jrmuhr@psian.org