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Cybertherapy, placebos and the dodo effect: Why psychotherapies never get better

The views expressed are those of the author and are not necessarily those of Scientific American.

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When the media report on a new diet that supposedly helps people lose weight once and for all, I wonder, "Does anyone still believe these claims, given the dismal track record of diets?" I have the same reaction to new treatments for psychological disorders, such as "cybertherapy."

In a long, lavishly illustrated article in The New York Times, Benedict Carey reported that psychotherapists are harnessing virtual reality for treating social anxiety disorder, alcoholism, agoraphobia, gambling addiction, post-traumatic stress disorder and a host of other mental ailments. Therapists can, in effect, place an alcoholic in a bar, an acrophobe in a rooftop party and someone who fears public speaking in front of a large, restless audience. They then can manipulate the virtual environment to test patients’ ability to cope with different situations.

Patients can also discuss their troubles with a virtual therapist, relying on voice recognition and artificial intelligence software to parse remarks and respond appropriately. The therapist can take any form—male, female, black, white, young, old. The virtual therapist is a souped-up version of Eliza, an automated therapist that was created at the Massachusetts Institute of Technology in the 1960s and communicated via typed messages. 

The U.S. Army is spending $4 million a year on research into cybertherapy for traumatized veterans, according to the Times. In a program developed at the University of Southern California, veterans roll through a virtual Iraqi village in a Humvee, which is attacked by bullets and bombs. The Army’s interest in cybertherapy evokes a certain cognitive dissonance because the military also employs virtual reality to prepare soldiers—from ground troops to pilots—for combat.

Cybertherapy sounds fascinating, and fun, but does it work? The Times story addresses this crucial question in its 31st paragraph. Researchers at the University of Quebec compared patients who received conventional talk therapy with others who got cybertherapy. "Both groups showed improvement, faring much better than a comparison group put on a waiting list," the Times reported.

So cybertherapy is about as effective—or ineffective—as more conventional talk therapy. This finding confirms the so-called dodo effect, which was originally proposed by the psychologist Saul Rosenzweig in the 1930s, when psychoanalysis was spawning a host of variants. He speculated that all talking cures share certain common factors—such as a caring therapist who establishes a bond with the patient—that make them equally helpful.

"Dodo" refers to an episode in Lewis Carroll’s fable Alice’s Adventures in Wonderland in which Alice and other characters wash up onto an island. There they encounter a dodo bird who persuades them to race around the island. The dodo finally announces that the race is over and proclaims, "Everyone has won, and all must have prizes!"

Over the last few decades, the psychologist Lester Luborsky of the University of Pennsylvania tested the dodo effect by comparing different psychotherapies, including psychoanalysis, cognitive-behavioral therapy and interpersonal therapy. His research confirmed that all methods are equally helpful to patients. Claims that one therapy is more effective than others, Luborsky showed, can usually be explained by the "allegiance effect," the tendency of researchers to find evidence for the therapy that they practice or favor.

Ironically, Luborsky, who died in 2009, displayed the allegiance effect himself. He strongly defended the value of psychotherapy in general and psychodynamic therapy in particular; psychodynamic therapy is a watered-down form of psychoanalysis that Luborsky favored in his clinical practice.

Other prominent researchers—notably Jerome Frank, a psychiatrist at Johns Hopkins—realized that the dodo effect undermined the validity of all psychotherapies. Frank’s own research corroborated the dodo effect. In one study, he and colleagues provided depressed patients with three treatments: weekly individual therapy, weekly group therapy and minimal individual therapy, which consisted of just one half-hour session every two weeks. "To our astonishment and chagrin, patients in all three conditions showed the same average relief of symptoms," Frank wrote in Persuasion and Healing: A Comparative Study of Psychotherapy, first published in 1961 by Johns Hopkins Press and reissued in 1993.

Frank asserted that "relief of anxiety and depression in psychiatric outpatients by psychotherapy closely resembles the placebo response, suggesting that the same factors may be involved." The specific theoretical framework within which therapists work has little or nothing to do with their ability to "heal" patients, Frank contended. The most important factor is the therapist’s ability to persuade patients that they will improve.

