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Editorial: Evaluation of psychotherapy

Of all forms of treatment, in all of medicine, psychotherapy is perhaps the hardest to comprehend. In its most extensive meaning, its history is as old, and its scope as wide, as medicine itself, and it is practised with more or less awareness by all doctors. The concept is difficult to elucidate at this level; and though most would regard its importance as self-evident, it is not susceptible to rigorous evaluation except perhaps in those limited situations where automation precludes the inevitability of a doctorpatient relationship. In a stricter sense, psychotherapy comprises an assemblage of methods and skills, important in helping patients whose illnesses have evident psychological causes and manifestations, which can be designated— rather unsatisfactorily—as the directive and supportive psychotherapies. These methods, closely interwoven into general psychiatric practice, lay emphasis on the painstaking application of such imponderables as friendly interest, concern, sensitivity and responsiveness to the patient's feelings, empathy, informed judgment, reflective advice, practical suggestions, and manifest respect for the patient's individuality. Their value in principle seems clear enough. Although these and similar variables can be studied, and to some extent measured and manipulated in clinical research, their absolute withdrawal for experimental purposes would generally be unethical. In its third, and most restricted usage, psychotherapy denotes highly developed and skilled psychological techniques for treating certain patients with specified disabilities. Behavioural therapies can be included under this heading. So are formal, analytic or 'dynamic' psychotherapies—the adjectives are here used synonymously—which are practised mainly by those with a special training, often involving a personal psychoanalysis. The techniques of dynamic psychotherapy, like those of behaviour therapy, are based on theoretical postulates and directed towards helping defined groups of patients; they are specific forms of treatment and, therefore, their effectiveness should be demonstrable. These three domains of psychotherapy, each distinguished from the others by the context in which it is practised and by its manifest purpose, share much common ground. Transactions between doctors and patients—like all but the most casual of relationships—have always been affected, in conspicuous or hidden ways, by those beliefs and attitudes which are fashionable in a society. And the contemporary climate of opinion in most Western societies has been deeply influenced by the emergence of psychoanalysis as a model or metaphor for understanding human experience, relationships, development, and behaviour. Partly as a consequence of this, two claims are made for the relevance of modern psychodynamic concepts to medicine. One is that they have a very wide significance in the management of patients, and therefore a large value in medical education. According to this idea, the practice of medicine in general, and psychiatry in particular, makes demands on certain important qualities of the practitioners. These qualities, it is suggested, can be communicated, evoked or facilitated during training, specifically by exposure to specialized teaching in psychodynamics, and by this means alone. The other claim is that dynamic psychotherapy is an effective and important specific treatment for certain patients. Both claims are so far-reaching as to call for close and dispassionate study. The need for careful examination of these intricate matters becomes even more clamant when seen in the light of developments in undergraduate medical education, postgraduate education in psychiatry, and in the planning of psychiatric services. In evaluating dynamic psychotherapy, five questions are at issue. Do patients chosen for this type of treatment fare better than they would if treated differently? What components of treatment determine its effectiveness? What proportion of patients with defined forms of