MSW with CBT vs Psychodynamic focus? How much does it matter?

[autumn7]

Hi all,

Deciding about MSWs. I've gotten the general message to go where you think you'll be setting up a practice, and to choose one that at least matches your chosen 'track', etc. I know that the general consumer does not care much about where you got your training, so long as you have the degree. However, if you know that you want to ultimately work in private practice, and you do have a preference for your training (say would prefer psychodynamic background vs. more CBT-based program) does it make sense then to relocate for an MSW? Or, is that more hassle than it's worth?

My reason is that I live near a a top-tier MSW program (University of Michigan), and they are known for having solid CBT training in the curriculum. NYU and Smith have a reputation for strong clinical training in psychodynamic and object relations. I see the CBT as being very useful tool, and highly sought after by most clinics and insure companies etc. However, my background in psychology and work experience leads me to have a stronger, I guess, 'intellectual' preference for having the psychodynamic training as a foundation, and doing post-grad training in CBT/DBT etc. Essentially, I'd like to have the strongest background in psychology, and build from there.

I know that a lot of this is determined by personal preference, state in which you practice, population served etc, but I'm just wondering if those in the therapy world could weigh in on this? How important is it to get that solid training from the get-go? Does doing a more Behavioral program like UMich make me less employable if I were to hypothetically end up on the East Coast and want to teach in one of the more psychodynamic oriented programs?

Thanks for reading my lengthy post!

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[R. Matey]

I have an LPC, so my experience might be a little different, but my program was definitely more Object Relations/Adlerian focused than CBT. I identify much more as a CBT therapist, and had to seek out training in practicum and post-master's licensure supervision with those who would train me in this approach. My colleagues in my cohort who bought into and trained in Object Relations had a difficult time post graduation finding jobs (again, I'm a LPC) which allowed them to practice this way without any additional experience. They had to go the route of EBPs and play serious catch up during the post-master's, pre-license phase. IMO, I think the reverse might actually be better: train at UMich and then do post grad training in Object Relations/psychoanalysis. It would open you up for more jobs in the short term while you become deemed an analyst at a respected psychodynamic training institute.

 

[autumn7]

IMO, I think the reverse might actually be better: train at UMich and then do post grad training in Object Relations/psychoanalysis. It would open you up for more jobs in the short term while you become deemed an analyst at a respected psychodynamic training institute.

Thank you, this is very helpful. It does make sense to have the CBT training first.

And just to clarify, I truly meant psychodynamic psychotherapy instead of straight psychoanalysis. From the therapy world that I'm familiar with, the term 'analyst' usually referred to those dyed-in-the-wool psychoanalysts using a method very similar to Freud's. But yes, I think you're very right that any of Object Relations/ psychodynamic/Adlerian training can be added on.

 

[autumn7]

You should also think of what is best for your future clients and not just the modality that you personally prefer. Psychodynamic therapy is not supported by the research evidence for most things and is even contraindicated for some (e.g., OCD, etc.).

I agree with you here. Psychodynamic is not the golden ticket. But I do think that knowledge of these philosophies is helpful to becoming an effective and sensitive therapist. The development of CBT, DBT, and mindfulness work has been a crucial piece for western psychologists - it really helps people, and gives them tools within the first few sessions. However, I still believe it would be a disservice to the fields of clinical psychology and clinical social work, if too few people have a solid psych background.

 

[R. Matey]

You should also think of what is best for your future clients and not just the modality that you personally prefer. Psychodynamic therapy is not supported by the research evidence for most things and is even contraindicated for some (e.g., OCD, etc.).

Huh, I believe there's evidence to support psychodynamic treatment for PTSD and personality disorders. I could be wrong though.

 

[autumn7]

Huh, I believe there's evidence to support psychodynamic treatment for PTSD and personality disorders. I could be wrong though.

There is plenty of evidence to support psychodynamic treatment, for many populations. And the research is out there. A place like Mass General Hospital/Harvard Medical School wouldn't still be employing this technique, and doing clinical research on psychodynamic psychotherapy outcomes if it wasn't an established effective treatment. It just absolutely is. Insurance companies are pushing for evidence-based, and CBT is much easier to study empirically. Psychodynamic studies are catching up, but the longer term treatments, and long-term benefits are more difficult to quantify.

