Klaus Grawe, University of Bern: Cognitive Psychotherapy Is "Highly Significantly More Effective" Than Person-Centered Psychotherapy and Psychoanalysis

What have the findings of Klaus Grawe and his research team at the University of Bern accomplished since 1994? Has this knowledge about effective and harmful psychotherapy improved patient care? Let us consider the current situation:

The Swiss psychotherapist Dietmar Luchmann analyzed in an article on August 14, 2025, why Switzerland remains a paradise of psychotherapy inefficiency.¹ A commenter confirmed this with his own experience:

"Fantastic article! For over 20 years I went to therapy, and at the end I was sicker than when I started. Constantly new suspected diagnoses, pathologized personality traits—'deficits' here and 'traumas' there. You are systematically conditioned into a helpless victim. What finally liberated me was shifting my focus from what was problematic to what was functional. The only thing missing from this article is the pronounced feminine dynamic of the psycho-industry. It had raised increasing doubts in me as to whether it could do me justice at all. I feel like a former cult member."

Affected individual, August 18, 2025, 1:59 PM Comment on Switzerland as a Paradise of Psychotherapeutic Inefficiency¹

Despite the psychiatrist glut in Switzerland and the swelling flood of psychotherapists, the mental health of the population is becoming ever more lamentable through feel-good events instead of medical treatments.^2,3 Why is that?

The Association of Swiss Psychotherapists (ASP) Wages War on Scientific Therapy Standards

The successful lobbying of long-term therapists has emboldened the Association of Swiss Psychotherapists (ASP) to such a degree of hubris that its president, Gabriela Rüttimann, filed a written complaint on September 1, 2025, against the public mention of scientific standards in psychotherapy:⁴

"We are particularly disturbed by [...] [claims that] anxiety disorders could be cured in as few as eight to ten hours, or that a life could be fully worth living again after just a few hours of therapy."

Gabriela Rüttimann, President Association of Swiss Psychotherapists (ASP)⁴

A revealing confession. The attack by the Association of Swiss Psychotherapists (ASP) against effective psychotherapy that makes life "fully worth living again" refers to quotations from the therapy report of a physician who, after a ten-year psychotherapy odyssey through psychoanalysis and depth psychology, wrote about his cure through cognitive psychotherapy:

"After eight therapy sessions [...], my supposedly so severe 'personality disorder' and my suicidal ideation had given way to a largely normal and absolutely worthwhile life."

Chronicle of a Misdiagnosis — A Physician Experiences Psychotherapists and Psychotherapy. Psychotherapie. March 11, 2003.

If it is not the goal of the Association of Swiss Psychotherapists (ASP) to make patients' lives "fully worth living again" through psychotherapy, the question arises: What goal are these psychotherapists actually pursuing—those who pay an annual membership fee of CHF 760 to the Association of Swiss Psychotherapists (ASP) for the representation of their interests?

Furthermore, the Association of Swiss Psychotherapists (ASP) is outraged by the cognitive psychotherapy of anxiety and panic disorders because of the

"alleged possibility of healing without the use of psychotropic medication [...]. Such claims lack scientific evidence."

Gabriela Rüttimann, President Association of Swiss Psychotherapists (ASP)⁴

Cognitive psychotherapy is "significantly more effective" precisely because it does not require psychotropic medication. Psychotropic medication impairs therapeutic outcomes. The renunciation of psychotropic medication reflects the current state of psychotherapy research, is the content of applicable treatment guidelines for anxiety and panic disorders—and is explained in our SKPT concept.

In this context, one may refer to the interview that the Süddeutsche Zeitung conducted with Peter C. Gøtzsche, Professor of Research Design and Research Analysis at the University of Copenhagen and specialist in internal medicine, who stated with a clarity that "disturbs" the ASP psychotherapists:

"I estimate that we could save 95 percent of the money we spend on drugs without patients coming to any harm. In fact, more people would be able to live longer and happier lives."

Peter C. Gøtzsche "The Pharmaceutical Industry Is Worse Than the Mafia." Süddeutsche Zeitung. February 6, 2015.⁵

Remove Psychotherapy From the Catalog of Covered Services

The attacks by the psychotherapy association ASP against the scientifically grounded and professionally recognized standards of psychotherapy reveal how fatally ill Swiss psychotherapy provision is—and how little health authorities and health insurers contribute to quality assurance.

