5 ms·

Effectiveness of Talk Therapy Is Overstated, a Study Says

31 points by khc 11y ago

mpweiher 11y ago
Hmm...I read about the lack of effectiveness of psychotherapy roughly 20 years ago in DER SPIEGEL. Within a set time period, around 10% of patients receiving psychotherapy got better. Of course, within the same period 10% of patients receiving no treatment also got better :-)
- tormeh 11y ago
  There being no effect at all is a ridiculous statement. Sure, it doesn't work for many people, but it worked for me. So if it works for some people, which I prove it does, then it has to inhibit recovery in others in order to have no net effect. I don't buy that at all.
  - brookside 11y ago
    Therapy absolutely has an effect. That effect, however, happens to be about equivalent to placebo.
    - mattmanser 11y ago
      This is wrong and you do many people a disservice who might read this and think it doesn't work. I don't know where you're getting this and the article in no way supports your stance. From the article: Engaging in a course of well-tested psychotherapy, according to the new analysis, gives them an added 20 percent chance of achieving an even more satisfying improvement, or lasting recovery. An added 20 percent chance. Don't forget they're already saying that talking therapy is only 25% less effective than originally thought. They are still saying that talking therapy is effective! And at no point do they compare it to placebo. The very article we're talking about: 1) Disagrees with your extremist stance 2) Never mentions it nearing placebo level 3) You probably didn't read it as you didn't address it CBT, for example, is known to be particularly effective when dealing with anxiety as well as dealing with secondary symptoms and making people's lives better. It has an effect WAY above placebo. So why did you say this? Are you actively attempting to make people's lives worse by putting them off therapy? Also from the article: for those who do well or fully recover, “psychotherapy, particularly cognitive behavior therapy, seems to be most effective in cutting the risk for a relapse long-term,” Dr. Hollon [one of the co-authors] said.
      - brookside 11y ago
        They are still saying that talking therapy is effective! The most generous interpretation of figures in this article is that NNTT for depression and therapy is 5. Meaning one out of every five people treated by therapy will show some improvement due to effects of therapy itself. We can certainly call this effective in that there is an effect for some people who try therapy. But not for 80% of them. Therapy is a 10 billion dollar/year industry in the United States, with its practitioners often charging desperately unhappy people high rates (beyond what most of us lucky software devs make), with no advantage to show for their various methodologies beyond what one gets from talking to an untrained stranger. Financially successful yet largely bogus businesses and industries are never going to put themselves out of business and have little impetus to change the status quo. Awareness of the current poor options for mental health treatment is important. However uncomfortable or against an established narrative of "help is out there' it is to address these realities, it will be easier to marshall efforts to finding real mental health solutions if we aren't pretending the current paradigms are working when the numbers show otherwise.
        mattmanser 11y ago
        Nowhere did it say only 20% are helped. It says 20% more effective with other treatments. Either you're not reading or you're not comprehending. I'm sorry therapy didn't work for you or you didn't want to try it, but I'm not sure what your agenda is. You seem to have some weird axe to grind about people making money. I'm not sure what else I can say as you seem to want to believe the whole thing's a big rip-off. Like where does the claim that untrained listeners are as good as trained ones come from?
        brookside 11y ago
        Making money is fantastic. Making money from desperate people with pseudoscience is bad. 20% more effective with other treatments. Not what the article says. (It is most unclearly worded.) You have a 20% greater chance of improvement with therapy above talking to a doctor (Note there no pharmaceutical course of action mentioned) not "with other treatment". My comparison of therapy to untrained listeners is not drawn from the article. There have been several studies done on this. Link to the one of first on google: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469.4634&rep=rep1&type=pdf http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469...
    - pessimizer 11y ago