There are plenty of cases of therapists who were less than skillful or careful. But those cases are the exception, not the rule. There are many more examples of the process leading to self-awarenes, insight, positive changes, building of trust. This method is especially powerful in psychodynamic psychotherapy groups. So, it isn't true or fair to say "Psychodynamic therapy is not supported by the research evidence for most things". I have to respectfully disagree with psycscientist on this.

 

[R. Matey]

That was educational. I would ask for something to read from you, but the truth is, I'm not actually going to get to it right now. Ah, grad school...

 

[R. Matey]

There is evidence for brief psychodynamic therapy for depression (though evidence is not as strong as that for CBT). There is also evidence for therapies based on psychodynamics for Borderline PD. There is no good evidence that supports use for PTSD (especially given gold standard treatments like PE and CPT).

This website maintained by APA's Div 12 provides a great overview of evidence-based treatments: http://www.div12.org/PsychologicalTreatments/

That was a very helpful link. Thanks! I'm learning so much today! It does say on that website that not all psychologists agree on exactly what constitutes an empirically validated treatment (Francine Shapiro and Marsha Linehan come to mind). Also, I'm curious if many psychiatrists would agree with you. I'm not looking to defend psychodynamic psychotherapy against research, I have no reason to (as I said, I practice CBT).

I am curious though if you think that therapists who achieve their licensing requirements and go on for psychoanalytic training at reputable centers
(such as this one: http://www.psychoanalysis.columbia.edu) are doing their clients a disservice by not practicing EBTs.

Thoughts?

 

[autumn7]

You might want to familiarize yourself with the literature before disagreeing. The RCT literature does not support your claim that psychodynamic therapies are a front-line treatment for anything. There are plenty of people doing research on psychodynamic outcomes in order to see what it's effective for and how it compares to other treatments. The fact that research is done does not mean that it is an empirically supported treatment. People like to argue that it's hard to study, but it's really not. We should be able to demonstrate outcomes for our treatments. That's good science and ethical practice. It's a disservice to clients (and I would argue unethical) to treat them with a protocol with less evidence over an established treatment that has repeatedly demonstrated effectiveness.

We may be debating around a topic without actually defining the terms. Have you read The Efficacy of Psychodynamic Psychotherapy by Jonathan Shedler?

I think that to administer strict CBT therapy without the awareness of psychological processes is analogous to asking someone to perform surgery without learning human anatomy. We may be misunderstanding each other's perspectives? By the sounds of it, you're just saying "away with psycho-dynamic psychotherapy", and that's a very misinformed statement. How could a person treat another without understanding concepts of projection, defense mechanisms, etc? This is crucial information for understanding the human psyche. Medicine has learned a lot about the importance of bedside manner on treatment outcomes of patients. Psychologists know this well, and repor is a big part of what makes for an effective psychotherapist. CBT is an important tool for therapists, but CBT alone cannot replace comprehensive treatments like those of well trained psychodynamic practitioners. The seasoned practitioners for whom I have greatest respect are able to use methods from many modalities, CBT included.

You may be assuming that we're debating Freud against Skinner, or something very basic? I'm not pitting one camp against another and say that their insights and findings are mutually exclusive. Both frameworks can coexist, and provide useful tools for helping humans learn to release themselves from suffering.

 

[autumn7]

I don't think Marsha Linehan or Francine Sharpiro would disagree that a rigorous scientific approach (e.g., RCTS and effectiveness trials) is the gold-standard for evaluating treatments (indeed both have evaluated their treatments in this way). DBT has enjoyed a lot of good evidence in a very difficult to treat population. EMDR is certainly a treatment that works according to the evidence. The issue there is that the science suggests that it does not work in the way that the developers claim it does (e.g., through the eye movement mechanism). The eye movements appear to be pretty irrelevant, and the active ingredient appears to be exposure. But I don't think anyone debates that the treatment works in terms of its main effect on outcomes.

