Q: Is it true that a person has to “believe in” mental health treatment for it to work? A heart patient does not need to believe in the pill that helps his ticker, but I have been told that mental health treatment requires an attitude of belief. Thanks, doc. – Sreed

Dear Sreed,

You’re correct that heart medication, for example, doesn’t necessarily require faith. But faith can help. A certain variety of faith known as the placebo effect has been well documented—that’s when a patient shows measurable improvement after receiving simulated treatment like a sugar pill or saline injection. The presumption is that the patient’s belief in the treatment is enough to make it work.

Staying with your heart medication example for a moment, studies dating back 20 years have demonstrated that the placebo effect can increase cardiac output and exercise tolerance (Packer, 1990), and it can reduce problems like hypertension and angina (Bienenfield et al., 1996). A more recent study by Meissner (2009) found that the placebo effect can increase or decrease the rate at which food moves through the stomach.

Autonomic functions like these are beyond our conscious control, yet it’s clear that our thoughts and expectations can affect them. Could the same be true of mental health treatment?

Since there are many psychological treatment options—some good and some bad—let’s limit our discussion to treatments that 1) have plenty of research backing them up, and 2) are delivered by highly trained, credentialed clinicians. We’ll save the treatments that absolutely don’t deserve your faith for a different day.

Before we discuss talk therapy, let’s briefly look at the effect that faith can have on psychotropic medications. Then I’ll offer a different question about faith.

Medication: Snake Oil or Life Changer?

Some medications act so directly on the central nervous system that no faith is required. Consider the antipsychotic class of medications. For the most part, they effectively reduce hallucinations, delusions, and other disordered forms of thought. Faith simply isn’t much of a factor.

Anti-anxiety medications like the benzodiazepines also work without faith. All other things being equal, these meds will slow you down. Period. (They can also increase anxiety problems over the long run, but that is another topic for a different day.)

The efficacy of other medications, especially antidepressants, is far less certain. An unsettling study from 1998 found that 75% of antidepressant effectiveness is due to the placebo effect (Kirsch & Saperstein, 1998). One might conclude that the main difference between a fancy antidepressant and a sugar pill is faith. Of course, there are also plenty of compelling studies arguing in favor of the efficacy of antidepressants.

We won’t settle that old debate, but here’s my opinion: if medication improves a person’s life, even if only by faith or placebo effect, then God bless and carry on. There are many paths to a life well lived, and medication is sometimes the best treatment option.

In other cases, talk therapy is the best option. Does it deserve your faith?

Talk Therapy and Positive Expectations

Psychologists have devoted quite a bit of study to the question of faith, which we prefer to call outcome expectation. (Maybe we like to call it that because we hope that a fancy term will increase your faith in us.) Outcome expectation is essentially a person’s prediction about the effectiveness of the treatment in which he or she is about to engage.

You’re correct, Sreed, that many psychologists believe that a positive outcome expectation (or faith) leads to good therapy outcomes. Roger Greenberg et al. (2006) concluded that positive outcome expectations are “important contributors to the effectiveness of different forms of psychotherapy.” They looked the various components of expectation, including the perceived attractiveness of the therapist, belief in the therapeutic method, and especially the therapeutic alliance, which is the degree to which a client believes that the therapist is allied with them against the problem. All of them seem to have an effect on the outcome of therapy, and Greenberg et al. lean toward the belief that therapy is less likely to succeed in the absence of positive outcome expectation.

Other researchers have been less enthusiastic about the need for positive outcome expectations prior to therapy, but still acknowledge an effect. In an extensive review of the literature, Micheal Constantino et al. (2010) found that positive expectations had a small but statistically significant positive effect on the outcome of mainstream, evidence-based treatment.

Studies like these leave me with this thought: there is nothing to lose by being optimistic about mental health treatment, and potentially much to gain–provided you’re working with a reputable, credentialed, experienced clinician who uses evidence-based treatment. (Suspending one’s skepticism for off-the-wall or fad treatments can be quite dangerous.)