      Talk therapy works a lot better than placebo, but it doesn't matter what kind. Talking to one type of therapist works as well as talking to another type of therapist. Even talking to a priest works as well as talking to a therapist. https://en.wikipedia.org/wiki/Dodo_bird_verdict https://en.wikipedia.org/wiki/Dodo_bird_verdict This article is more interesting for me in that it supports the dodo bird verdict. Cognitive behavioral therapy results have for a while been put forward as the exception. According to the article, those results have been inflated, and there are no exceptions. edit: of course, if you consider a priest the control for the psychology industry - then it may be fair to say that established therapies have no better success than placebo. Is a priest a placebo? edit: tl;dr ----- "The most commonly studied of [talk therapies is] cognitive behavior therapy — in which people learn to identify and defuse automatic, self-defeating assumptions, like 'I’m unlucky in love' or 'I always choke' — and interpersonal therapy, which focuses on reshaping how people interact with others. These studies typically have subjects engage in weekly, hourlong sessions with a therapist for three to four months. "The researchers found that 13 of these funded studies were completed but never published, usually because those who did the trials did not think a finding of no benefit stood much chance of being published. The team contacted each of the 13 investigators originally paid to do the work and requested their data. Once that data was included with those from the other, published papers, the effectiveness of the therapies dropped significantly — by about a quarter. "'That seems to be the magic number, a quarter — about the same as you see in the pharma trials' of antidepressants, said a co-author, Dr. Erick Turner, an associate professor of psychiatry at Oregon Health & Science University and the lead author of the 2008 paper detailing bias in those drug trials."
      - mattmanser 11y ago
        Your opening arguments completely disagree with the bottom quote. This isn't what you think it is. They're not saying CBT doesn't work or isn't more effective, they're saying it's not quite as effective as thought because people don't always report the failures. What's happening is that people who do a study that results in no positive benefit aren't publishing. But one study doesn't give the whole picture. There are many reasons why a singular study might show no benefit, a lot of them statistical reasons. What you need to do is look at all the studies, but the problem has been that the failing studies haven't always been published, which is bad science. So what's been happening is the published studies were: B NB B B NB B B B (6 benefit / 2 no benefit) When in fact the results were: B NB B B NB B B B NB NB (6 benefit / 4 no benefit) In science and statistics you have to report the false negatives too.
  - rimantas 11y ago
    How do you know you are not one of the 10%?
    - raverbashing 11y ago
      Ignoring the scope of the study, let's ask a question Treatment A had a 10% effectiveness, Placebo had 10% as well (which for some kind of 'talk therapy' - and for a lot of other things may not have an exact placebo, but let's assume it is) is another 10% Question: Are those the same 10%? Or with a better example, naive blood transfusion (that is, if you ignore blood type) has a low rate of success
      - netrus 11y ago
        Naive blood transfusion has a low success rate, but it is surely higher than with placebo blood transfusion (whatever that would look like).
        raverbashing 11y ago
        But when it doesn't work it usually kills the patient, so there's that
PhasmaFelis 11y ago
The original article title doesn't seem to be accurate. Should be "Effectiveness of Talk Therapy On Depression Is Overstated, a Study Says".
InclinedPlane 11y ago
Not surprised. Though really just deciding to do something about depression can often be enough to be helpful. Simply feeling like there's a path out of it can give you the strength to keep your life together and maintain ordinary levels of self-care (keeping your home clean, going to work regularly, keeping to a sleep schedule, engaging in activities, and so on).
DanBC 11y ago
These threads always fucking suck on HN. Before you comment I would urge you to go find some reporting by the NYTimes of something you know a lot about - your favoured programming language or a company you work for, and see how well their reporting matches your understanding of the topic. Here's the stuff that newspaper articles usually fail to mention in reports on therapy / drug studies 1) The definition of major depression has broadened and now includes a much greater range of people. The effect size of treatment is normally greater for people with more severe symptoms, although the relapse rate is also usually higher. 2) The way trials are run has changed, and many trials are not very good. One of the causes of this is odd regulation. 3) People seem to say that pills for psychiatric use are no better than placebo (not true) but that pills for physical health (eg hypertension) are better than placebo (true) but those people should also look at the effect size, which is often similar for both types of meds. http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/abstract http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/abstrac... Anti-depressants vs placebo: http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/epdf http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/epdf http://onlinelibrary.wiley.com/doi/10.1002/wps.20263/epdf http://onlinelibrary.wiley.com/doi/10.1002/wps.20263/epdf Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS) http://onlinelibrary.wiley.com/doi/10.1002/wps.20267/abstract http://onlinelibrary.wiley.com/doi/10.1002/wps.20267/abstrac... etc.