With regard to your question, I think it depends. I know many psychoanalysts who build their practices with the "worried well" (e.g., people who do not have a diagnostic disorder, but want therapy for more existential, growth reasons). I think in cases like this, someone could certainly attain that type of benefit from a psychoanalytic or dynamic approach. I also certainly think that these approaches can be appropriate if a client has already tried the front-line treatment and has not benefited.

Where I think it becomes unethical is when someone with a disorder that causes distress and functional impairment presents for treatment and a therapist treats this person in their preferred modality, without concern for whether that modality is the most appropriate treatment and without fully informing the client of the state of the evidence for that modality versus other treatments out there. For example, if a client with OCD presented for therapy and the therapist treated them with psychodynamic therapy rather than alerting them to the existence of the gold standard effective therapy and referring them for Exposure and Response Prevention therapy, I would say that's a breach of ethics.

If someone wants to practice psychoanalytic therapy, I say have it. But don't prevent people who are suffering from having a chance to access the most effective known treatments first.

We probably agree on a lot of this. DBT is a great development. (I have more concerns about EMDR, but that's another discussion...)

I agree that in many cases, CBT techniques should be offered within the first couple of session. I also agree that it would be unethical to treat OCD with psychotherapy alone, knowing what we do now. I'm not sure how many clinicians though, know exactly what their treating at first. That's why it's helpful to have well-trained therapists with breadth of knowledge in the field. I guess I'm mainly arguing against tossing out the important framework in favor of "you're in you're out, all better" or strict "evidence based" procedures. It just seems inhumane to me.

 

[R. Matey]

.

You make great points psychscientist, but I think your tone is a bit aggressive. I would think through UMich's MSW program and post grad training at a psychodynamic institute, autumn7 would hopefully learn how to select EBTs and as well as, when and under what circumstances, should autumn7 administer psychodynamic psychotherapy through supervision and coursework. Even if autumn7 didn't, it's not productive to react so strongly to the nascent thought processes of a person considering a career in psychotherapy. Sure, it maybe better to address this now rather than later, but show a little more tact. You're a practicing psychologist. You are much more of a field insider than autumn7 at this point. Reading this thread is like watching LeMarcus Alderage play the high school basketball team. Wouldn't be better if he coached?

 

[autumn7]

Sure, if this person took that course of training, they could potentially get the training needed to make those determinations. However, that doesn't seem like the for sure course, given that the original question was about which training to go for.

These are pretty pressing issues for the field, especially since Master's level training is even less uniform and regulated in terms of what folks get trained in than doctoral programs. I think it's necessary to respond to misconceptions of those who don't know what they don't know early on. I don't think I lacked tact. The poster wanted info from folks in the field and so I provided a relevant perspective that this person will eventually encounter if they move forward with this path.

If you have an axe to grind about this topic, I think your energy would be better spent elsewhere. I'm not submitting for peer review here, yeesh. I'm a prospective student choosing a direction, asking for some input.

This is a topic I'd like to do more research on, but I have spent time working on interdisciplinary teams, and working in clinical research. So I'll certainly keep reading! There is a lot to learn!

And, to clarify the mis-read from the beginning - I didn't say "Only psychodynamic! For everyone! Forever!" I asked "which one first/primary?"

Anyway, this does ignite a topic of interest for me... so I'll keep learning. I appreciate the thoughts.

 

[AllUnits]

I'd like to add my perspective and experience here because this is a topic that interests me as well. My personal interests are in psychodynamic modalities. Their theories fit my personality, my beliefs about mental processes and the basis of disorders. I have personally responded very well to psychodynamic therapy and very poorly to CBT. I believe it is in the best interest of the population that I am interested in and plan to work with to practice psychodynamic therapy.

However, I work at a place where the clinicians (not I, I am not in grad school yet) practice CBT and have a very strong bias for CBT for the reasons articulated by many in this thread. I am educating myself on CBT as much as I can because I want to be very familiar with the modality, even though, as I learn a lot about it, it is not convincing to me. The research that supports CBT is solid and CBT has its place in helping people, but it is not the only evidence-supported form of therapy. This is a misconception based on the scientific ability we have to study different modalities. Psychodynamic therapy is simply less quantifiable than CBT, but it is definitely not evidence-less.

