Efficacy of Psychodynamic Psychotherapy

[Professor Xero]

Hello everyone-

I am interested to learn whether any of you have read the article published by Jonathan Shedler in the most recent issue of the APA's flagship journal the American Psychologist entitled "The Efficacy of Psychodynamic Psychotherapy" ? (freely distributed on APA's website:http://www.apa.org/pubs/journals/releases/amp-65-2-shedler.pdf)

For those who have read it, I am hoping to stimulate a discussion regarding the potential implications of Shedler's conclusions. For those on this board who champion the positivist empiricism of outcome data, do you find his methodology/statistics compelling? If no, then what methodological weaknesses present themselves? Along those same lines, what then must be done for psychoanalytic forms of psychotherapy to convincingly demonstrate either its efficacy, or lack thereof, concerning its ability to promote symptom reduction (although I think it has more to offer than just the relief of behavioral symptoms).

Playing devil's advocate, what if, after reading the article, you are reasonably confident that the effect sizes that Shedler reports are valid and reliable - will this meaningfully change the way you approach providing psychotherapy?

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[Ollie123]

Will reply in greater depth when I have more time, but briefly...

No, it was just another demonstration of lack of methodological rigor. I don't doubt psychodynamic therapy may be effective...in some cases, for some disorders.

I have a serious problem with collapsing across disorders. This is NOT equatable to not ruling out co-morbidities. Samples could be made more externally valid, but by collapsing disorders together, we may miss some robust interactions. I suspect if we compared treatment for OCD, the results would paint a very different picture than they currently do...but we can't because as far as I can tell, no one from the psychdynamic crowd is willing to even try to produce evidence for that. I have a problem with the research that confounds treatment length with treatment modality and tries to draw conclusions about modality, which a decent portion of the literature does. If you were a client, would you rather go 2x a week for a year to fix the problem, or once a week for 16 weeks? What if you were an insurer? Free market, so people can pay for whatever they want, but I think in that case people need to disclose treatment options, which is very rare in this field.

Upsides: A call for more, better research. I agree, and am not inherently against psychodynamic practice, I just want to be convinced before it goes into regular use. A discussion of why the bias exists. I agree its unfair...that needs to be changed and psychodynamic therapy needs to get attention from the scientific community. I agree that some research needs to be made more accessible to practitioners. At the same time, doctoral-level providers have a responsibility to be more capable of understanding complex research. Those who don't, and schools that don't train people to do so should not be licensed/accredited. The findings for continued gains post-treatment are fascinating and should be explored further. I'm not sold that is a solid effect due to the problems described above, but it needs to be examined further to see.

The BIGGEST downside: This article is once again published in a major APA journal that ALL members receive and will be abused as a blanket "See, now we can do whatever we want!" by practitioners. I pointed out a few of the flaws above. Plus, treatment in research settings frequently differs from treatment as usual in the average clinic where there is no one watching over your shoulder.

 

[lamorena]

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[Therapist4Chnge]

As lamorena pointed out, there are distinct differences between psychdynamic and psychoanalytic practice. Timed-limited psychodynamic therapy can be a realistic option (in some cases/disorders).

I'd also like to offer that psychodynamic treatment can take longer compared to the various cookbook therapies out there (<--tongue in cheek), it can provide an alternative treatment for patients who have not found benefit with the most common EBTs.

This offers a nice opportunity to explore some design limitations in the current literature of both psychodynamic and other orientations (CBT, ET, etc). I haven't gotten a chance to read the article yet, but I'm hoping we can have a worthwhile discussion about not only study design, but also about some of the philosophical differences between orientations and how that informs outcome "success".

 

[FadedC]

there also has been research that shows that it is the therapeutic relationship that heals. which can be present regardless of your approach.. just some food for thought 🙂

Well it should be stressed that while the therapeutic relationship definitely heals, it doesn't mean it's the ONLY thing that heals. It's kind of like the placebo effect where even if you take a drug that does nothing, you'll still feel better. The importance of the research then becomes finding out what things have an effect beyond the placebo, or in the case of psychology, beyond the relationship.

 

[JockNerd]

there also has been research that shows that it is the therapeutic relationship that heals. which can be present regardless of your approach.. just some food for thought 🙂

It's REALLY important to not misinterpret common factors research as saying "everything works." That is *not* the thrust of common factors. The relationship is necessary to therapy in the same way that a good physician-patient relationship improves medication treatment--in that case, not because the relationship magically heals the patient, but because a good relationship improves treatment adherence and treatment expectations.

 

[lamorena]

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[Ollie123]

i have not yet read this article, and will do when i get a sec.. but quickly, i think there may be some confusion here between psychodynamic and psychoanalytic therapy. psychoanalytic therapy typically requires the client to be seen a few times per week, costing a ton of money and taking years, and historically has been available to more privileged clients. psychodynamic therapy can take place in sessions that occur only once week. there are plenty of psychodynamic providers that insurance pays for and require that clients only come in for weekly sessions.

