The Best Intervention Is the One You’ll Use: Lessons for Health Behavior Change from Psychotherapy

Blog Post!In 1995, Martin Seligman asked an interesting question: How do we find out whether psychotherapy works? To investigate the answer, he looked at a Consumer Reports survey of people who had received mental health care for a variety of problems. In his peer reviewed article, Seligman argued that the Consumer Reports study had methodological virtues that made it a reasonable way to assess what types of psychotherapy worked best. More importantly for my purposes, Seligman also reports that the Consumer Reports respondents generally improved, with no one type of therapy being any better than any other. He writes:

No specific modality of psychotherapy did any better than any other for any problem. These results confirm the “dodo bird” hypothesis, that all forms of psychotherapies do about equally well (Luborsky, Singer, & Luborsky, 1975). They come as a rude shock to efficacy researchers, since the main theme of efficacy studies has been the demonstration of the usefulness of specific techniques for specific disorders.

What’s going on here? Well, a strong possibility is that the real world nature of the Consumer Reports study is behind the discrepancy from controlled trials, which typically must show head-to-head improvements in efficacy over other treatment methods. In the Consumer Reports study, patients self-selected into the type of therapy that they preferred, and tended to do well there. In fact, Seligman notes that “Respondents whose choice of therapist or duration of care was limited by their insurance coverage did worse.” This means that people whose insurance did not permit them to freely choose a method of treatment were less successful in therapy. Bottom line: People will try to choose a solution that fits their style.

[On a total side note, this study raises an interesting question about traditional efficacy studies, where participants are randomized into treatment groups and not given any choice about what type of treatment they receive. If it’s true that people do better with psychotherapy treatments of their own choosing, then it follows that any psychotherapy method will be more effective in the real world than it was in clinical trial. This is pretty incredible considering that psychotherapy has very strong and robust data to support its efficacy, as reflected by the American Psychological Association’s Recognition of Psychotherapy Effectiveness*.]

The reason I bring up Seligman’s study on the effectiveness of psychotherapy is that I believe it has an important pearl of wisdom for those of us who work to change health behaviors through coaching. That is, the best interventions are the ones people will use. Put another way, the best exercise is the one you’ll do.

Former Surgeon General C. Everett Koop made a similar point about medication adherence and efficacy.
Former Surgeon General C. Everett Koop made a similar point about medication adherence and efficacy.

Why? Because doing something is better than doing nothing. If a person needs to lose weight but isn’t ready or willing to go running, he is better off walking than sitting on the couch. It’s not ideal, but it’s better if a hypertension patient takes medicine some of the time than none of the time (medical doctors, correct me if I’m wrong on this example). And yeah, maybe it’s not great that your user is still eating pizza for dinner, but the fact that she switched to breakfast oatmeal is a win.

It’s tempting when providing health coaching to shoot for the moon, the absolute perfect set of behaviors that will most quickly restore a person to the best possible health. But that’s not realistic for most people seeking health coaching. People have different preferences and levels of readiness for change. We have limited willpower that prevents us from doing well when we try to do too much. Some people will never get to the top levels of healthy behavior, while others might eventually but will take a long time getting there. And in fact, research on how habits are formed suggests that it’s actually a good thing when people take their time making changes, since slowly incorporating them into existing routines helps them to stick long term.

The lesson I have taken to heart from Seligman’s work is that we cannot let perfect be the enemy of the good in coaching people through health behavior changes. We may have a clinical responsibility to communicate guidelines and standards, but in actually working with a person, we will do better if we offer them interventions they are willing and ready to use–even if they’re not ideal.


*Also the title of my new album.

One thought on “The Best Intervention Is the One You’ll Use: Lessons for Health Behavior Change from Psychotherapy

  1. This makes perfect sense. It also reminds me of the cliche that you can lead a horse to water but you can’t make him drink. When people are ready to change, they will, but even then, it’s probably going to be in baby steps.

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