Working in a CBT field, I have learned that I definitely will need to do my field practice at a place where I get to learn and apply psychodynamic theories. Doing it in CBT just to get through my grad school will make me unhappy because it will not match my personal views of the purpose and goals of therapy (again, for the population in which I am interested.) Different clients will respond to different modalities and it is our job, as professionals, to identify them and to treat them accordingly or refer them to a clinician who might be able to serve them better.

For example, someone suffering from an ED would be treated very differently by a CBT vs a psychodynamic therapist. The person might respond well to homework, learning about nutrition, keeping a diary, and practicing mindfulness. But other clients might not. They might need to explore the underlying reasons for their ED with much more depth and CBT simply is not set up to do that. Long-term therapy has become a dirty word in the field because of insurance companies and a misunderstanding of how psychoanalysts and psychodynamic clinicians view the client but long-term therapy has been shown, again and again, to have long-lasting benefits (in some studies, more long-lasting and farther-reaching than CBT.) The client may also not respond well (or at all) to the didactic/professorial/parental type of stance that the CBT therapist employs. They might respond better to a therapist who is a guide, an empathic listener, a collaborator in exploring a more comprehensive picture of the entire person, not just of the behaviors directly interfering with their wellness. In this case, CBT can be a very good entry into exploring those motives, but psychodynamic therapy may be where the bulk of the work ends up being. Anyone presenting with a dx generally claimed by CBT has a high likelihood of dealing with other comorbid diagnoses and CBT is not set-up to explore those fully.

I believe that there is a place for all of us in the field. Human beings are complex and unique and to say that all will respond to the same treatment would be a huge disservice to the clients. Our field is still divided by the direction of research between case study and large studies and this division is to the detriment of our clients. The benefits of these 2 directions should be dictated by the individual client, not by our personal beliefs in what works based on our own experiences, histories, and biases. My personal opinion is that we should all do the work to expose ourselves to all the research and theories, but practice as much as we can and as ethically as we can, in the modality for which we are best suited. It's okay that we disagree but it's not okay to claim that what we disagree about should be the deciding factor on what is best for ALL clients. Referrals and collaboration, based on facts and comprehensive education, should be the basis of all of our practice.

 

[erg923]

My personal interests are in psychodynamic modalities. Their theories fit my personality, my beliefs about mental processes and the basis of disorders. I.

This is irrelevant to guiding the professional practice of psycholology.

"AllUnits, post: 15506436, member: 611799] They might need to explore the underlying reasons for their ED with much more depth and CBT simply is not set up to do that.

This is NOT accurate and shows surface level understanding of CBT theory and practice. Please read up on "core beliefs" and how social cognitive theory uses developmental explanatory models of psychopathology. Also, collaborative is the name of the game in CBT, although so is psychoeducation. If you think its "professorial" you either are mispercieving or had a bad model.

What constituties "long-term therapy" is subjective. If you are talking about a year or two and the GAF never moves, yes, this a dirty thing, both from a cost analysis perspective and from a clinical perpective. Seems quite obvious. As I do peer review for the managed care industry, I feel I have a solid grasp of both side of the coin here. Controlling costs in inextricabley linked with controling quality of service. Allow me to illustrate an example of recent conversation I had:
E.g., "But doctor X, we do not cover on going, long term, non-directional, psychdyanamic psychotherapy with no end in site especially when there has not been any benefit from 30 visits of psychotherapy as evidenced by your charting which reflects a GAF score of 55 at visit one and a Gaf Score of 55 at visit 30."

Anyone presenting with a dx generally claimed by CBT has a high likelihood of dealing with other comorbid diagnoses and CBT is not set-up to explore those fully.

This is false

I could seize on numerous other points of this post, but I am not going to for the sake of time. Unless you are trained mental health professional, I suggest not making assertions like you have. You have surface level understanding of some issues and frank misconceptions about others.

