I agreee... you have some good points! I'll try to respond, in turn.
psychgeek said:
Before we all jump on the death to psychodynamics bandwagon lets get a little historical perspective.
First of all, the body of research supporting psychodynamic and psychoanalytic approaches to therapy is substantially larger than that supporting CBT. True, there are issues (some irresolvable) involving studying a dynamic therapy rather than a prescriptive therapy, but the fact remains that psychoanalytic and psychodynamic approaches have withstood the intense and often critically biased attention of science for over a hundred years. To suggest that these treatments have no support depends upon a fairly narrow view of the literature.
Im not certain if you are referencing my post directly, but at no point have I suggested that there is no support for psychodynamic therapy. However, as you reference above, there are serious issues in the empirical study of these therapies (there are often built-in tautologies) and very little standardization across studies for purposes of meaningful comparison.
Moreover, its hard to say that the literature supporting these therapies outweighs the literature supporting CBT. Ill be the first to agree that there is a larger literature on psychodynamic therapy, but quantity is not always quality - historically many of these studies (not all) utilize non-randomized treatment designs, lack adequate comparison groups, etc.
Second, recent literature does provide quite a bit of support for the effectiveness of psychodynamic approaches to therapy. The meta-analysis found in the December (I think) issue of the Archives of General Psychiatry is an example of such support. Early comparative studies that did find significant differences favoring CBT were flawed largely because they were conducted by proponents of CBT. The psychodynamic comparison groups in these studies were little more than straw men.
It is noteworthy that the meta-analysis in the December Archives covers the years spanning 1970-2004, yet the authors were only able to include 17 studies in their analysis. Only 17 studies in 34 years? Yes, they used rather strict criteria for inclusion, but those criteria are considered the Gold Standard of psychotherapy research and are routinely utilized in CBT research. I think the paper provides some preliminary and intriguing evidence, but I think we need to see more of this.
Third, so-called empirically-supported therapies suffer from their own empirical shortcomings. Dont agree? Then demonstrate the existence of an cognitive-emotional schema and prove the role its activation serves in psychopathology.
I initially put that expression in quotes for a reason you are absolutely correct to say that the studies examining the ESTs suffer from methodological shortcomings. In fact, that is why they are called empirically-supported and not empirically-validated. Nonetheless, there is research demonstrating that dysfunctional attitudes and cognitions (measured by interview, self-report and by using information processing paradigms) do change post-Tx and do predict long-term outcome. I dont think that proves the existence of a cognitive schema, but it certainly provides some support for the underlying theoretical foundation.
Finally, many of the ESTs draw upon (or are reformulations of) psychodynamic therapies. A personal favorite of mine is IPT. IPT was originally designed as a manualization of an object relations/interpersonal approach to psychotherapy. After a manual was created and preliminary results indicated that it was superior to CBT in the treatment of depression, CBT theorists decided that IPT wasnt actually a psychodynamic treatment at all. In fact, since the approach worked they decided that IPT must actually be CBT in disguise! How Orwellian.
Im in full agreement up to a point. I believe that we have benefited from the early conceptualizations of psychotherapy and can use some of these ideas in our current practice. We work in an evolving field, so of course ideas build on themselves. I have, in fact, been trained in IPT (and IPSRT) and am aware of its early connections to object relations. But the treatment, as it is currently manualized, looks quite different from object relations therapy. Where I disagree with you is your interpretation of how CBT folks responded to the TDCRP being that my clinical specialty is in depression research and treatment (and I have worked with some big names), I dont think that anyone would ever claim that IPT is another form of CBT. In fact, as IPT is manualized, you are strictly directed to NOT address cognitions in any way. I think that most CBT-oriented psychologists have a lot of respect for IPT as its own treatment.
This is not to say that there is anything wrong with CBT. I like CBT and use it when my client seems likely to benefit from the approach. But I also use psychodynamic approaches and feel quite comfortable that the research supports this choice as well.
To sum up, when it comes to psychotherapy, my attitude is: show me the money. First and foremost, I describe my theoretical orientation to be that of empiricist. If I can empirically justify using a particular therapy with a particular patient, then I feel that I am doing my job. As it stands now, psychodynamic therapy is working to catch up with the rest of the field and perhaps it will. In the meantime, given my empirical leanings, I plan to follow the research.
Given that there is some general support for psychodynamic approaches, I wouldnt suggest that they be tossed out of practice nor out of psychiatry training programs. However, where I continue to remain stumped is on the issue of the relative imbalance these approaches receive within psychiatry training programs. CBT at least deserves as much attention as psychodynamics a 1/2 year training course does not cut it.
Sorry for the (equally) long post.
🙂