Absolutely true that more time-limited forms of psychodynamic therapy exist. They better, as it represents a significant real-world problem that needs to be addressed. However, based on my reading of the literature, even in these cases the average number of sessions is typically greater than that of other modalities. Furthermore, even some of the "better" comparison research will compare say, 16 sessions of CBT with 32 sessions of psychdynamic. The author of this article uses some of this information to conclude equal efficacy. I disagree. Strongly. Even if they do have equal effect sizes at EOT, unless there is a compelling reason why not (i.e. previous treatment failure) that outcome still means other modalities should be the first-line treatment. Again, I'm all for adopting a positive psychology approach and looking at factors beyond symptom remission....but that needs to be established empirically, not just assumed to exist. Furthermore, if positive findings are found for that, it still opens up a whole new can of worms...should insurance pay for treatment that extends beyond symptom remission? Obviously it only matters if treatment length were increased, but then there is also the facet to which the "positive" changes buffer against future psychopathology, in which case it gets even murky. I say no to insurance paying for anything beyond symptom remission, just like I don't feel they should pay for plastic surgery, but I can pretty much guarantee there would be a substantial portion of APA screaming yes for the sole purpose of securing more money for themselves without any consideration of the larger picture.

there also has been research that shows that it is the therapeutic relationship that heals. which can be present regardless of your approach.. just some food for thought 🙂

Also true, and I don't doubt for a second that alliance accounts for a substantial portion of the variance in treatment outcome. However (and please don't take this personally), I think this is another area where people make WAYYYY too much of some results in order to justify continuing with the status quo of questionable practice. I've seen the statistic "70-80% of the variance in outcome" thrown around here and elsewhere with some regularity. The only study I've found that demonstrated a number close to this one wasn't causal. In other words, both alliance and outcome were assessed at the same time point (end of treatment). This is relatively meaningless since it seems equally probable to me that people who get substantially better "Like" their therapist more because of this. Good research would account for that. There has been some better work done on the topic, but I haven't seen that number reproduced in a quality design, though if someone can point me to one I'd be very interested to read it.

Again, to me it seems like people often use the alliance literature as an excuse and/or, haven't actually read original sources (not saying this is the case for you). I make no claims to be an expert myself - in fact its incredibly removed from pretty much everything I study. However, I have done some digging for primary sources, in part motivated by discusions here, and have been relatively underwhelmed with what I've seen relative to the veracity with which it is frequently discussed. That doesn't mean an effect isn't there...like I said before I'm sure they are. However I'm also certain its only a part of the picture. I'd want a therapist that stays as up to date as possible and attends to everything that promotes successful outcomes, not just someone who attends to a single one (even if it is substantial) and then says "Close enough".

 

[lamorena]

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[JockNerd]

of course! i was just merely mentioning that it is another healing factor-- that regardless of whether you use CBT, psychodynamic theory, gestalt, whatever, your approach can be healing. i certainly agree with what you are saying. in fact, im someone who tends to favor a blending of various approaches, and determining what approach(es) will best benefit the client in particular to assist them with their specific issues. and im definitely all about EBT's, believe me 😉

That's good! And I think you get at the real crux of common factors--what works, for whom, under what conditions, for what presenting problem? But see how clearly we have to talk about these things... you mentioned prettymuch bona fide therapies up there. Now, that doesn't mean that the alliance is healing, or that therapy itself is healing, for *everything* people do clinically. And, people DO use common factors as an excuse to do silly or dangerous and potentially harmful things, like rebirthing.

I think we're on the same page, really; I think I'm just a bit knee-jerky when I detect any hint of "everything works." 🙂

 

[phillydave]

I try to re-birth myself at least twice a month.

 

[lamorena]

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[FadedC]

while i agree with you that the relationship is not the only healing factor in therapy, i dont think you can compare the therapeutic relationship to a placebo effect. at all.

I kind of figured you might reasonably take issue with that. I agree it's far from a perfect comparison because while I'm sure that the act of going into therapy itself has a strong placebo effect, it's likely that the therapeutic relationship adds something significant beyond that.

But still....the placebo effect can be very strong and can make a lot of people feel and function better. It represents a certain baseline that every treatment can be expected to have no matter what it does. In that extent it's very similiar to how we might view the therapeutic relationship. The purpose of a study is to determine what effect a treatment has beyond the simple relationship.

 

[phillydave]

I wish I could find a reference and maybe there isn't one, but here's a note from one of my first techniques classes I took a couple years ago.

Agents of change during therapy:
40% outside factors
30% therapeutic relationship
15% hope/safety placebo
15% therapy techniques

Maybe from Yalom? I can't remember... Anyway, any thoughts? I'll also add that my institution is a psychodynamic/systems oriented school.