- icelancer 11y ago
  >Before you comment I would urge you to go find some reporting by the NYTimes of something you know a lot about - your favoured programming language or a company you work for, and see how well their reporting matches your understanding of the topic. The Gell-Mann Amnesia Effect. Which was coined of course by... Michael Crichton. Anyway, it's a good rule of thumb. http://www.goodreads.com/quotes/65213-briefly-stated-the-gell-mann-amnesia-effect-is-as-follows-you http://www.goodreads.com/quotes/65213-briefly-stated-the-gel...
- marincounty 11y ago
  I won't even comment on Therapy. I noticed you assumed, and rightly so, the uproar would be over psychiatic drugs? I don't have a problem with Therapy. Is hard to study, and at worst it doesn't seem to have any bad side side effects--besides on the wallet? We do get are feathers ruffled when Psychiartic drugs(mainly tricyclic, and hetricyclic antidepressants) are brought up. Why, because so many of us took them. I took them. My friends took them. I even encouraged a ex-girlfriend to take them. In my case they never worked, but I believed the literature, and thought I was just unlucky. I spent thousands on different drugs for depression and anxiety. I can't put a price on the side effects, and disillusionment. I imagine a lot of people are still on them. They were billed as the Wonder drugs. They were very expensive. Patients and Doctors were equally lied to by drug companies. They caused a lot of unnessary pain, and suffering. Too many people are still on them. I sometimes wonder if there's a correlation between some of these drugs and violence? I know if I was a prescriber, I don't think I would prescribe a heterocyclic Drug(Proxax, Zoloft, etc.). I just don't believe they work, but the industry is trying so hard to still justify their use--in selected patients--you know the "sickest patients seem to get a bit better--sometimes--in some situations?" If the history, and study of Erythromycin is in any way like the history, and study of Prozax; I will never take another antibiotic again. It's not that we hate all Psychiatric drugs, but some of them, especially the Happy Pills; were studied terribly, some even fraudently, and a lot of psychiatric patients are still very leary of a lot of these drugs; And so are the drug companies. I don't see any dancing pills in commercials anymore like I did in the 90's and 2000's? I just see ads by Lawyers. I don't see hubristic Psychiatrists advertising as "Chemical Imbalance Specilists" anymore. Psychiatry was hit hard by the deceitfulness of these drug comapnies. The profession just doesn't have the glamor factor anymore. Patients don't look at them the same way. I actually feel sorry for the honest ones, and the ones who keep their office visit prices reasonable. I couldn't imagine doing my residency in Psychiatry after graduation from med school these days. My fear is the wrong students will be admitted to Psychiatric residencies--students who weren't the best and brightest in medical school? So yes, there's usually an uproar when articles like this hit. I don't care if a particular drug is slightly better than Placebo; it's when they are so close to placebo, or not even close to Placebo when you include all the discarded/badly done studies, and all the metadata that boils my brain. They history of Proxaz makes makes a good read. Personally, I can't even read it anymore; it literally makes my head hurt. http://www.theguardian.com/society/2007/may/13/socialcare.medicineandhealth http://www.theguardian.com/society/2007/may/13/socialcare.me...
jrapdx3 11y ago
The problem I have with this kind of research are the intrinsic ambiguities regarding "depression" and its treatment. Depression is notably heterogeneous in its characteristics and origins. Even when careful diagnosis declares two people to have the same illness, it can't be assumed their conditions are actually identical. Furthermore, we know drug treatments can affect recipients unpredictably, depending on physiological factors. Similarly, psychotherapies, which are harder to administer in a consistent way, are subject to even greater variability in delivery and effect vs. medications. The bottom line is estimating the real-world effectiveness of any therapy is at best hazardous, and the results of research (or meta-analysis of studies) are likely only tangentially applicable to individual treatment situations. From many years on the front lines, I'm convinced depression and other disorders can be effectively treated and suffering reduced. What's important to remember is treatment is as much art as science, it can't be bottled or reduced to formulas. Outcome mileage varies, but it's largely dependent on the quality of the treatment team, the power of the partnership between patient and practitioner can't be overemphasized.