 

[R. Matey]

I have to agree with erg and psychscientist here. AllUnits, Your personal preferences matter little in terms of psychotherapy service delivery. The ethics of the profession (whether it be social work, counseling, or clinical psychology) mandate the use of evidence based practices in psychotherapy for client protection. The picture you painted of CBT reflects a gross misunderstanding of what CBT actually is. Therefore, erg is right to say to that you should educate yourself before you make such a strong assertion. As psychscientist mentioned previously, there is a place for therapuetic rapport in CBT as in many other evidenced based treatments. Most of us who practice psychotherapy are aware of how to utilize therapist and client factors while using evidenced based treatments. That is the role of skill in this profession.

 

[AllUnits]

All of us will be naturally attracted to different modalities. That is why we choose to go into different types of practice and that is precisely why this debate exists, not just in this student forum but among researchers and practitioners on all sides. How is that irrelevant to the practice of psychotherapy? If you believe that there is only one evidence-based modality, then of course it would be unethical to practice any other. I do not see convincing evidence that CBT is the only evidence-based therapy.

It is true, as I stated in my initial post, that I am not sufficiently educated in CBT. I am actively learning more about it and seeking to educate myself, but the initial poster asked a question, and I added my *opinion* to the list of responses, as have you. This is a student forum not a forum for mental health professionals, so of course I can make assertions based on my experience.

This is irrelevant to guiding the professional practice of psycholology.



This is NOT accurate and shows surface level understanding of CBT theory and practice. Please read up on "core beliefs" and how social cognitive theory uses developmental explanatory models of psychopathology. Also, collaborative is the name of the game in CBT, although so is psychoeducation. If you think its "professorial" you either are mispercieving or had a bad model.

What constituties "long-term therapy" is subjective. If you are talking about a year or two and the GAF never moves, yes, this a dirty thing, both from a cost analysis perspective and from a clinical perpective. Seems quite obvious. As I do peer review for the managed care industry, I feel I have a solid grasp of both side of the coin here. Controlling costs in inextricabley linked with controling quality of service. Allow me to illustrate an example of recent conversation I had:
E.g., "But doctor X, we do not cover on going, long term, non-directional, psychdyanamic psychotherapy with no end in site especially when there has not been any benefit from 30 visits of psychotherapy as evidenced by your charting which reflects a GAF score of 55 at visit one and a Gaf Score of 55 at visit 30."



This is false

I could seize on numerous other points of this post, but I am not going to for the sake of time. Unless you are trained mental health professional, I suggest not making assertions like you have. You have surface level understanding of some issues and frank misconceptions about others.

 

[AllUnits]

R. Matey, thank you for your response. I absolutely do NOT believe that a therapist should treat every client that comes through the door in the therapist's preferred therapy (and by preferred therapy I mean the type of therapy in which one specializes, not a personal preference). If someone is not suited for psychodynamic therapies and there is evidence for better treatment, the client should be referred to a more appropriate clinician. It was a point I tried to make at the end of my post. I can imagine many situations in which I would opt to inform the patient of more appropriate courses of treatment and refer them to a CBT clinician.

psych scientist said this well: "Where I think it becomes unethical is when someone with a disorder that causes distress and functional impairment presents for treatment and a therapist treats this person in their preferred modality, without concern for whether that modality is the most appropriate treatment and without fully informing the client of the state of the evidence for that modality versus other treatments out there."

I have to agree with erg and psychscientist here. AllUnits, Your personal preferences matter little in terms of psychotherapy service delivery. The ethics of the profession (whether it be social work, counseling, or clinical psychology) mandate the use of evidence based practices in psychotherapy for client protection. The picture you painted of CBT reflects a gross misunderstanding of what CBT actually is. Therefore, erg is right to say to that you should educate yourself before you make such a strong assertion. As psychscientist mentioned previously, there is a place for therapuetic rapport in CBT as in many other evidenced based treatments. Most of us who practice psychotherapy are aware of how to utilize therapist and client factors while using evidenced based treatments. That is the role of skill in this profession.

 

[erg923]

All of us will be naturally attracted to different modalities. That is why we choose to go into different types of practice and that is precisely why this debate exists, not just in this student forum but among researchers and practitioners on all sides. How is that irrelevant to the practice of psychotherapy?