 

[lamorena]

I kind of figured you might reasonably take issue with that. I agree it's far from a perfect comparison because while I'm sure that the act of going into therapy itself has a strong placebo effect, it's likely that the therapeutic relationship adds something significant beyond that.

But still....the placebo effect can be very strong and can make a lot of people feel and function better. It represents a certain baseline that every treatment can be expected to have no matter what it does. In that extent it's very similiar to how we might view the therapeutic relationship. The purpose of a study is to determine what effect a treatment has beyond the simple relationship.

i would agree that the very fact someone is in therapy could be a placebo effect. that makes sense to me. just as the very act of taking a sugar pill makes ppl think they are being treated. thats a different factor than the relationship itself, though, in my opinion. does that make sense?

 

[Professor Xero]

To quickly respond to Lenora, Shedler, similar to many psychoanalytically-inclined clinicians, tend to use the terms "psychodynamic" and "psychoanalytic" interchangeably, with the former term typically being employed when speaking to non-psychoanalytic audiences. Defining what is considered "proper" psychoanalysis in terms of the frequency of sessions has been the subject of much internal debate within the psychoanalytic literature, and thus cannot reliably be used to distinguish psychodynamic vs. psychoanalytic modes of therapy. I think the important distinction, and the one most relevant to research studies, is what psychodynamic clinicians actually do within the therapy session, whether they meet with a patient once or four times a week.

I also agree with Ollie123 that the pressure to reductively collapse across disorders limits the generalizablity to co-morbid conditions which, let's face it, more accurately represents what patients present with in real clinical situations... how often does it occur that a patient comes into a treatment situation reporting complete life satisfaction except for a debilitating phobic reaction to spiders (etc.)? Nevertheless, as was stated, this represents an existing problem across a good number of outcome studies regardless of intervention types.

At the recent APA Div. 39 conference it was publicly disclosed that Shedler underwent 4 rewrites before his paper was finally accepted, and it was initially supposed to be one of a series of articles that discussed various socio-political forces that negatively biases public and scientific opinion, but several of the other authors were unwilling to withstand the somewhat abusive demands of the editorial committee of the American Psychologist... I think that while it is true that psychoanalytic clinicians/researchers are reluctant to conduct research (research being defined as whatever NIH, NIMH and similar organizations decide worthy to fund) within the narrow purview of outcome studies, many who are end up encountering insurmountable institutionalized resistances.

 

[phillydave]

I just finished reading the article. I found it interesting and obviously provocative, but as Ollie points out, less than methodologically rigorous. One thing I disagree with Ollie about though is the idea that this will be used to justify the "Well now I can do whatever I want" approach. In Shedler's defense, he does specify desired outcomes as measured by SWAP and specific psychodynamic means of arriving at these outcomes (i.e. 7 features of psychodynamic therapy).

I think the more compelling piece of this article is the discussion on what defines successful therapy. Whether on not these are original ideas, Shedler's discussion on successful outcomes other than symptom reduction, and the data regarding long-term assessment, are compelling, to me at least. Just my initial thoughts.

Thanks to psytudent for the link.

 

[Ollie123]

I also agree with Ollie123 that the pressure to reductively collapse across disorders limits the generalizablity to co-morbid conditions which, let's face it, more accurately represents what patients present with in real clinical situations... how often does it occur that a patient comes into a treatment situation reporting complete life satisfaction except for a debilitating phobic reaction to spiders (etc.)? Nevertheless, as was stated, this represents an existing problem across a good number of outcome studies regardless of intervention types.

Though I don't disagree with this per se, I think you misunderstood my point.

Shedler describes a number of meta-analyses and other studies that collapse together diagnoses. In other words, the relationship between diagnosis and treatment outcome isn't considered. My point was that this misses important interaction effects between treatments (i.e. little/no evidence supporting psychodynamic treatments of OCD...and to nip this one in the bud, please don't anyone point me to a case study...they are VERY low on the evidence quality chain and should not be used to justify treatment choice in the face of better evidence). We cannot make a blanket statement that psychodynamic practice is equal because frankly, I'm not sure it has even been evaluated for many disorders using quality designs. Of course, CBT hasn't either, but the discrepancy in terms of what HAS been studied is substantial and the research on CBT has generally been better designed and of higher quality. Of course, absence of evidence is not evidence of absence. However, psychodynamic therapy is by no means new, and I say the onus is on the providers to prove it works before widespread implementation.

External validity is of course a concern. I agree that there are far too many studies that rule out common comorbidities (though it makes sense as a first step...efficacy before effectiveness). However, collapsing studies of pure OCD with studies of pure depression does not improve external validity in my eyes. It just misses important effects. Wampold does this in some of his work, and I've never understood it. He even tried to explain it in an article once and I couldn't make any sense of it (it sounded something like "You can't look for effects across disorders until you know effects across disorders are there"). Maybe someone else familiar with his work can explain it, but it seems circular to me.