31 points by khc 11y ago

Hmm...I read about the lack of effectiveness of psychotherapy roughly 20 years ago in DER SPIEGEL. Within a set time period, around 10% of patients receiving psychotherapy got better. Of course, within the same period 10% of patients receiving no treatment also got better :-)

tormeh 11y ago
There being no effect at all is a ridiculous statement. Sure, it doesn't work for many people, but it worked for me. So if it works for some people, which I prove it does, then it has to inhibit recovery in others in order to have no net effect. I don't buy that at all.
- brookside 11y ago
  Therapy absolutely has an effect. That effect, however, happens to be about equivalent to placebo.
  - mattmanser 11y ago
    This is wrong and you do many people a disservice who might read this and think it doesn't work. I don't know where you're getting this and the article in no way supports your stance. From the article: Engaging in a course of well-tested psychotherapy, according to the new analysis, gives them an added 20 percent chance of achieving an even more satisfying improvement, or lasting recovery. An added 20 percent chance. Don't forget they're already saying that talking therapy is only 25% less effective than originally thought. They are still saying that talking therapy is effective! And at no point do they compare it to placebo. The very article we're talking about: 1) Disagrees with your extremist stance 2) Never mentions it nearing placebo level 3) You probably didn't read it as you didn't address it CBT, for example, is known to be particularly effective when dealing with anxiety as well as dealing with secondary symptoms and making people's lives better. It has an effect WAY above placebo. So why did you say this? Are you actively attempting to make people's lives worse by putting them off therapy? Also from the article: for those who do well or fully recover, “psychotherapy, particularly cognitive behavior therapy, seems to be most effective in cutting the risk for a relapse long-term,” Dr. Hollon [one of the co-authors] said.
    - brookside 11y ago
      They are still saying that talking therapy is effective! The most generous interpretation of figures in this article is that NNTT for depression and therapy is 5. Meaning one out of every five people treated by therapy will show some improvement due to effects of therapy itself. We can certainly call this effective in that there is an effect for some people who try therapy. But not for 80% of them. Therapy is a 10 billion dollar/year industry in the United States, with its practitioners often charging desperately unhappy people high rates (beyond what most of us lucky software devs make), with no advantage to show for their various methodologies beyond what one gets from talking to an untrained stranger. Financially successful yet largely bogus businesses and industries are never going to put themselves out of business and have little impetus to change the status quo. Awareness of the current poor options for mental health treatment is important. However uncomfortable or against an established narrative of "help is out there' it is to address these realities, it will be easier to marshall efforts to finding real mental health solutions if we aren't pretending the current paradigms are working when the numbers show otherwise.
      - mattmanser 11y ago
        Nowhere did it say only 20% are helped. It says 20% more effective with other treatments. Either you're not reading or you're not comprehending. I'm sorry therapy didn't work for you or you didn't want to try it, but I'm not sure what your agenda is. You seem to have some weird axe to grind about people making money. I'm not sure what else I can say as you seem to want to believe the whole thing's a big rip-off. Like where does the claim that untrained listeners are as good as trained ones come from?
        brookside 11y ago
        Making money is fantastic. Making money from desperate people with pseudoscience is bad. 20% more effective with other treatments. Not what the article says. (It is most unclearly worded.) You have a 20% greater chance of improvement with therapy above talking to a doctor (Note there no pharmaceutical course of action mentioned) not "with other treatment". My comparison of therapy to untrained listeners is not drawn from the article. There have been several studies done on this. Link to the one of first on google: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469.4634&rep=rep1&type=pdf http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469...
  - pessimizer 11y ago
    Talk therapy works a lot better than placebo, but it doesn't matter what kind. Talking to one type of therapist works as well as talking to another type of therapist. Even talking to a priest works as well as talking to a therapist. https://en.wikipedia.org/wiki/Dodo_bird_verdict https://en.wikipedia.org/wiki/Dodo_bird_verdict This article is more interesting for me in that it supports the dodo bird verdict. Cognitive behavioral therapy results have for a while been put forward as the exception. According to the article, those results have been inflated, and there are no exceptions. edit: of course, if you consider a priest the control for the psychology industry - then it may be fair to say that established therapies have no better success than placebo. Is a priest a placebo? edit: tl;dr ----- "The most commonly studied of [talk therapies is] cognitive behavior therapy — in which people learn to identify and defuse automatic, self-defeating assumptions, like 'I’m unlucky in love' or 'I always choke' — and interpersonal therapy, which focuses on reshaping how people interact with others. These studies typically have subjects engage in weekly, hourlong sessions with a therapist for three to four months. "The researchers found that 13 of these funded studies were completed but never published, usually because those who did the trials did not think a finding of no benefit stood much chance of being published. The team contacted each of the 13 investigators originally paid to do the work and requested their data. Once that data was included with those from the other, published papers, the effectiveness of the therapies dropped significantly — by about a quarter. "'That seems to be the magic number, a quarter — about the same as you see in the pharma trials' of antidepressants, said a co-author, Dr. Erick Turner, an associate professor of psychiatry at Oregon Health & Science University and the lead author of the 2008 paper detailing bias in those drug trials."
    - mattmanser 11y ago
      Your opening arguments completely disagree with the bottom quote. This isn't what you think it is. They're not saying CBT doesn't work or isn't more effective, they're saying it's not quite as effective as thought because people don't always report the failures. What's happening is that people who do a study that results in no positive benefit aren't publishing. But one study doesn't give the whole picture. There are many reasons why a singular study might show no benefit, a lot of them statistical reasons. What you need to do is look at all the studies, but the problem has been that the failing studies haven't always been published, which is bad science. So what's been happening is the published studies were: B NB B B NB B B B (6 benefit / 2 no benefit) When in fact the results were: B NB B B NB B B B NB NB (6 benefit / 4 no benefit) In science and statistics you have to report the false negatives too.
- rimantas 11y ago
  How do you know you are not one of the 10%?
  - raverbashing 11y ago
    Ignoring the scope of the study, let's ask a question Treatment A had a 10% effectiveness, Placebo had 10% as well (which for some kind of 'talk therapy' - and for a lot of other things may not have an exact placebo, but let's assume it is) is another 10% Question: Are those the same 10%? Or with a better example, naive blood transfusion (that is, if you ignore blood type) has a low rate of success
    - netrus 11y ago
      Naive blood transfusion has a low success rate, but it is surely higher than with placebo blood transfusion (whatever that would look like).
      - raverbashing 11y ago
        But when it doesn't work it usually kills the patient, so there's that