In the face of the hubris of psychoanalytic, depth-psychological, existential-analytical, bioenergetic, and body-centered psychotherapists in fighting effective psychotherapy, parliament must intervene as a matter of emergency and remove psychotherapies from the catalog of covered services, as Swiss parliamentarians led by Philippe Nantermod demanded on December 16, 2025.⁶

The "feel-good events"³ that the Association of Swiss Psychotherapists (ASP) sells to the insured community as psychoanalytic, depth-psychological, existential-analytical, bioenergetic, and body-centered psychotherapy are so far removed from the standard of effective psychotherapy that the question arises on what basis they are officially licensed as psychotherapy.

The IKP Institute for Body-Centered Psychotherapy Zurich,⁷ under the "professional direction" of ASP President Gabriela Rüttimann, is itself the best example of misleading advertising for methods as psychotherapy that, due to the absence of efficacy evidence, do not qualify as scientifically recognized psychotherapy methods. The "body-centered psychotherapy" sold by the IKP Institute for Body-Centered Psychotherapy Zurich and the "Gestalt therapy" as its foundation are not psychotherapy, as the Scientific Advisory Board for Psychotherapy—the authoritative body for the scientific recognition of psychotherapy methods in Germany—determined.⁸

When methods only create dependency on psychotherapists and do not empower patients toward self-help and autonomy, they are not psychotherapy. Anyone who wishes to attend such "feel-good events"³ must pay for them out of their own pocket.

Who Sets the Licensing Standard: Natalie Rickli or Gabriela Rüttimann?

The question posed at the outset—what the findings of Klaus Grawe and his colleagues at the University of Bern have accomplished since 1994—can be answered by the example of the successful lobbying by the Association of Swiss Psychotherapists (ASP) under Gabriela Rüttimann: The Department of Health of the Canton of Zurich continues to issue licenses for the independent practice of psychotherapy to psychotherapists who present training certificates from therapy schools that have been known for decades to be inefficient—and, through their years-long duration, rather harmful to health.

Since the publication of the landmark work of psychotherapy research by Klaus Grawe in 1994, evidently nothing has changed. The question thus arises: Is Natalie Rickli protecting inefficient psychotherapy schools?⁹

Cantonal Councillor Natalie Rickli, at the helm of the Zurich Department of Health since 2019, shows no political will to align psychotherapeutic provision with the scientific standards that Klaus Grawe defined decades ago. Were the authority to apply these standards consistently, the professional practice license for the psychotherapist Gabriela Rüttimann's practice in Zurich would have to be revoked pursuant to Article 26 of the Psychology Professions Act (PsyG). For anyone who, like Rüttimann, takes the field against efficient methods in defiance of the evidence thereby demonstrates that the elementary scientific foundation for the activity as a psychotherapist in independent professional responsibility is lacking.

The standard of care for effective psychotherapy in anxiety and panic disorders is a total of 7 to 14 hours — without psychotropic medication!¹⁰

Anyone who wants effective psychotherapy in order to achieve the therapeutic goal in a few hours is forced, in the paradise of psychotherapy inefficiency, to perform the missing quality assurance themselves—only thus does one escape the risk of becoming the financial and mental victim of psychotherapists who, by the standard of science, should never have been granted a professional practice license.

The Healing Art Without a Prayer Book — Empirical Psychological Therapy

Book Review

Klaus Grawe, Ruth Donati & Friederike Bernauer: Psychotherapie im Wandel. Von der Konfession zur Profession (Psychotherapy in Transition: From Confession to Profession). Göttingen: Hogrefe-Verlag, 1994. XIV and 886 pp.

By Dietmar Luchmann
April 10, 1994

What kind of book about psychotherapy must this be, that long before its publication it provoked "a flood of outraged reactions in the form of newspaper articles, letters to the editor, and correspondence in response to the advance publication of partial results" (as the authors note on p. 694)? A new psychotherapeutic doctrine of salvation, an eccentric outcry in the psycho-marketplace, yet another occult psycho-theory? None of the above!

Grawe and his colleagues have produced, over more than 13 years of painstaking detail work, a unique cost-benefit analysis of the various therapeutic methods. Their investigation encompassed all significant known therapy methods and ranges from 10 humanistic therapy forms (e.g., psychodrama, Gestalt therapy, person-centered psychotherapy) through 9 psychodynamic therapies (e.g., long-term psychoanalysis, psychoanalytic brief therapy, guided affective imagery) to interpersonal therapies (3 methods), relaxation techniques (4 methods), eclectic approaches, and 14 cognitive-behavioral therapies.