Anyways, unless of course we presume that doctoral-level providers are incapable of learning more than one modality, I'm not convinced that external validity is improved by collapsing. I don't believe we are limited to one modality, I believe we are trained to scientifically evaluate the evidence, learn treatments, and implement them - we should not just be memorizing the DSM, SCID, and a selection of therapy manuals. Unfortunately, I feel that is where the field is moving (i.e. "Therapy technicians") or rather, where a substantial section of APA is pulling us towards, and it does the field a disservice and will cause a number of problems for us down the line including decreased reimbursement, etc.

 

[Ollie123]

I just finished reading the article. I found it interesting and obviously provocative, but as Ollie points out, less than methodologically rigorous. One thing I disagree with Ollie about though is the idea that this will be used to justify the "Well now I can do whatever I want" approach. In Shedler's defense, he does specify desired outcomes as measured by SWAP and specific psychodynamic means of arriving at these outcomes (i.e. 7 features of psychodynamic therapy).

I think the more compelling piece of this article is the discussion on what defines successful therapy. Whether on not these are original ideas, Shedler's discussion on successful outcomes other than symptom reduction, and the data regarding long-term assessment, are compelling, to me at least. Just my initial thoughts.

Agree on what is most compelling.

To clarify, that point had little to do with Shedler's writing and more my perception of how psychologists use research to justify their own beliefs about what modality they want to use without actually reading it critically. That's not a slam on one group in particular, I've even seen many champions of EBP do the same thing. The alliance literature being a perfect example (again, not directed at you lamorena since you have made your views clear and they seem quite reasonable). If this were an opinion piece in a less mainstream journal I would not be as worried, but it seems very likely this article will join the alliance literature and we will be hearing "See, Shedler said psychodynamic therapy works, so I can continue to not do exposure and response prevention with my OCD patients and instead bleed their insurance dry providing treatment there is no evidence for". I say that a bit tongue in cheek, but I really don't believe its far from the reality of what is going on in an ENORMOUS number of private practices and other clinics around the country.

 

[phillydave]

... but it seems very likely this article will join the alliance literature and we will be hearing "See, Shedler said psychodynamic therapy works, so I can continue to not do exposure and response prevention with my OCD patients and instead bleed their insurance dry providing treatment there is no evidence for". I say that a bit tongue in cheek, but I really don't believe its far from the reality of what is going on in an ENORMOUS number of private practices and other clinics around the country.

I totally agree. It is my opinion (being a student of a psychodynamic school) that it is incumbent upon the clinician to be clinically honest with themselves (and of course the patient) about the limitations of psychodynamic therapy, in addition to the strengths. It is my hope that articles, like Shedler's, will be used as a spring board for more research rather than to justify unethical practice.

 

[bmorepsych]

Oh psychoanalysis...

I agree, it definitely can have its merits as previously discussed. However, to have client referred to you and offer then psychoanalysis rather than CBT for example, for the majority (but not all) of disorders, is nonsensical. And (I'm genuinely asking this) has psychoanalysis incorporated all we've learned about interpersonal and/or family-based interventions? Correct me if I'm wrong but psychoanalysis is really about healing in an intrapersonal rather than an interpersonal way. In my opinion, the latter is really crucial. And what about disorders which require social skills training, exposure therapy, etc.? You have to look at all of it and I really don't see how anyone could go by any other orientation than eclectic.

 

[phillydave]

Oh psychoanalysis...

I agree, it definitely can have its merits as previously discussed. However, to have client referred to you and offer then psychoanalysis rather than CBT for example, for the majority (but not all) of disorders, is nonsensical. And (I'm genuinely asking this) has psychoanalysis incorporated all we've learned about interpersonal and/or family-based interventions? Correct me if I'm wrong but psychoanalysis is really about healing in an intrapersonal rather than an interpersonal way. In my opinion, the latter is really crucial. And what about disorders which require social skills training, exposure therapy, etc.? You have to look at all of it and I really don't see how anyone could go by any other orientation than eclectic.

I'm having a hard time following your post, but I'll try to address what I think you mean. And real quick, to answer your question about being eclectic, I don't think anyone here would disagree that there is no magical cure-all therapy modality.

Be careful when you charge a theoretical orientation with being "nonsensical" while in the same paragraph asking a question about how it works, showing that there's much you don't know about it. Sorry, that's foolish. There are many forms of psychodynamic therapy. My orientation and training is in object relations therapy mixed with family systems theory. Before you call it nonsense, do some research on it, then we can all have a happy, delightful, non-orientation bashing conversation. I am not a fan of CBT, but I don't call it nonsense.

