A great deal of time, money, and effort has gone into creating and implementing high-quality psychotherapies for youth. Researchers and clinicians have devised hundreds of distinct clinical protocols for various mental health issues and have implemented these protocols around the world. Increasingly, clinicians are trained in evidence-based techniques and are adherent to therapy protocols. Many psychotherapies involve training clinicians to improve the quality of the therapy delivery.
Unfortunately, despite these efforts, barely any progress has been made in terms of actually improving youth psychotherapy outcomes, based on data from five decades of randomized controlled trials (see Weisz et al., 2019). For the mental health problems that account for most clinical referrals, youth psychotherapy today is roughly as effective as it was 50 years ago – and in some cases, it is less effective. In other words, efforts to improve the quality of youth psychotherapy do not appear to have directly translated into improved outcomes (except perhaps for anxiety, to a nonsignificant degree; Weisz et al., 2019).
Why isn’t youth psychotherapy improving? One possibility is that we are already nearing the “upper limit” of effectiveness that can be achieved with traditional psychotherapy models. That might be true because so many factors barely touched by most therapies impact the lives of young people: genetic endowment, biological makeup, family context, and the broader social environment all play a role in mental illness. Ultimately, youth psychotherapy typically involves 1-2 hours out of the 110+ waking hours of the week. It can only do so much. This may be especially true for young people, whose ability to control life events and living conditions is constrained compared to adults.
But how do we know whether we are already near the “upper limit”, or whether youth psychotherapy still has a lot of room to grow? Luckily, researchers have collected a multitude of data on youth psychotherapy quality and outcomes. These data are no crystal ball, but they can still provide valuable insights. In our study, we considered meta-analytic data from 502 randomized-controlled trials (RCTs) of youth psychotherapy. We incorporated the data into a mathematical model called a copula. With the copula built, we created a simulation of the upper limit of youth psychotherapy by setting the mathematical dimension of “therapy quality” to the 99.9thpercentile and observing the outcome.
Our simulation predicted that the upper limit of youth psychotherapy is at an effect size of roughly g =0.83. This is a large effect size, which is encouraging – psychotherapy can make a big difference – but it is also not much bigger than the effect sizes we expect from today’s gold standard treatments. In other words, our model predicted that the best youth psychotherapies today are already near the upper limit.
What does this mean for researchers and clinicians? The burden of mental illness is enormous, and we are unlikely to make a large difference solely by beating the drum of gradual improvements to therapy quality (Kazdin & Blase, 2011). It may be more productive to alter therapy models and methods in ways that reach beyond the therapist’s office and into the ecosystem of young people’s lives—for example, through digital technology that prompts, guides, and rewards the application of therapy skills in real life (Weisz et al., 2013). We might also focus on areas where benefits have not already been maximized. For example, we might prioritize strategies that allow us to bring evidence-based care to more and more people, such as scalable interventions and effective short-term treatments (Kazdin, 2019; Schleider & Weisz, 2017). Researchers might also focus on aspects of therapy quality that are understudied, like facilitative interpersonal skill (Anderson et al., 2016). More broadly, practitioners might consider collaborating with other professionals to address factors such as socioeconomic status, job stress, and lack of education, which often go unaddressed in psychotherapy.
The idea of an upper limit to youth psychotherapy may seem disappointing at first, but it is also exciting. We may have reached a critical turning point in clinical psychology research and practice. How we choose to respond to that turning point may affect the impact of mental illness on young people and their families for many years to come.
Discussion Questions
- Which contributors to mental illness can plausibly be addressed by psychotherapy? Which factors are likely to remain outside a clinician’s control, even in the best of cases?
- To reduce the burden of mental illness, what are the most important areas of focus for clinical researchers and practitioners today?
- If you had the power to fundamentally restructure how youth mental illness is treated in your community, which changes would you make first?
Reference Article
Jones, P. J., Mair, P., Kuppens, S. & Weisz, J. R. (in press). An Upper Limit to Youth Psychotherapy Benefit? A Meta-Analytic Copula Approach to Psychotherapy Outcomes. Clinical Psychological Science.
Author Bios
Payton J. Jones, M.A.is a doctoral student in clinical psychology at Harvard University. He studies the etiology of emotional disorders (anxiety, PTSD, depression) using both a quantitative and theoretical approach. He is interested why mental illness is often equally or more prevalent in highly-developed nations despite widespread improvements in violence, poverty, and nutrition.
Patrick Mair, Ph.D.is a senior lecturer in statistics at Harvard University. His research focuses on Computational and Applied Statistics with special emphasis on psychometric methods such as latent variable models and multivariate exploratory techniques. The research typically involves some programming work in the R environment for statistical computing.
Sofie Kuppens, Ph.D.is head of Research & Knowledge Transfer at KdG University of Applied Sciences and Arts and a visting professor at KU Leuven. She is an expert in methodology, with research interests focusing on meta-analysis and measurement. Her substantive reserach interests involve unravelling atypical development, such as mental health problems, in children and adolescents from a biopsychosocial perspective and improving the quality of care for these youth.
John R. Weisz, Ph.D.is a professor at Harvard University. His research involves development and testing of interventions for youth mental health problems, as well as meta-analyses and systematic reviews characterizing, critiquing, and encouraging the science of youth mental health care. His most recent work involves development and testing of transdiagnostic approaches to youth psychotherapy, including treatment that uses modular design and treatment guided by a small number of broad principles of psychological change.
References
Anderson, T., McClintock, A. S., Himawan, L., Song, X., & Patterson, C. L. (2016). A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome. Journal of Consulting and Clinical Psychology, 84 (1), 57-66.
Kazdin, A. E. (2019). Annual Research Review: Expanding mental health services through novel models of intervention delivery.Journal of Child Psychology and Psychiatry, 60, 455–472. doi:10.1111/jcpp.12937
Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6, 21–37. doi:10.1177/1745691610393527
Schleider, J. L., & Weisz, J. R. (2017). Little treatments, promising effects? Meta-analysis of single-session interventions for youth psychiatric problems. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 107–115. doi:10.1016/j.jaac.2016.11.007
Weisz, J. R., Kuppens, S., Ng, M. Y., Vaughn-Coaxum, R. A., Ugueto, A. M., Eckshtain, D., & Corteselli, K. A. (2019). Are psychotherapies for young people growing stronger? Tracking trends over time for youth anxiety, depression, ADHD, and conduct problems. Perspectives on Psychological Science, 14, 216–237. doi:10.1177/1745691618805436
Weisz, J. R., Ugueto, A. M., Cheron, D. M., & Herren, J. (2013). Evidence-based youth psychotherapy in the mental health ecosystem. Journal of Clinical Child and Adolescent Psychology, 42(2),274-286. DOI: 10.1080/15374416.2013.764824.