One has a moral, ethical, and legal obligation to provide services that are based on what research literature supports as most effective and efficient. That's what being a "mental health professional" means. Its what differentiates you from my grandma (grandmas are always therapeutic). Or having coffee with a "life coach." People who are not mental health professionals have no such obligations, and thus can use whatever maybe therapeutic as a first line treatment. Licensed professionals do not have that luxury.

It is true, as I stated in my initial post, that I am not sufficiently educated in CBT. I am actively learning more about it and seeking to educate myself, but the initial poster asked a question, and I added my *opinion* to the list of responses, as have you.

No, you didn't state your "opinion" about CBT. You made assertions that it wasnt equiped for that, and did not look at that, etc. Those were presented as factual statements, not opinion. Those statement were not accurate. You should expect inaccurate information to be corrected by the "Doctors" on Student-Doctor Network.

 

[AllUnits]

I appreciate your feedback and your comments on my post. I am here to learn and I do have a lot more to learn about the practice of psychotherapy and about the research in the field, as I keep pointing out.

It does sound to me, however, that there isn't anything one can say to support one's interest in the practice of psychodynamic therapies that would not trigger you to assert that psychodynamic therapies are "not the front-line treatment for anything" and that practicing them is somehow unethical or not sufficiently supported by research. It seems to me that until autumn7 and I agree with you and concede that CBT is the way to go, you will continue to tell us that we are not educated or informed enough.

Actually, this is not entirely accurate. SDN self described in the following way

"We are a vibrant nonprofit organization of thousands of pre-health, health professional students and practicing doctors from across the United States and Canada. Membership is free. The educational mission of SDN is to assist and encourage all students through the challenging and complicated healthcare education process and into practice."

So really this is a forum for students and prospective students to get guidance and advice from those who have already been there and have expertise. People can post whatever opinions they like, of course, but let's not pretend that all opinions are equal. There is a clear difference between expert opinion and opinions from those that simply don't have the full knowledge yet. I always cringe when I see people who have had limited to no training in treatment making assertions about treatment and the best way to practice as if they have the appropriate knowledge to do so.



I'm glad you agree, however you still seem to hold the opinion that psychodynamic therapies can be a front-line treatment in cases where it is clear that the evidence favors a different treatment. However, there is no research to suggest that, for most disorders, psychodynamic therapies are a front-line treatment.

There also seems to be a misconception by some in this thread that evidence-based therapies aren't evidence-based for comorbidity and so when someone has multiple disorders, you can do whatever you like because nothing has been shown to work. This is false and based on the misconception that modern RCTs only enroll patients with the disorder of interest and exclude those that have comorbidity. This was true in the very early days of RCT research, but most RCTs contain comorbid samples. I do treatment outcomes research and my samples are as messy diagnostically as what you would find just about anywhere.

We also don't have good enough research at this point to predict who will respond to what type of treatment, so there's really no way for a practitioner to make that decision based on evidence. And making that decision based on their own opinion is problematic. We have lots of research that suggests that using the evidence to inform practice decisions is always more accurate than nebulous "professional judgement" alone. Individual judgements are biased. That's why we do research. Things that seem like they would be helpful do not always pan out. Consider all the well-meaning folks who treated people using Critical Incident Stress Debriefing. Sounds good in theory, get people to talk about trauma to try to prevent them from developing psychopathology. Unfortunately, the research has shown that CISD is actually harmful. There are lots of well-meaning practitioners out there who do not guide their practice by science, and unfortunately have the potential to cause harm.

 

[erg923]

I appreciate your feedback and your comments on my post. I am here to learn and I do have a lot more to learn about the practice of psychotherapy and about the research in the field, as I keep pointing out.

It does sound to me, however, that there isn't anything one can say to support one's interest in the practice of psychodynamic therapies that would not trigger you to assert that psychodynamic therapies are "not the front-line treatment for anything" and that practicing them is somehow unethical or not sufficiently supported by research. It seems to me that until autumn7 and I agree with you and concede that CBT is the way to go, you will continue to tell us that we are not educated or informed enough.