As for intrapersonal vs interpersonal, yes, in fact you are wrong. Psychodynamic therapy focuses both on fostering change in intrapersonal and interpersonal areas. In regard to social skills training and exposure therapy, of course, yes, these are preferred for use with certain disorders. What's your point? Not all problems can be fixed but psychodynamic therapy, just as not all problems are fixed by other modalities.

 

[FadedC]

I wish I could find a reference and maybe there isn't one, but here's a note from one of my first techniques classes I took a couple years ago.

Agents of change during therapy:
40% outside factors
30% therapeutic relationship
15% hope/safety placebo
15% therapy techniques

Maybe from Yalom? I can't remember... Anyway, any thoughts? I'll also add that my institution is a psychodynamic/systems oriented school.

I'm sure all those factors are things that play a role in therapy, but it kind of makes me think of the saying that 73% of all statistics are made up on the spot.

 

[phillydave]

I'm sure all those factors are things that play a role in therapy, but it kind of makes me think of the saying that 73% of all statistics are made up on the spot.

Yeah totally, I really just wanted to know if anyone knew if this was a real stat with an author, or if it's what you suggest.

 

[JatPenn]

I am not a fan of CBT, but I don't call it nonsense.
.

Can you explain to me what you mean, exactly, when you say you are "not a fan" of CBT? As a psychologist, or, at least, someone interested in clinical psychology, what is there not to like? The ample evidence to suggest that it is an effective approach for many prevalent disorders? The relative ease of implementation and transportability? The efficiency (8-16 sessions)? The prophylactic effects vs. relapse?

Sorry to single you out like this, and I actually don't mean my questions to be taken in a hostile manner.

 

[phillydave]

Can you explain to me what you mean, exactly, when you say you are "not a fan" of CBT? As a psychologist, or, at least, someone interested in clinical psychology, what is there not to like? The ample evidence to suggest that it is an effective approach for many prevalent disorders? The relative ease of implementation and transportability? The efficiency (8-16 sessions)? The prophylactic effects vs. relapse?

Sorry to single you out like this, and I actually don't mean my questions to be taken in a hostile manner.

Sure. I respect CBT as an effective treatment and recognize it's strengths. CBT, however, is not my preferred method of treating patients or conceptualizing cases. Take this as least contentious as possible, but not being a fan of a therapeutic approach does not assign a value judgment. Let me rephrase my original statement to say that CBT is not my preferred method because of my personal theoretical taste.


edit:

It's funny (and totally tongue in cheek here), people in this thread have had some pretty harsh words about psychodynamic therapy and used all kinds of colorful words to describe their feelings about PT, yet, all I say is "I'm not a fan of CBT" and I get someone giving me all the reasons I'm crazy and asking me how I could possibly feel this way. 😀

 

[JatPenn]

Sure. I respect CBT it as an effective treatment and recognize it's strengths. CBT, however, is not my preferred method of treating patients or conceptualizing cases. Take this as least contentious as possible, but not being a fan of a therapeutic approach does not assign a value judgment. Let me rephrase my original statement to say that CBT is not my preferred method because of my personal theoretical taste.

My question remains: why not?

Forgive my curiosity (naivete?), but it's important for me to understand what it is that others find distasteful or unpalatable about CBT. If the evidence is out there, and the evidence clearly shows it works and works well, why not use it? Why not make it part of your repertoire?

 

[phillydave]

My question remains: why not?

Forgive my curiosity (naivete?), but it's important for me to understand what it is that others find distasteful or unpalatable about CBT. If the evidence is out there, and the evidence clearly shows it works and works well, why not use it? Why not make it part of your repertoire?

Because it is my belief (and you may call me crazy) that PT is just as effective. And (here's the bonus) it fits my therapeutic style and interests me more than CBT. If you do not agree with me here (which is okay with me) than I could understand if your question yet still remains "why not."

I have two screwdrivers, I believe they both work, although they look different. I'll go ahead and use the one that fits my hand better. This is not an "everything works" argument. This is a "two things work" argument. You may also disagree that both screwdrivers work, that's just where we differ.

 

[bmorepsych]

I'm having a hard time following your post, but I'll try to address what I think you mean. And real quick, to answer your question about being eclectic, I don't think anyone here would disagree that there is no magical cure-all therapy modality.

Be careful when you charge a theoretical orientation with being "nonsensical" while in the same paragraph asking a question about how it works, showing that there's much you don't know about it. Sorry, that's foolish. There are many forms of psychodynamic therapy. My orientation and training is in object relations therapy mixed with family systems theory. Before you call it nonsense, do some research on it, then we can all have a happy, delightful, non-orientation bashing conversation. I am not a fan of CBT, but I don't call it nonsense.

As for intrapersonal vs interpersonal, yes, in fact you are wrong. Psychodynamic therapy focuses both on fostering change in intrapersonal and interpersonal areas. In regard to social skills training and exposure therapy, of course, yes, these are preferred for use with certain disorders. What's your point? Not all problems can be fixed but psychodynamic therapy, just as not all problems are fixed by other modalities.