The volume, comprising over 800 pages, delivers with the finest scientific rigor an overwhelming abundance of evidence on the perversion of psychotherapeutic healthcare provision in Germany that could scarcely be more alarming: "The most expensive way for society to deal with mental disorders is the current one. The failure to utilize the best available treatment options produces the greatest costs—not their utilization" (p. 681).

Consequently, the authors "harbor no illusion that most psychotherapists are eager to learn something about the actual effects of the various therapeutic methods" (p. 694), but not without observing: "A healthcare system in which the welfare of patients serves merely as a pretext for the pursuit of financial interests will not be able to conceal its fundamental need for reform much longer" (p. 16).

Grawe's Research as the Sum of All Controlled Psychotherapy Studies

Without question, this is the most comprehensive, methodologically most conscientious, and scientifically most meticulous comparative psychotherapy study that makes available to the German-speaking reader the results of the entire international body of efficacy research in the field of psychotherapy. That this book is simultaneously a political one follows less from the circumstance that its first author is also one of the experts commissioned by the German Federal Government on the question of a psychotherapy law, than from the measurable data and verifiable facts that this handbook of psychotherapeutic efficiency lays bare with merciless clarity: A total of 16 researchers, over the course of more than a dozen years, "had to review over three and a half thousand therapy studies in which the effect of a psychological treatment method was tested in a controlled experimental design" (p. 30).

Of these studies, distributed across more than 300 scientific journals, Grawe and his colleagues "then evaluated, according to methodological quality and clinical relevance, 897 studies that relate directly to the core domain of psychotherapy, with great care and attention to detail, and compiled the results by individual therapy method" (p. 31). A distinctive feature of this "major collaborative research effort" at the University of Bern is that the authors "had the aspiration to take into account, in their entirety, all controlled psychotherapy studies ever conducted" (p. 31).

"Never" Has Any Psychotherapy Been Superior to Cognitive Behavioral Therapy

It is impossible even to suggest the wealth of data, material, and findings that Grawe et al. have assembled and analyzed. The following observations from the study and from the direct efficacy comparisons of various therapy forms can therefore serve only as a warmly extended invitation to read further and deeper, and by no means as a summary. The lucid structuring of the assembled material, the problem areas identified, and the clear discussion of results make the book eminently readable despite its numerous tabular compilations and abundance of data.

On the central question of which psychotherapy is how effective, Grawe et al. mince no words: "Never, in any review of the comparative effectiveness of therapies, has any other form of therapy been shown to be superior to cognitive-behavioral therapies. The only question that ever arises is whether one can or must regard the differences in favor of behavior therapy as significant. The reverse case is not even up for debate. The actual state of evidence could therefore not be more unambiguous than it is: Cognitive-behavioral therapy is, on average, highly significantly more effective than psychoanalytic therapy and person-centered psychotherapy" (p. 670).

Grawe et al. also address at length the extreme overestimation of the time required for psychotherapy—a legacy of decades of psychoanalytic imprinting—which persists stubbornly as a myth in many minds, completely ignoring both the objective reality of modern cognitive-behavioral therapy and the results of the entire body of scientific efficacy research. "The timeframe in which effective therapies achieve their results is measured in months, not years. Precisely in those forms of therapy that have proven most effective, the positive effects of therapy emerge in astonishingly short periods or are achieved with an astonishingly small number of sessions. This is particularly pronounced for many of the cognitive-behavioral procedures. [...] The view still held by many psychoanalytic therapists today—that severely disturbed patients require years of therapy—has been definitively refuted" (p. 696).

Psychoanalysis Increases Costs; Cognitive Psychotherapy Reduces Costs

The aforementioned "flood of outraged reactions" from psychoanalytically oriented physicians and psychologists is understandable but not to be underestimated, once one grasps the real threat that the loss of this myth among health policymakers and insurers poses to these therapists. The consequences for psychotherapeutic care in Germany that result from the resistance of advocates of psychoanalytic and psychodynamic therapy schools are, however, devastating. No health policymaker would likely conceive of introducing a budget cap for psychotherapy if he were aware that a highly effective cognitive-behavioral treatment spanning scarcely more than a dozen sessions saves multiples of its cost in subsequent medical expenses—a return that would be difficult to realize even on the stock exchange. Here lies the undiscovered futures market of healthcare provision, one that will likely be properly exploited only when the patients' lobby has grown larger than that of the practitioners at ministries, insurers, and billing offices.

