Psychodynamic verses CBT

[lisa4747]

I am wondering everyone's thoughts on these two orientations and their future in the psychological world. I realize that most people who are going to more research-oriented programs probably lean toward cbt. However, do current professionals in the field (and anyone else who has an opinon) think that the psychodynamic orientation is nearly obsolete at this point? Personally I want to attend a program that is eclectic and considers both these points of view (and more) but I am wondering, aside from perhaps NYC and San Fran, how much room there is in the future of the field for psycodynamic therapy?
Any input would be appreciated!

---

Members don't see this ad.

 

[soaringheights]

I was really against psychodynamic approach when we were learning about it coz most of it didn't seem to be relevant, and most importantly, not supported by research. However, with my pts with schizophrenia, I found that to be the single most effective appraoch to conceptualize their case history.
However, I haven't used the psychodynamic approach for counselling because I didn't I had enough information to apply it effectively. I have used the CBT approach so far in my therapy sessions, and it works well with most pts and most disorders.

 

[Logic Prevails]

I am wondering everyone's thoughts on these two orientations and their future in the psychological world. I realize that most people who are going to more research-oriented programs probably lean toward cbt. However, do current professionals in the field (and anyone else who has an opinon) think that the psychodynamic orientation is nearly obsolete at this point? Personally I want to attend a program that is eclectic and considers both these points of view (and more) but I am wondering, aside from perhaps NYC and San Fran, how much room there is in the future of the field for psycodynamic therapy?
Any input would be appreciated!

The short answer, is yes, there is room in the future for psychodynamic approaches, and they do have an advantage in conceptualizing certain types of clients who would not do as well with cognitive therapy. Psychodynamic therapy is useful, for example, when treating those who are very intellectualizing, who have a history which might have dramatically impacted their psychological health, and who are currently very detached from their emotions. This type of individual might be very logical in their thinking and are capable of 'talking about their emotions', but cannot experience them.

Now, as you have already suggested, most programs will focus on CBT training and will skip out on the psychodynamic bit. This is likely for two reasons: 1) CBT approaches have been empirically supported by research (through efficacy studies); since many programs are accredited, they are pressured to teach only those clinical courses and approaches that are supported by efficacy/effectiveness research. Since the psychodynamic approaches are much more variable in their techniques and are typically longer and more flexible, they don't really lend themselves well to efficacy studies; this does not mean that they are not effective. 2) Psychodynamic approaches are somewhat seen as an approach that should not be used by new clinicians. There are no real 'manualized' psychodynamic approaches, and most require some experience before learning and using them in treatment. Maybe they aren't taught as much for this reason.

So there you have it: my two cents

 

[MsAnaF]

Brad3117, want kind of setting do you work in? I ask because I would also ideally like to attend a program with a more eclectic approach, because I am interested in both CBT and psychodynamic theories. But I was wondering what kinds of approaches are used in the 'real world' - does insurance companies pushing CBT have an impact on the type of therapy that is practiced in hospitals or private practice or other settings?

Also, I know you can recieve training at a psychoanalytic institute (or a CBT institute like Ellis's) after you finish school - does anyone know if it is more difficult to get accepted into a psychodynamic post-doc institute if you studied at a primarily CBT doctoral program (or vice versa)???

 

[Flutterbyu]

Boston offers several options for pursuing psychoanalytic training, along with more traditional cognitive approaches. From my experience, those currently practicing psychodynamic therapy started in another perspective. I know several cognitive behaviorists and strict behaviorists who establishsed themselves in their chosen perspectives and then later in life went on to complete psychoanalytic training. Those whom I have spoked to are quite happy and successful. I would say that for an early career move, however, it is a harder road starting off in a psychodynamic practice, especially becasue you will need to make money and insurance companies don't normally want to approve of a years worth of psychoanalysis. From what I have seen, the more successful practices are built up with wealthier clients who pay fee-for-service and bypass the whole insurance fiasco.

 

[flanagan10]

Personally, I don't think the psychodynamic point of view is obsolete, but more and more, it is not given serious consideration in clinical programs. I think programs are very different though in how they deal with---completely against it, supportive, curious, apathetic. For example, I worked in a lab for a couple of years that was primarily interested in development and cognitive work, though not a clinical lab. They were rather supportive of it. This summer, I was at a VERY VERY CBT program working, and nobody on the clinical faculty even would consider it, made fun of it, and was generally very disapproving of anyone who even mentioned it.

