Efficacy and Cost-Effectiveness of Psychotherapy

The title of this collection of essays, edited by David Spiegel, does not fully capture the breadth and richness of their content. The efficacy and cost-effectiveness of psychotherapy is a timely topic that most of the chapters address to some degree. In addition, material about the nature of psychotherapy itself helps to define what has been studied.

The efficacy of a particular treatment for an illness is only one dimension of the relevant data. Equally important is its effectiveness: its broader impact on physical health and mental suffering, capacity for relationships, and function in the family and the workplace. Much sought after in today's economics-driven environment is cost-effectiveness—the value of gains from a treatment relative to costs in money, time, and emotional effort.

This volume deals with both efficacy and cost-effectiveness. It concentrates on posttraumatic stress disorder, psychosis, borderline personality disorder, depression, and psychiatric aspects of general medical illness, particularly cancer. The chapters that most directly and successfully address the stated topic are those by Gabbard and Lazar on borderline personality disorder, Hersh and Lazar on depression, Foa and Jaycox on the cognitive-behavioral treatment of posttraumtic stress disorder, and Spiegel on cancer patients. Their data are well presented, well referenced, and impressive.

The reader who wants more can consult the comprehensive, systematic, and critical review of efficacy research on psychotherapy by Roth and Fonagy (1) and the extensive review of efficacy, effectiveness, and cost-effectiveness data on psychoanalytic psychotherapies edited by Lazar (2).

The broader scope of Efficacy and Cost-Effectiveness of Psychotherapy gives the reader a rationale for how psychotherapy works. It reflects the tension between specificity and integration of psychotherapeutic approaches. On the one hand, systematic application of a coherent, specific method of psychotherapy, such as psychodynamic, cognitive-behavioral, or interpersonal therapy, may achieve maximum effect. On the other hand, tailoring psychotherapy to the needs of each patient may require integrating techniques developed by disparate schools of therapy. (Elsewhere Beitman and Yue [3] offer a highly developed curriculum that identifies and teaches the common elements of all established psychotherapies to beginning residents.)

The book opens with Horowitz' configurational analysis method of case formulation, integrating the spectrum of psychotherapies and richly illustrated with case material. Later, van der Kolk and associates present a synthesized approach to posttraumatic stress disorder. They draw on psychodynamic, behavioral, and cognitive elements, as does Spiegel in work with cancer patients, in which group psychotherapy may have particular value.

Specific modes of treatment are elaborated in other parts of the book. Foa and Jaycox give a concise overview of cognitive and behavioral techniques for treating posttraumatic stress disorder. Munich offers the reader a practical and systematic perspective on a wide range of psychoanalytically derived approaches to working with severely ill patients. Youakim and Thompson discuss psychotherapy of the medically ill from a predominantly psychodynamic perspective. All of these presentations are clear and informative, although they could benefit from case examples to illustrate principles and concepts.

This book is both a good entrée to the literature on efficacy and cost-effectiveness and a stimulating exercise in integrative thinking about psychotherapy.