Gotcha. Sorry bout that. You're right...it may have been too harsh and I know what I know about psychodynamic from undergrad psych classes. I def think a good amount of psychodynamic is interesting and I know a basic amount about object relations, which I do like a fair amount. I guess my real problem is with non-objective assessment measures aka projective tests which I know are used more often by psychodynamically-oriented psych's than say, people who swear by CBT.

 

[phillydave]

Gotcha. Sorry bout that.

No worries. Sorry if I came off as hostile.

 

[phillydave]

I guess my real problem is with non-objective assessment measures aka projective tests which I know are used more often by psychodynamically-oriented psych's than say, people who swear by CBT.

Yep, they are pretty much exclusively used by PT oriented clinicians, and I can certainly understand a person being not so keen on them. I myself am somewhat ambivalent on the topic of projective tests. Although they are still used pretty widely, they were more popular in decades past.

 

[KillerDiller]

Oh psychoanalysis...
I really don't see how anyone could go by any other orientation than eclectic.

I used to think this too. My experience in practicum has changed my views on the issue, though. I agree that every therapist should be familiar with a wide variety of interventions that span various orientations. However, one cannot conceptualize cases easily from an "eclectic" perspective. It would be extremely difficult, for example, to see one client with depression and conceptualize the problem from an IPT perspective and then see another and conceptualize it from a CBT perspective and the next from a psychodynamic perspective etc. etc. And conceptualizing a single client from ALL those perspectives simultaneously? Sure, it's fine as a mental exercise, but completely overwhelming in treatment planning.

Having a "home" orientation is useful because it defines your approach to thinking of how a client's difficulties are framed. It simplifies things and shapes the way you approach treatment, even if you end up using interventions from a variety of theoretical perspectives.

 

[phillydave]

So true about treatment planning. Also important not to baffle and or annoy your supervisor from treatment plan to treatment plan.

 

[KillerDiller]

Can you explain to me what you mean, exactly, when you say you are "not a fan" of CBT? As a psychologist, or, at least, someone interested in clinical psychology, what is there not to like?

I agree with PhillyDave on this one, though I don't know if we have the same reasoning.

Before I raise people's hackles, I'll explain. I definitely adhere to EBTs and stay away from interventions that do not have empirical support. I consider myself an ACT or ABBT therapist...or sometimes even a strict behaviorist (but the relationship between those orientations is another thread). Anyway, my problem lies with the CT part of CBT. I dislike speaking with clients in language that suggests their thoughts are "distorted' or "wrong". It feels invalidating to me.

Additionally, at least one seminal study showed that CBT added nothing beyond BT in treating depression.

 

[JatPenn]

Additionally, at least one seminal study showed that CBT added nothing beyond BT in treating depression.

Which is why, when I treat someone with depression, I go the BT route. It's not fair to the client for me to stick with something that isn't as efficient or effective simply because it is my "home" orientation.

 

[phillydave]

Which is why, when I treat someone with depression, I go the BT route. It's not fair to the client for me to stick with something that isn't as efficient or effective simply because it is my "home" orientation.

Right, I second your point. However, as I said before to Ollie about being clinically honest with oneself about one's own therapeutic limitations, I would not continue to treat a person who would clearly benefit from a different type of therapy, such as CBT, for example.

 

[Professor Xero]

In reading Shedler's article I don't see anywhere where he says CBT doesn't work, per se, but rather he questions whether it is equally or more effective than psychodynamic approaches both in short and long-term symptom reduction. The fact is, as every honest psychoanalyst will tell you, CBT does work, but only if we are in agreement with what "work" denotes.

My qualms concerning CBT takes a more philosophical bent - I am not as concerned with the "if" as I am with the "how" of CBT's effects. I believe that short-term manualized approaches are inherently reductionistic and technocratic and often confuse the symptom with the problem. Symptoms are meaningful (one does not passively "catch" GAD, depression, personality disorders, etc. as they would a virus) and therefore deserve to be explored within the context of the patient's reality. I do not feel that simply suppressing symptoms best serves the long-term mental health of those who seek our help. In mainstream psychoanalytic thought, symptoms represent the psyche's creative struggle to resolve unconscious conflict(s), whether they be intrapsychic, interpersonal (or a combination of both) in origin; symptoms are functional. In contradistinction, CBT, as I was taught, conceptualizes symptoms as springing from incorrect interpretations of reality... if only the patient knew better they wouldn't be experiencing psychological distress. The CBT clinician must modify the patient's beliefs to conform to societal norms using directive, perhaps even authoritarian, techniques. I may be presenting a simplified portrait of CBT, but I think it would be the intervention of choice in The Brave New World.