PhasmaFelis 11y ago

The original article title doesn't seem to be accurate. Should be "Effectiveness of Talk Therapy On Depression Is Overstated, a Study Says".

InclinedPlane 11y ago

Not surprised. Though really just deciding to do something about depression can often be enough to be helpful. Simply feeling like there's a path out of it can give you the strength to keep your life together and maintain ordinary levels of self-care (keeping your home clean, going to work regularly, keeping to a sleep schedule, engaging in activities, and so on).

DanBC 11y ago

These threads always fucking suck on HN. Before you comment I would urge you to go find some reporting by the NYTimes of something you know a lot about - your favoured programming language or a company you work for, and see how well their reporting matches your understanding of the topic. Here's the stuff that newspaper articles usually fail to mention in reports on therapy / drug studies 1) The definition of major depression has broadened and now includes a much greater range of people. The effect size of treatment is normally greater for people with more severe symptoms, although the relapse rate is also usually higher. 2) The way trials are run has changed, and many trials are not very good. One of the causes of this is odd regulation. 3) People seem to say that pills for psychiatric use are no better than placebo (not true) but that pills for physical health (eg hypertension) are better than placebo (true) but those people should also look at the effect size, which is often similar for both types of meds. http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/abstract http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/abstrac... Anti-depressants vs placebo: http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/epdf http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/epdf http://onlinelibrary.wiley.com/doi/10.1002/wps.20263/epdf http://onlinelibrary.wiley.com/doi/10.1002/wps.20263/epdf Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS) http://onlinelibrary.wiley.com/doi/10.1002/wps.20267/abstract http://onlinelibrary.wiley.com/doi/10.1002/wps.20267/abstrac... etc.