Individual failed investments by therapists are certainly regrettable; it is, however, not acceptable that a society continues to pour billions down the drain because many psychoanalysts cannot bring themselves to recognize that with their training and training analysis they have invested in an option that has since expired. "The only empirically demonstrated effect of prolonged training analyses known to us is that therapists who have completed a particularly long training analysis subsequently also conduct particularly long therapies," observe Grawe et al. (p. 699), noting that "one can hardly regard this as an increase in competence. It is, moreover, a very costly consequence for the healthcare system" of psychoanalytic doctrine.

In 1993, the World Health Organization (WHO) published a comprehensive review of the efficacy of psychotherapeutic treatment methods and arrived at the same unambiguous conclusion as Grawe et al.: "Cognitive-behavior therapy has been shown to be a powerful specific treatment in the neuroses, with some early evidence of its benefit in some personality disorders. Dynamic psychotherapy, although popular with patients and therapists [...], has not been demonstrated to be superior to placebo in the neuroses or personality disorders" (Andrews/WHO, 1993, p. 244). It is therefore entirely logical that the highly esteemed Prof. Hans J. Eysenck of the London Institute of Psychiatry, in light of these facts, simply concludes: "It is time psychoanalysis and psychotherapy joined phlogiston on the list of scientific theories that misled whole generations" (Eysenck, 1994, p. 491).

Psychotherapy Within University Clinics: "Systematically Inferior"

When one considers these and the multitude of equally clear and unambiguous findings from efficacy research in the international literature, one can confirm that Grawe et al. have produced an extraordinarily sober assessment and a thoroughly cautious and very fair discussion of the results. If one takes as a starting point Grawe's finding that "for a considerable number of therapy methods, particularly from the cognitive-behavioral spectrum, but also for hypnotherapy and relaxation techniques, it has been compellingly demonstrated that they effectively improve psychosomatic disorders" (p. 692), how much longer, one then asks, will society accept without protest the following situation, which Grawe et al. only rarely subject to an evaluation as an "irrational state of affairs": "Of all therapy forms, the very one that has proven conspicuously unsuitable for the treatment of psychosomatic disorders—psychoanalytic therapy—plays the dominant role in psychosomatic care and training. Every university chair for psychosomatics/psychotherapy in the Federal Republic of Germany is occupied by a psychoanalyst. [...] For the patients who are treated within these university departments, this state of affairs has tangible negative consequences. They reasonably expect to receive a particularly qualified therapy there, but are in fact treated, virtually as a rule, less well than would be possible with the same or less effort" (pp. 692f.).

To illustrate the preposterous practical implications of the still-prevailing situation with (traditionally) strongly dominant psychoanalytic and depth-psychological treatment offerings, Grawe et al. point, for example, to a calculation by Kächele & Kordy (1992, p. 524): "A five-year psychoanalysis with four sessions per week requires the same therapeutic expenditure as the treatment of 40 patients with a six-month treatment of 26 therapy sessions. Previous research results have shown that it is primarily mildly disturbed patients who can benefit from long-term psychoanalyses. It would be quite absurd to draw the conclusion that one should expend the effort for a rather mildly disturbed individual that could also be used to treat 40 more severely disturbed patients" (Grawe et al., p. 702).

Psychotherapy by Psychotherapists Suffering From "Self-Produced Distortion of Reality"

The authors do not shrink from naming the urgent consequences that flow directly from this state of affairs: "Therapists who must conclude for themselves that the majority of their therapies last longer than 40 therapy sessions need to go back to the drawing board. They are victims of a faulty training and/or a self-produced distortion of reality" (p. 698). This definition by Grawe et al. of the therapeutic efficiency standards that are routinely achievable today is, of course, a challenge for a system of guideline psychotherapy in Germany that is still significantly shaped by psychoanalytic theory and its lobby, and whose fee structure tends to incentivize lengthy psychotherapies.

The standard of modern therapeutic efficiency outlined by Grawe et al.—a framework of 25 to 40 sessions—may, however, be considered rather moderate. Perris & Herlofson (1993, p. 185) define, in the WHO study, a significantly more demanding routinely achievable state of the art in cognitive therapy: "The length of treatment is relatively short for the treatment of the average patient (12 - 15 sessions)." In practice, this means nothing other than that an efficient cognitive therapy may already reach successful completion after eight sessions, while the psychoanalytic practitioner has only just completed his final probationary session before submitting his application for long-term therapy! A truly grotesque state of affairs, when one considers that a behavioral therapy practitioner in such cases, under our current system, can easily come under suspicion of having nothing but treatment dropouts.