So. Here’s my thought, Sreed: Yes, psychology, as a profession, has produced evidence-based treatments that are entirely worthy of faith. However, I believe that your individual psychologist must earn your trust by explaining what he’s going to do, how he’s going to do it, and how it has worked in the past. Just as importantly, you should sense that he or she truly understands the problem that you’re facing, and that he is truly on your side. That sort of alliance is difficult to quantify, but you will probably be able to sense whether or not your psychologist is fighting for you.

That brings me to a different question: should we psychologists have faith in our clients? Clinical psychology is draining work, after all, and it can be heartbreaking when therapy doesn’t work. Sometimes clients drop out of treatment, they aren’t ready for change, or bad things happen on the road to recovery. Why should we psychologists invest our faith in the success of our clients when there are factors beyond our control?

Faith Healing

Psychologist Kelly Wilson believes that we psychologists should have faith in the success of our clients, no matter what. He believes that psychologists should treat each and every therapeutic relationship as if it offers the opportunity for something special to happen:

“Imagine that it’s at least remotely possible that for any given client, something extraordinary could happen in his life. Here I don’t mean extraordinary on my terms, but rather on his, the client’s terms. Extraordinary might look very, very different for different clients. Extraordinary might mean finding meaningful work, reconciling with a child, or [serving others]” (Wilson & DuFrene, 2008).

Modeling his own argument after Pascal’s Wager (the philosopher’s rationale for believing in God), Dr. Wilson asserts that having faith in our clients is the only reasonable wager for any psychologist to make. His decision matrix (below) is based on two possible outcomes: either the client will succeed in thereapy or he won’t. Betting in favor of the client’s success offers the possibility of joy along with the possibility of sadness, whereas betting against the success of the client offers no chance for joy.

Betting against the client is a sucker’s bet. Whether or not the client succeeds, no one ends up feeling very good. It’s also just plain rude, in my opinion, and any psychologist who finds himself betting against his clients must examine the reason for doing so. (Psychologists can become burned out, which is understandable, but it must be dealt with before it harms clients.) Dr. Wilson sums up his stance with characteristic candor:

“I assume that it’s my job to bet yes on every single client who walks through my door. No matter what.”

It’s a wonderful sentiment, but does it really matter if a psychologist has faith in his clients? At least one study says yes. Timothy Coppock et al. (2010) found that a therapist’s hope for their client contributes significantly to the outcome. They noted that therapists tend to base their degree of hope on factors such as the client’s resources (like a strong social network), the client’s readiness for change, and the severity of symptoms. All things being equal, Coppock et al. found that the therapist’s degree of hope is a stronger predictor of success than the client’s.

So, Sreed, the literature supports what you have heard: it is generally useful to have faith in us psychologists. But our faith in you is more important than your faith in us.

-IS

References

Bienenfeld, L., Frishman, W., & Glasser, S.P. (1996). The placebo effect in cardiovascular disease. American Heart Journal, 132(6), 1207-1221.

Constantino, M.J., Arnkoff, D.B., Glass, C.R., Ametrano, R.M., & Smith, J.Z. (2010). Expectations. Journal of Clinical Psychology: In Session, 67(2), 184-192.

Coppock, T.E., Owen, J.J., Zagarskas, E., & Schmidt, M. (2010). The relationship between therapist and client hope with therapy outcomes. Psychotherapy Research, 20(6), 619-626.

Greenberg, R.P., Constantino, M.J., & Bruce, N. (2006). Are patient expectations still relevant for psychotherapy process and outcome? Clinical Psychology Review, 6(26), 657-678.

Kirsch, I., & Sapirstein, G. (1998). Listening to prozac but hearing placebo: a meta-analysis of antidepressant medication. Prevention & Treatment, 1(2), no pagination specified.

Meissner, K. (2009). Effects of placebo interventions on gastric motility and general autonomic activity. Journal of Psychosomatic Research, 66, 391-398.

Packer, M. (1990). The placebo effect in heart failure. American Heart Journal, 120(6), 1579-1582.

Wilson, K. G., & Dufrene, T. (2008). Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy. Oakland, CA: New Harbinger.