Frank’s view should disturb anyone who thinks psychotherapy has a scientific basis. It doesn’t matter whether your therapist is a Jungian, cognitive behaviorist, witch doctor—or a cybertherapist that exists only in a computer. What matters is whether you believe you will get better.

If talk therapy is really just a form of faith healing, should we abandon it and rely only on psychopharmacology for treating disorders such as depression and anxiety? Not necessarily. As Sharon Begley, one of my favorite science writers, pointed out in Newsweek in January, the placebo effect—and the allegiance effect—may also account for the reported benefits of antidepressants. All are losers, and none must have prizes.

Image of Sigmund Freud courtesy of Wiki Commons.

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  1. 1. OneEye 4:09 pm 11/29/2010

    Okay, so I’m a fundamental Christian and a creationist – not your run-of-the-mill Scientific American reader. And many of the writers for and articles in SciAm have me gritting my teeth. But I just may be turning into a John Horgan fan.

    Those of us who have for years been subjected to the prejudicial polemics of self-styled "skeptics" have been waiting for Mr. Horgan – a man who will be skeptical about even the scientistic sacred cows – to come along.

    I’m sure that Mr. Horgan and I could find plenty of substance to disagree about. But for now, I can only say, "Bravo, Mr. Horgan!" Keep on being skeptical about the things that no other "skeptic" dares to be!

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  2. 2. Marc Lévesque 5:43 pm 11/29/2010

    The placebo, alligiance, or "What matters is whether you believe you will get better" effect works.

    Its probably been said but I think the "placebo effect" is hooking into a "natural" bio-social mechanism necessary to human’s health. Meaning all therapies get the prize but a better understanding of the mechanism and how it can go wrong would greatly help average recovery rates and reduce side effects.

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  3. 3. Marc Lévesque 6:27 pm 11/30/2010

    Correction to my previous comment:

    The placebo, alligiance, *anti-depressant*, or "What matters is whether you believe you will get better" effect works.

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  4. 4. henrykaminer 11:25 pm 11/30/2010

    let us not degenerate into polemics about this. therapy for psychologic conditions is like any therapy for any medical condition- the body/mind exists in a dynamic homeostasis and various external or internal factors can disturb this, resulting in pathology or "malfunction". Therapies, from surgery to pills to talking cures all try to allow the body’s own natural processes to heal the disruption and then proceed with normal living. Even surgery depends on the fibroblast cells to heal the incision after the defective tissue is removed, and then the body resumes its normal functioning. anything that allows the mind to come out of the funk of despair and anxiety caused by any number of things, intrinsic, extrinsic, chemicals legal and illegal, past traumas, brain disease, etc, will be helpful. when the mind goes into a funk (I like that concept) all sorts of chemical and neurological events spiral downhill- the hypothalamo-pituitary-adrenocortical axis goes into overtime, the cortisol levels wreak havoc with the hippocampus and the amygdala, and all hell breaks loose. any situation which restores the person to a calmer more optimistic attitude can be restorative, and the mind/body starts to reverse this pathological process. unfortunately, most people who are in a mind funk are too far gone to be helped by a friendly bartender or even a friendly friend or relative- a trained person who will not get trapped in the inappropriate reactions of the patient is needed. forget what they claim is their theory. fi it works, that does not mean their theory is the curative factor. a lot more goes on beyond the narrow dictates of the theories, and the similarities are grater than the differences. and the process is not trivial! do not minimize or scorn it and do not call it "placebo" because it is a real therapy and has a real impact. "placebo" implies a "sugar pill" which has no possible effect beyond tricking a self-deluding person. that is insulting nonsense to the patient and to the therapist. enough for one post. henry akminer md

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  5. 5. GreenMind 6:51 pm 12/1/2010

    John Horgan assumes his conclusion in his title, "Why Psychotherapies don’t get any better," without ever giving any data showing that psychotherapies don’t get any better. The New York Times article he cites says that psychotherapists have been using virtual scenarios to help clients deal with anxiety and other specific conditions, and that it helps. I would like to refer him to the article from Scientific American Mind last month about research comparing Cognitive Behavioral Therapy with Psychodynamic Therapy. It says that psychodynamic therapy provides more and longer lasting effects, and that even CBT is effective in proportion to how much a therapist goes beyond CBT to use psychodynamic techniques. There are indeed differences between therapies.