Physicians Exploit Psychotherapy — Without Competence and "Without Any Sense of Wrongdoing"

Given the absurd and irresponsible situation in the German healthcare system, in which psychoanalytically oriented physicians serve as reviewers for applications for both psychoanalysis and behavior therapy — thereby controlling the implementation of a treatment for which they often lack any competence whatsoever — it is a systemic problem, and hardly surprising, that a multitude of such nonsensical initial applications for up to 160 sessions of psychoanalysis imprint a reality-detached understanding of psychotherapy upon statutory and private health insurers. What is surprising, however, is that payers and politicians who talk incessantly about cost savings allow themselves to be skimmed so brazenly and "without any sense of wrongdoing" (Grawe et al., p. 693) and, in response to concrete proposals — such as a letter from a health insurer to this reviewer dated January 1994 — are capable of demonstrating only a concentrated ignorance in (for example) the following form: "Whether and to what extent [costs of statutory health insurance could be reduced through flexible reimbursement for modern cognitive-behavioral methods] is, based on our experience in other areas, more than questionable." The conclusion: In the dark, everything is black, regardless of whether what lies before you is a door or a wall.

Although Grawe et al. discuss the fatal financial consequences of the current handling of mental disorders more from the perspective of the researcher and therapy scientist, and less with reference to the specific institutional constraints facing therapists — who are themselves dependent on institutions and the associations of panel physicians — the reader can, thanks to the open and critical discussion that distinguishes the book, generally bridge the gap to practice quite effectively.

Certain underlying motives of psychotherapeutic practitioners may, however, not always be readily apparent to outsiders: Indeed, it is difficult to explain why a therapist who applies for and conducts long-term psychotherapy is rewarded with an hourly fee that is effectively approximately 10% higher. A more efficient punishment of an efficient psychotherapist — one who is able to successfully discharge all or the overwhelming majority of his patients within 25 to 30 therapy sessions (the short-term psychotherapy framework) — is difficult to imagine. Despite its inclusion in the public healthcare system, behavior therapy with its most efficient methods is thus forced into a Procrustean bed of bureaucratization that, through the prescription of session frequencies and the restriction of therapeutic options, not only gives rise to the fear of "a canonization and potential rigidity" (cf. Kuhr, 1994, p. 7) but actually produces them. The realization of psychotherapeutic efficiency and the achievement of psychotherapeutic success are, despite the availability of the best methods, severely impeded by the current healthcare system.

Anxiety Disorders Without Cognitive Behavioral Therapy — "Against the Rules of the Art"

The therapy of agoraphobia and panic disorder may serve to illustrate the absurdity of the current healthcare system to which Grawe et al. persistently draw attention: According to the current state of therapy research, for this disorder in vivo exposure (massed stimulus confrontation) is the method of choice — the method that "demonstrably would help the individual patient with the greatest probability" (Schulte, 1992, p. 337). Regarding the economic advantages of massed stimulus confrontation carried out in the patient's actual living environment over a more expensive inpatient treatment, Grawe et al. (p. 343) observe: "Whereas agoraphobias [...] were still counted among the very difficult-to-treat disorders thirty years ago, and patients with these disorders populated the psychiatric clinics in large numbers, the picture has changed drastically today. Patients with such disorders now have a rather favorable prognosis, and this is almost entirely attributable to exposure-based therapies." With reference to these therapeutic successes, achievable through exposure therapy embedded in a comprehensive outpatient treatment concept, Grawe et al. (p. 344) state regarding the requirement for exposure therapy in agoraphobia, and emphasize: "Therapists who — for whatever reason — fail to do this impose upon their patients a wholly unnecessary prolonged or never-ending suffering and violate, as one can say today, the rules of the art."