So even while I remain sympathetic to the idea of best-practice theoretical eclecticism, I concurrently wonder whether this is based on the illusory premise that by simply reducing the frequency/intensity of symptoms we are providing complete psychological well being. If the therapeutic goals differ among theoretical orientations, then how can they fairly be compared against each other in outcome studies?

 

[phillydave]

If the therapeutic goals differ among theoretical orientations, then how can they fairly be compared against each other in outcome studies?

That's precisely the most compelling part of Shedler's article that I found. Perhaps that question would make for a good thread on it's own.

 

[loveoforganic]

Is there a "standard of care" for psychotherapy in any situations?

 

[lamorena]

.

 

[KillerDiller]

My qualms concerning CBT takes a more philosophical bent - I am not as concerned with the "if" as I am with the "how" of CBT's effects. I believe that short-term manualized approaches are inherently reductionistic and technocratic and often confuse the symptom with the problem. Symptoms are meaningful (one does not passively "catch" GAD, depression, personality disorders, etc. as they would a virus) and therefore deserve to be explored within the context of the patient's reality. I do not feel that simply suppressing symptoms best serves the long-term mental health of those who seek our help. In mainstream psychoanalytic thought, symptoms represent the psyche's creative struggle to resolve unconscious conflict(s), whether they be intrapsychic, interpersonal (or a combination of both) in origin; symptoms are functional. In contradistinction, CBT, as I was taught, conceptualizes symptoms as springing from incorrect interpretations of reality... if only the patient knew better they wouldn't be experiencing psychological distress.

I agree that manualized treatments can have this type of drawback. I think, though, that clinicians who understand the full theory behind the treatment also have the flexibility to adapt the manual to their individual clients. So, while I share your concern, I direct mine not at manualized treatments themselves, but at less educated therapists trying to use manualized treatments. Not that I think the latter is harmful per se. It can certainly work. I just think it's not as effective as being seen by someone who understands the theory.

I also wanted to say that when you look at the theory behind BT, it clearly agrees with you that symptoms arise because they serve a functional purpose 😉. I know much less about how CBT would answer your point.

 

[KillerDiller]

which, killer diller, brings up the topic of DBT. which i love. and can be modified to not only treat PD's. you said you don't like how invalidating CBT can be. DBT is so validating its not even funny! one of the major hallmarks of DBT is to validate, validate, validate. and, DBT is a spin off of CBT, but also blends other theories such as (gasp!) object relations, IMO. not to mention ACT, which encourages clients not to judge their thoughts but to accept them.. i think these approaches are much more validating.

I like DBT a lot. I know a lot people consider it a spin-off of of CBT, yet some of the most hard-core ACT therapists/theorists I know insist it is really from BT instead. This makes a lot more sense to me theoretically as both DBT and ACT treat thoughts in the opposite way as CBT.

P.S. Wow, I feel like I'm the behavioral therapy spokesperson all of a sudden. Perhaps I need to take it down a few notches.

 

[nicu4leo]

It has been interesting to watch this thread develop... To me, I found Shedler's article to be interesting- not because it necessarily "proves" anything, but it offers further discussion on alternative therapeutic methods. The one thing I found most interesting was the follow up studies that assessed the continued benefit of treatment after termination.... I recall reading something by Yalom which made similar assertions as Shedler- many clients that receive psychodynamic treatment tend to report continued benefit years after termination.

As far as I see it when assessing differing modalities of treatment it is all a matter of how one decides to slice the pie. Where do I, as a therapist, place my emphasis in the treatment? Behavior? Cognition? Emotion?

In the end I have found that the client will guide you to utilize the treatment that best addresses their issues.. just my 2 cents.

 

[Professor Xero]

I agree that manualized treatments can have this type of drawback. I think, though, that clinicians who understand the full theory behind the treatment also have the flexibility to adapt the manual to their individual clients. So, while I share your concern, I direct mine not at manualized treatments themselves, but at less educated therapists trying to use manualized treatments. Not that I think the latter is harmful per se. It can certainly work. I just think it's not as effective as being seen by someone who understands the theory.

I also wanted to say that when you look at the theory behind BT, it clearly agrees with you that symptoms arise because they serve a functional purpose 😉. I know much less about how CBT would answer your point.

I would like to add that often times patients who engage in psychodynamic forms of therapy continue their treatment even after gaining relief from their acute symptoms because sometimes it takes a while (yes, even years), for a therapeutic alliance to develop to the point where the patient feels comfortable disclosing certain anxiety-provoking symptoms. I would like to quote a pithy statement by Shedler that I thinks nicely captures the psychoanalytic attitude towards treatment goals:

"...the goals of psychodynamic therapy include, but extend beyond, alleviation of acute symptoms; it is the positive presence of inner capacities and resources that allow people to life life with a greater sense of freedom and possibility" (p. 105).