icelancer 11y ago
>Before you comment I would urge you to go find some reporting by the NYTimes of something you know a lot about - your favoured programming language or a company you work for, and see how well their reporting matches your understanding of the topic. The Gell-Mann Amnesia Effect. Which was coined of course by... Michael Crichton. Anyway, it's a good rule of thumb. http://www.goodreads.com/quotes/65213-briefly-stated-the-gell-mann-amnesia-effect-is-as-follows-you http://www.goodreads.com/quotes/65213-briefly-stated-the-gel...
marincounty 11y ago
I won't even comment on Therapy. I noticed you assumed, and rightly so, the uproar would be over psychiatic drugs? I don't have a problem with Therapy. Is hard to study, and at worst it doesn't seem to have any bad side side effects--besides on the wallet? We do get are feathers ruffled when Psychiartic drugs(mainly tricyclic, and hetricyclic antidepressants) are brought up. Why, because so many of us took them. I took them. My friends took them. I even encouraged a ex-girlfriend to take them. In my case they never worked, but I believed the literature, and thought I was just unlucky. I spent thousands on different drugs for depression and anxiety. I can't put a price on the side effects, and disillusionment. I imagine a lot of people are still on them. They were billed as the Wonder drugs. They were very expensive. Patients and Doctors were equally lied to by drug companies. They caused a lot of unnessary pain, and suffering. Too many people are still on them. I sometimes wonder if there's a correlation between some of these drugs and violence? I know if I was a prescriber, I don't think I would prescribe a heterocyclic Drug(Proxax, Zoloft, etc.). I just don't believe they work, but the industry is trying so hard to still justify their use--in selected patients--you know the "sickest patients seem to get a bit better--sometimes--in some situations?" If the history, and study of Erythromycin is in any way like the history, and study of Prozax; I will never take another antibiotic again. It's not that we hate all Psychiatric drugs, but some of them, especially the Happy Pills; were studied terribly, some even fraudently, and a lot of psychiatric patients are still very leary of a lot of these drugs; And so are the drug companies. I don't see any dancing pills in commercials anymore like I did in the 90's and 2000's? I just see ads by Lawyers. I don't see hubristic Psychiatrists advertising as "Chemical Imbalance Specilists" anymore. Psychiatry was hit hard by the deceitfulness of these drug comapnies. The profession just doesn't have the glamor factor anymore. Patients don't look at them the same way. I actually feel sorry for the honest ones, and the ones who keep their office visit prices reasonable. I couldn't imagine doing my residency in Psychiatry after graduation from med school these days. My fear is the wrong students will be admitted to Psychiatric residencies--students who weren't the best and brightest in medical school? So yes, there's usually an uproar when articles like this hit. I don't care if a particular drug is slightly better than Placebo; it's when they are so close to placebo, or not even close to Placebo when you include all the discarded/badly done studies, and all the metadata that boils my brain. They history of Proxaz makes makes a good read. Personally, I can't even read it anymore; it literally makes my head hurt. http://www.theguardian.com/society/2007/may/13/socialcare.medicineandhealth http://www.theguardian.com/society/2007/may/13/socialcare.me...

jrapdx3 11y ago

The problem I have with this kind of research are the intrinsic ambiguities regarding "depression" and its treatment. Depression is notably heterogeneous in its characteristics and origins. Even when careful diagnosis declares two people to have the same illness, it can't be assumed their conditions are actually identical. Furthermore, we know drug treatments can affect recipients unpredictably, depending on physiological factors. Similarly, psychotherapies, which are harder to administer in a consistent way, are subject to even greater variability in delivery and effect vs. medications. The bottom line is estimating the real-world effectiveness of any therapy is at best hazardous, and the results of research (or meta-analysis of studies) are likely only tangentially applicable to individual treatment situations. From many years on the front lines, I'm convinced depression and other disorders can be effectively treated and suffering reduced. What's important to remember is treatment is as much art as science, it can't be bottled or reduced to formulas. Outcome mileage varies, but it's largely dependent on the quality of the treatment team, the power of the partnership between patient and practitioner can't be overemphasized.