We (psychologists) should be fascinated by the dynamic working of the human psyche. That's not in debate. What IS in debate is how you practice. You should concede to evidence (not myself or Psyscientist) if you are a rationale and scientifically oriented person. Which, by the way, is required if you desire to practice "professional" psychology.

Obviously, one can cherry pick literature/certain studies to fit our preconceptions or desires. That's a well known cognitive bias demonstrated over and over in the cognitive and social psychology literature, right? I could probably find a study that supports the idea that the sun will turn into a brand muffin next Tuesday. But that's not how we really use science, is it? Science is more like a civil court case. Preponderance of the evidence. And, the preponderance of the evidence suggests that CBT interventions are the most effective and the most efficient treatment modality currently available. Underlying explanatory models based on C-B psychological principles also happen to be the most parsimonious and are supported by experimental psychopathology research.

Is long-term, explorative therapy (of any type) neat, educational, and possibly improve health. Maybe (it could also enable, result in dependency, result in no improvements, or be be counterproductive). Is it medically necessary? Absolutely not. Why on earth would BlueCross of (insert state name here) pay for 100 sessions of something when it is not medically necessary and the desired health outcome can be produced in 16 sessions?

Lastly, in case you are tempted to challenge the above with the assertion that if a patient wants long-term treatment, who am I to deny that, please consider the following ethical code for psychologists.
10.10 Terminating Therapy
(a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.

 

[turtlereef]

Some pretty strong opinions. First of all, what is meant by "evidence based"? And is that the same as "empirically supported"? These are not interchangeable terms and have different epistemological implications. If random control trials is the only conditions for producing evidence then we cannot have the science of evolution or geology to name two. Does that mean there is no evidence? or just that the evidence is not what is labelled as empirical guided by the research method that choses RCT over all others. No true scientist would be so narrow toward finding the truth. And psychology is as much a human endeavor with a component of relational and emotional responsiveness that is highly subjective and has to be. Like it or not there is an art to therapy. It is not pure science by any means. We are not behaviorists studying rats in a controlled lab environment.

Psychodynamic can mean many things. It has been treated as one entity which couldn't be farther from the truth. If you want to understand and "review the literature" as was recommended, then a fuller understanding of how many different approaches there are and how they work needs to be at least acknowledged. Newer branches use infant research and neuroscience. There is an emphasis on the therapeutic relationship, which common factors research tells us have a larger effect size than methodology by double. That emphasis is also supported by attachment theory, which is no longer a "theory" but proven to be universal and cross-cultural. Attachment therapies are very effective and have a strong evidence base. Attachment comes directly out of psychoanalysis and is psychodynamic in principle. Infant research has shown that humans are hard-wired to be relational and that that can be taken as one of the most important "drives" so there is a whole school of psychoanalysis called Relational that is highly effective and is used in agencies as the treatment of choice.

Psychoanalytic approaches differ widely, and no longer share commonalities. There is a pluralism now. And many of the fundamental principles have been rejected and replaced. So when I see "psychodynamic" I have to wonder which one? What particular approach is meant? For people who believe that there is no evidence base for these approaches, it is their responsibility to specify which approach is meant before one can dismiss it. Otherwise it is similar to saying no emotionally oriented therapy is effective. That only behavior and cognition matter and produce change. Well, that is so sweeping and broad that it requires investigation. It is also narrow at the same time.

There are studies that question the effectiveness of CBT long term for depression. There are supposedly empirically sound research studies that use CBT to address rumination but completely leave out stressors. How many people do you think have depression only due to rumination and have no stressors? Yet this qualifies as empirical because it is RCT. You see there is a circularity to insisting that that is the only form of evidence and that the evidence supports the use and effectiveness of the treatment. It leaves so much out that I wonder how such studies get published or even funded in the first place.

There are also studies that compare "master" therapists of different approaches. It turns out that none follow a "manualized" method at all. But manualization is a pre-requisite for certain types of studies to prove empirical truth. Problematic. The truth is much more complex and less neat. And the messiness is something that various schools of psychoanalytically informed therapies are rather good at handling.