If, as many on this thread have stated or alluded to, an understanding of the patient's individuality in conjunction with the therapeutic relationship is what drives the treatment, how can either be properly developed within the proscribed limits of 16-30 sessions?

What I fear is that "market forces" pressure clinicians into providing the psychotherapeutic equivalent to medication, which, by default, truly only claims to suppress symptoms.

 

[Ollie123]

In reading Shedler's article I don't see anywhere where he says CBT doesn't work, per se, but rather he questions whether it is equally or more effective than psychodynamic approaches both in short and long-term symptom reduction. The fact is, as every honest psychoanalyst will tell you, CBT does work, but only if we are in agreement with what "work" denotes.

I'm not sure anyone thinks Shedler is arguing CBT doesn't work. However, I do think he's saying "PT is just as effective" but using a sort of smoke & mirrors approach to hide the fact that the evidence is spotty/weak or downright non-existant for many of the circumstances (i.e. diagnoses) it is actually used in. Basically trying to cover up the fact that we don't really KNOW if it works for a great deal of the things it is being used for because in all the decades it has been in existance, there have been very few attempts to demonstrate that.

As for what "works" means...I'm totally open to that discussion. Again though...prove it works "better" on that front. Positive psychology is reasonably established at this point, and there has been a decent amount of discussion in the literature on how to measure the "good" as well as the "bad". I agree that we have tended to have an overly narrow focus on the "negative" in the past...I think its a function of the medical model approach to psychopathology that is unfortunately still pervasive, but we are starting to break from that more and more. However, studies examining the positive side are not impossibly hard studies to run, and there has been ample time to do so, which is why people are skeptical. I identify with being evidence-based, not as a CBTer. Show me solid data backing PT showing symptom reduction AND an elevation above baseline on a roughly equivalent timeline, and I'm on board 100%, at least until better data comes along elsewhere.

As for this idea behind healing "beyond" symptom remission, I again think this raises some interesting ethical issues. I've stated my views on reimbursement for this, but would be curious to hear what other people think. Should insurance pay for treatment that requires more sessions, but is meant to elevate beyond baseline rather than just eliminate pathology? Again, if we reach a point where there is evidence to suggest that it actually works I am all about people pursuing this and would consider doing so myself. Well, once I'm out of grad school and have ya know...money That said...demonstrate it. Carefully, in a controlled, scientific way. The assumptions, intuition, "I KNOW this works so we don't need proof" need to stop if this field is ever going to get the respect it deserves.

 

[phillydave]

also, i think it should be mentioned, that all of PT does NOT equal freudian psychosexual stages and the rorschach or TAT.

Yes, and this needs to be mentioned over and over again. The stigma associated with PT is in such a large part due to the damage (and I say this lightly because it was also the reason we're in this field today) that the psychoanalysis era did. Similarly important to note, as Shedler points out, the "arrogant" nature of the psychoanalysis movement by the MDs, the original practitioners of therapy.

 

[KillerDiller]

If, as many on this thread have stated or alluded to, an understanding of the patient's individuality in conjunction with the therapeutic relationship is what drives the treatment, how can either be properly developed within the proscribed limits of 16-30 sessions?

I don't know, that number of sessions seem perfectly reasonable to me to affect permanent change. That brings to mind another ethical issue beyond what Ollie raised. I currently do my practicum at a clinic with over 70 people on the waiting list. Is it ethical to continue seeing someone who is solely interested in self-improvement of non-clinical symptoms when there are individuals on the waiting list for treatment who are at high-risk?

 

[phillydave]

I don't know, that number of sessions seem perfectly reasonable to me to affect permanent change. That brings to mind another ethical issue beyond what Ollie raised. I currently do my practicum at a clinic with over 70 people on the waiting list. Is it ethical to continue seeing someone who is solely interested in self-improvement of non-clinical symptoms when there are individuals on the waiting list for treatment who are at high-risk?

Good point. In the situation you describe above, it does not seem right to continue maintenance treatment when there are high-risk people waiting for treatment. But I think the question is, if the number of sessions is only 16-30, what is actually being addressed? Symptoms? Or the underlying problem? Maybe not all pathologies are as easily fixed by a course of treatment that only lasts for so long.

 

[Professor Xero]

I don't know, that number of sessions seem perfectly reasonable to me to affect permanent change. QUOTE]

But what if, as Shedler indicates, two year-out from a short-term treatments the results decay into where many experimental and control groups can no longer be differentiated?

I agree that there are some provocative ethical considerations to the example you provided, but I think that speaks to the pragmatics of the profession which have been molded to work within the parameters of short-term interventions. It is a more systemic question that should be addressed once the value of long term psychotherapy becomes better appreciated.

 

[phillydave]

But what if, as Shedler indicates, two year-out from a short-term treatments the results decay into where many experimental and control groups can no longer be differentiated?

Right, and perhaps the waitlists would not be as flooded with relapsed patients.