The absurdity of current psychotherapy, however, begins less with those physicians who, today as thirty years ago, out of helplessness, ignorance, or for the sake of therapy-school proportionality, first futilely supply their patients with psychotropic medication and then send them to the clinics. No, the absurdity begins where representatives of health insurers and payers issue formal warnings to behavioral therapy practitioners because these practitioners point out the economic advantages of efficient exposure therapy or fulfill their duty to inform patients about the in vivo exposure that is strictly indicated according to "the rules of the art." Anyone who has ever attempted, on the basis of the "applicable guidelines" of the psychotherapy agreements, to persuade a payer to take into account the therapeutic and financial particularities of exposure therapy knows whereof we speak. Thirty flexibly deployable therapy hours and perhaps an additional DM 1,000 for exposure-related expenses (vehicles, tickets, travel costs, etc.) would, in an individual case, for example, suffice to enable an adequate exposure therapy that would demonstrably help with the greatest probability. This, however, the applicable psychotherapy guidelines do not permit. Instead, 45 therapy sessions (long-term therapy) would assuredly be approved. And since the fee cap imposed by the latest health reform legislation has already reduced the per-session fee, and since the patient has an in-kind benefit entitlement vis-à-vis his health insurer and consequently may not make any copayment for exposure costs, and since the therapist in turn will not ruin himself by absorbing the exposure costs, the peer-reviewed behavior therapy ultimately takes place only within the therapist's office — which is of little help to the patient, but costs the health insurer considerably more, potentially already during the therapy itself and certainly in downstream costs.

Protection From the Medical-Industrial Complex of Psychiatry — Personal Responsibility

If a patient in this case desires a rapid and effective therapy, he will seldom have any choice other than to pay for the therapy out of his own pocket. Only some patients will be able to do so; others will opt instead for reimbursable psychotropic medication or a less productive inpatient treatment. From this perspective, the analysis and critique by Grawe et al. appears, at certain points, almost moderate.

An altogether insufficient public awareness of the economic value of psychological treatment options also prevails in the domain of psychiatric disorders. Grawe et al. illustrate this with the examples of alcoholism and schizophrenia and calculate the potential societal benefit of psychotherapy: "When all costs were taken into account, the savings in costs for inpatient stays, crisis intervention, court costs, and community aftercare exceeded the costs associated with the additional family therapy treatment, calculated over a nine-month period, by DM 4,200 per patient. The great gain in quality of life for the patient and his family was thus not associated with additional costs but actually produced considerable real savings" (pp. 680f.). The therapeutic procedures for this are available; therapy manuals such as Perris (1989) and case studies such as Luchmann (1994) illustrate the possibilities of modern psychological therapy. Scotti et al. (1993, p. 547) note that "the chronic psychiatric disorders are not 'too severe for behavior therapy,' nor should any 'biological basis' for these disorders rule out the use of behavior therapy as a primary or secondary treatment option."

Effective Psychotherapy — "Reduced Costs ... Fewer Suicides"

In the fight to preserve market share in the field of psychotherapy, even physician representatives articulate the egregious neglect of this domain — as, for example, Zeller (1994, p. 44): "On the one hand, the applicable fee schedule evaluates psychiatric-psychotherapeutic activity wholly inadequately [...]. On the other hand, some analytically practicing reviewers exclude such severely disturbed patients with neuroses, borderline disorders, and psychoses from regular psychotherapeutic treatment. Herein lies the real scandal." Grawe et al. leave no doubt that immense public persuasion is still required to dispel the shortsighted "fear that a much more widespread utilization of psychological treatment options would only drive healthcare costs further upward." "Naturally, an effective psychotherapeutic treatment initially costs something, but these costs are more than offset — in the short term and especially in the long term — by savings elsewhere: through reduced medication consumption, reduced costs for inpatient stays and outpatient physician visits, fewer early retirements, fewer absences from work, better job performance, fewer accidents, fewer suicides" (p. 681).

This common sense is sometimes possessed by patients in greater measure than by their health or pension insurers. A patient once asked this reviewer: "Would you please write something in support stating that you recommend your therapy for my condition and that a psychosomatic residential cure would be bad for me." Whom did life punish? Both. The patient, naturally, who receives approval for the inpatient stay or a denial of outpatient psychotherapy, and the pension insurer, who must bear the higher costs of a less suitable treatment and its consequences. It is almost an advantage of the book by Grawe et al. that it reflects the absurd reality of the current state of psychotherapy and practices in the German-speaking world strictly through the lens of sober scientific generalization. The reality would otherwise be scarcely bearable.

Thus, as Grawe et al. demonstrate in detail, a paradoxical situation arises across all psychotherapeutic indication areas: the limited financial resources that statutory health insurers, private health insurers, and pension insurers in Germany allocate for psychotherapy are, given the vastly predominant treatment share of psychoanalytic and depth-psychological methods, by no means deployed for efficient and professional psychotherapy with demonstrable reduction of known psychosomatic downstream costs. Instead, the medical and societal downstream costs are actually increased through treatment with less effective or inefficient methods that is "neither ethically nor economically justifiable" (p. 1).