    Despite Mr. Horgan’s obvious contempt for the whole field of Mental Health, I actually agree with him to a certain extent, and that is that some theories of psychotherapy are no better than placebo. For example, traditional Freudian psychoanalysis actively avoids creating a bond between the therapist and the client, resulting in clients who have deeply analyzed the roots of their unhappiness, and yet are just as unhappy after years of paying high fees. There was an article in The New Yorker magazine recently by a woman who recounted her decades of expensive, time consuming, and useless psychoanalysis, and yet she still has hope for happiness someday. Yet other forms of therapy are much more effective, so it is not just the placebo effect that makes the difference. My life has been utterly transformed by therapy, and I know many others who say the same. Somehow I doubt that Mr. Horgan has ever had a close encounter with any therapist, let alone a good one.

    Much of the improvement in therapy has happened in the 50 years since Dr. Frank did his fascinating research. Is it asking too much for Mr. Horgan to look at some more recent research before dismissing all of clinical psychology as faith healing?

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  6. 6. Dr. Paradox 11:47 am 12/2/2010

    It does beg the question… What is ‘belief’, relative to other aspects of conscious experience, that makes it such a powerful predictor of the success of various medical/psychological interventions?

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  7. 7. Michael E. 6:24 pm 12/2/2010

    Kudos to John Hogan

    I have discovered this applies hypno-healing as well. The state of the art is in the practitioner and not in their techniques.

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  8. 8. Michael E. 6:27 pm 12/2/2010

    Oops- Apologies for the typos – My mouse was drunk…

    Kudos to John Horgan!

    I have discovered this applies to hypno-healing as well. The state of the art is in the practitioner and not in their techniques.

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  9. 9. skiprizzo 12:24 am 12/5/2010

    Thank you GreenMind for this thoughtful reply! For a while I thought I was the only one that thought the only "dodo" in this piece was Horgan himself! His position is based on such a selective presentation of the evidence that one needs look no further than what he selectively reported from the actual NY Times piece. He goes on to point out that in paragraph 31 that cybertherapy was no better than real therapy and leaves out what followed that first clause: "…Both groups showed improvement, faring much better than a comparison group put on a waiting list, preliminary results suggest. But those who got virtual therapy achieved the same gains without having to practice interactions in the real world, deliberately putting themselves in embarrassing situations or dreaded encounters. The researchers are now working to identify which people benefit most, and whether combining virtual and real-world experiences accelerates recovery." He also discounted some of my own work mentioned in the piece regarding a virtual healthcare guide that we are developing called SimCoach by making a comparison to the Eliza program from decades ago. If he was an authentic scientific critic, all he would have needed to do was to look up some literature on the state of that work which goes well beyond the reflective non-directive Rogerian emulator that Eliza was designed to be. He wouldnt have even had to do a real literature search, like most scientists routinely do when gathering information on which to based an argument–he could have simply listened to the Science Podcast that accompanied the piece to actually learn more about the project to inform his judgment. There is plenty of randomized controlled trials to support the value of therapy and cybertherapy as well, but in this day when "shouting fire" seems to pass for credible and critical journalism in the blogosphere, I guess he didnt have much incentive to look beyond his pointy nose for some facts to support his thin case.

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  10. 10. RedRoseAndy 2:09 am 12/5/2010

    Sleep experts say that most mental illness is due to poor and little sleep. To get the sleep that you get at the coast when the wind blows in from the sea just heat salt water in an oil burner overnight. If you are in pain just add some lavender as well.

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  11. 11. Patrick Rea 11:43 am 12/5/2010

    In the UK, the charity and network for military PTSD, PTSD Resolution, has had success with treating services veterans.
    It offers better than 80 percent success in treating military PTSD. It’s brief, with an average of just three to five one-hour therapy sessions. The out-patient treatment supports family and work routines. We are able to work in prisons, where the authorities permit. It is nationwide in the UK, confidential and with no waiting list – no referral is needed and it is complementary to the work of other services’ charities.

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  12. 12. joycebender 3:44 pm 12/11/2010

    Fascinating idea! Can you give more specifics? I don’t know exactly what you mean by an oil burner.

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