Psychoanalysts and Psychiatrists Perceive Effective Psychotherapy "as a Threat"

In the case of the analytic school, discussed at length by Grawe et al., the treatment costs thus serve more to promote confessional activity than demonstrably effective healing. Should one actually expect that psychotherapists could perceive the advances of research as encouragement and opportunity, "leading them to familiarize themselves with these new methods and employ them? The full perversion of school-oriented demarcations in the field of psychotherapy is," according to Grawe et al. (p. 746), "expressed in the fact that the exact opposite occurs. These new developments are perceived by the majority of psychotherapists not as a welcome enrichment but as a threat, to which they respond with a cascade of defense mechanisms. Ignorance, for as long as possible; then devaluation strategies (clinically irrelevant, mere conditioning, superficial, symptom treatment, inhumane, technocratic, etc.) that reveal a response to a stereotype rather than to something with which one has actually acquainted oneself; and finally exclusion (something for behavior therapists, not for me). The fact and extent of these well-documented defense mechanisms provide an unedifying insight into the professional self-concept of the therapists in question. The primary concern is not to achieve something for those being treated, but to preserve something for the treaters: their therapeutic worldview, their self-worth, status, financial advantages, etc. The quality of treatment outcomes is rarely mentioned in the engagement with these new developments, and that is telling" (p. 746).

Among the most memorable documents of "a self-produced distortion of reality" (Grawe, p. 698) that this reviewer has received in this context is a letter from a joint practice of three neurologists, dated February 1994: "Dear Colleague Luchmann, our credo is as follows: There exist the most diverse psychotherapies, all of which claim to be effective — and are. [...] We have no priorities regarding the various psychotherapeutic orientations." Indeed — in the understanding of those psychoanalysts, therapy need not actually be effective; it merely needs to continue claiming effectiveness! An illuminating and instructive supplement to the book, for all those who are not among the "insiders," would have been an appendix of the "well-documented defense mechanisms." The authors were, admittedly, not wrong to spare the trees and the good paper: "Psychotherapy, and the dynamic theories on which it is based, is an example of a 'degenerating program shift'," writes Eysenck (1993, pp. 17f.), "behavior therapy, and the conditioning theory on which it is based, is an example of a 'developing program shift'."

"Psychologists ... Better Prepared Than Physicians for the Psychotherapy Profession"

Anyone who acquires the book by Grawe et al. invests less than the cost of a single psychotherapy session but has the opportunity to achieve an inestimable gain in reality. This applies equally to psychotherapists and to health policymakers, pension insurance representatives, and health insurer officials. For the latter, it requires a simple cost-effectiveness calculation to arrive at a realistic impression of psychotherapeutic efficiency; for the former, however, it often requires the surrender of their identity — and what resistances and abysses open up there, the well-disposed reader surely knows from the work with his own patients. Grawe et al. further draw attention to the circumstance — regularly suppressed for precisely these confessional reasons — that "psychologists [...] are, on average, substantially better prepared than physicians for the psychotherapy profession; it is they who have primarily investigated the application of psychotherapy for healing purposes scientifically and who practice it in the majority; they conduct, on average, more effective therapies than physicians" (p. 20). This cannot come as a surprise, since the most efficient psychotherapy methods — cognitive-behavioral methods, for example — have their origins almost without exception in the research and development of experimental and clinical psychology and are further advanced through its progress!

Nevertheless, Grawe et al. continue, "it remains one of the most absurd anachronisms of our healthcare system that the medical profession still asserts, vis-à-vis psychologists, the claim to be primarily responsible for psychotherapy" (p. 20). Until such time as a legislative framework is created that places psychologically practicing psychologists and physicians on an equal collegial footing, this state of affairs is not altered by the gratifying and encouraging fact that — unlike among physician functionaries — the number of practicing physicians who, on the basis of this insight and for the benefit of their patients, cultivate a fruitful and collegial collaboration with psychologists is growing. Grawe et al. discuss, on the basis of various concrete studies, the cost savings that can be realized through sufficiently available outpatient psychological treatment offerings. The globally unprecedented number of inpatient psychotherapy beds in Germany costs extreme sums and is by no means economical. When patients, after multi-week and multi-month stays in psychosomatic/psychotherapeutic clinics, very quickly present again with all their symptoms to their outpatient practitioner in their actual living environment, the clinic costs have served more as a contribution to a reality-removed "greenhouse effect" than to an effective treatment.

Physicians Will Lose Their Anachronistic Medical Primacy Over Psychotherapy

Research demonstrates that through qualified outpatient psychological therapy following psychiatric-neurological and internist-surgical acute treatment and rehabilitation, a measurable gain for therapeutic and rehabilitative goals as well as an enormous cost reduction can be achieved. What is more: for every single Deutsche Mark invested in behavior therapy prior to the required acute treatment, empirical calculations show that at least DM 2.50 to DM 3.50 in downstream medical costs can be saved. Yet the medical profession's fight to preserve its anachronistic primacy over psychotherapy continues. Rather than promoting an outpatient psychological therapy that intervenes early (preventively and curatively), is reality-oriented, efficient, and empirically grounded, and therefore affordable, the self-defeating call for yet more inpatient psychotherapy beds issues from the medical profession: "Psychosomatic departments or functional units in the general hospitals [...] would be the most economically favorable ad hoc measure. As a physician today, one hardly dares to argue on the basis of patient welfare" (Hoffmann, 1994, p. A117). True enough, one can only say to the latter. As Grawe et al. observed: "The primary concern is not to achieve something for those being treated, but to preserve something for the treaters" (p. 746).

Fortunately, a process of public consciousness-raising has commenced that is beginning to accept modern psychological therapy as a rigorously scientific, problem-oriented, and highly efficient service in the domain of mental and physical health, for "the available information cannot be permanently suppressed" (p. 748). The book by Grawe et al. will help to accelerate this process and increase the accommodation pressure on the therapy schools. "Accommodation pressure exists for every therapy school, without exception, including those that, on the basis of the results reported, may for a moment feel like victors. The therapy-school behavior therapists may bask in the glow of the efficacy evidence; the scientific behavior therapists, however, would be well advised to turn their attention to the facts they have hitherto ignored and to accommodate their theoretical conceptions accordingly" (p. 748).

The Best Psychotherapy Emerges From "the Development of Empirically Oriented Psychology"

Grawe et al. derive from what they are convinced is the ongoing obsolescence of the therapy schools a future for psychotherapy that will not consist "of one of the currently existing therapy forms prevailing over the others, but of something emerging that does not yet exist — namely a 'General Psychotherapy'" (p. 748). This future of an empirically grounded General Psychotherapy is outlined by Grawe et al., distilled from the results of the study, in a highly readable and uncompromising concluding chapter of (regrettably only) thirty-nine pages: "What we propose is neither what is commonly understood by 'integrative therapy' nor an eclectic approach. [...] The foundation of a General Psychotherapy would by no means be a patchwork of theoretical set pieces from the various existing therapy forms. [...] The constructs of these therapy forms are fundamentally unsuited to explain the psychotherapeutic process completely" (p. 786). In the search for "an entirely new theoretical approach of greater explanatory breadth," Grawe et al. are convinced "that the conceptual development of empirically oriented psychology can today already serve as the viable foundation of such a General Psychotherapy" (p. 786).

With the outline of a theoretical conception founded on the construct of the schema, the authors undertake the attempt to formulate such a foundation. As a stimulus, this is certainly successful; the concept itself, however, is hardly new and has its origins in the very beginnings of experimental and cognitive psychology (e.g., Bartlett, 1932). The reader may be surprised by the close connection between modern psychotherapeutic practice and experimental psychology. A genuine surprise is, rather, that it was possible for therapists of certain therapy schools over decades (and still is) to tell patients that, for example, their fear of heights on church towers and observation decks is related to the purported character of a tower as a sexual symbol. It was therefore far more than merely desirable that Grawe et al. have, with their book, contributed to placing psychotherapy on its scientific foundation and to defining it as what it actually can be: an empirically oriented, psychological healing art without a prayer book that obstructs the view of reality.

It is the singular achievement of the research group led by Klaus Grawe to have contributed, through the results of their decades-long work, an inestimably valuable advance toward an empirically oriented psychotherapy and toward the transformation of a situation that appears "neither ethically nor economically justifiable" (p. 1). For this, and for this eminently important book, they are to be thanked. The book requires no purchase recommendation; it is the most affordable survival guide for psychotherapists and their institutional contracting partners.

Published April 10, 1994.

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