I can't see how people can honestly say it is obsolete. It clearly works, for a variety of people, and it strongly informs a variety of research in other areas, too (development, neuroscience, attachment et. cetera). That being said, I think psychoanalysis has some of its own hubris to blame for some of its downfall, as well as the fact that ego psychologists of the 1950s really believed they were simply above emprical models. But if you look carefully, I think there are people almost everywhere who will at least chat with you about it, but you have to search. For example, this summer at my strong CBT focused program, I found a couple of psychiatrists that were psychodynamic, and they were very willing to sit and talk with me, and even said that many students from the clinical program have seen them privately for supervision.

Myself, I'm interested in psychoanalysis very much. I've been involved in a four-time-per-week analysis for over four years, and I read psychoanalysis and consider it a serious theory of the mind. But I also realize that I can't run around programs saying I love psychoanalysis, and I don't plan on making it my research goal to reunite psychoanalysis and psychology. I plan on doing research that interests me, and using psychoanalytic concepts where I can in my research, but definitely not in any overt way. I think the clinical work I do will primarily be informed by psychoanalytic/psychodynamic work. I struggle with this a lot though, because there is also a part of me that recognizes clinical research has to be more translational to practice (though as I mentioned, almost all development and attachment research is really psychoanalytic at some level).

I don't think NYC and SF are the only places that are alive with it. Chicago has a great analytic community, and Northwestern's Clinical Psychology program has several analysts that teach classes as adjunct faculty (though again, see, they hide it). Boston and Western New England in New Haven are also pretty alive analytic communties.

 

[50960]

A good therapist needs to be proficient at more than one modality to even hope to adequately treat a diverse population. If your practice is just seeing adults with panic d/o then only practicing CBT is fine, but who has that?? Ever tried CBT with kids?? Doesn't usually work well. Playtherapy doesn't always work well either; we need to be able to adjust our approach based upon the needs of our patients.

 

[clinpsychgirl]

A good therapist needs to be proficient at more than one modality to even hope to adequately treat a diverse population. If your practice is just seeing adults with panic d/o then only practicing CBT is fine, but who has that?? Ever tried CBT with kids?? Doesn't usually work well. Playtherapy doesn't always work well either; we need to be able to adjust our approach based upon the needs of our patients.

Of note, CBT is an evidence-based treatment for children (depression, behavioral disorders, anxiety, ptsd, and other disorders). The disclaimer is that CBT works best for children over the age of 7. There are modified versions for younger children (probably more BT than CBT) that exist- Personally, I'm not as familar with the research in that area.

I agree with you psisci- knowing different means to treat a diverse population is essential if you want to see good results. For example, if you are treating child depression, there are going to be some who respond better to CBT for depression, while others will respond better to IPT. But they are both solid, evidence-based treatments.

As a newbie to the field, I personally like to stick with EBPs, when possible. However, I get annoyed with people in a "CBT" or "EBP" bubble. As someone who is involved with dissemination research, I can tell you that evidence-based practices don't always have superior results when taken out of the confines of the ivory tower. Sometimes, the clinicians who have been psychodynamically trained have (gasp) comparable results to those clinicians who use the "evidence-based" treatment (Chorpita et al., 2005?).

Now, I think there is a lot of value to adding EBPs into "real world" settings. But, it has to be approached in a such a way where the researchers who have developed the EBPs must approach the task with the understanding that they have just as much to learn from the clinicians who actually serve the "real world" populations as the clinicians have to learn from them.

 

[codetype4/9]

One of the things you will notice is the high dropout rate of subjects in EBT studies. Are the people that remain in the study representative of the whole spectrum of the problem?

Of note, CBT is an evidence-based treatment for children (depression, behavioral disorders, anxiety, ptsd, and other disorders). The disclaimer is that CBT works best for children over the age of 7. There are modified versions for younger children (probably more BT than CBT) that exist- Personally, I'm not as familar with the research in that area.

I agree with you psisci- knowing different means to treat a diverse population is essential if you want to see good results. For example, if you are treating child depression, there are going to be some who respond better to CBT for depression, while others will respond better to IPT. But they are both solid, evidence-based treatments.

As a newbie to the field, I personally like to stick with EBPs, when possible. However, I get annoyed with people in a "CBT" or "EBP" bubble. As someone who is involved with dissemination research, I can tell you that evidence-based practices don't always have superior results when taken out of the confines of the ivory tower. Sometimes, the clinicians who have been psychodynamically trained have (gasp) comparable results to those clinicians who use the "evidence-based" treatment (Chorpita et al., 2005?).

Now, I think there is a lot of value to adding EBPs into "real world" settings. But, it has to be approached in a such a way where the researchers who have developed the EBPs must approach the task with the understanding that they have just as much to learn from the clinicians who actually serve the "real world" populations as the clinicians have to learn from them.

 

[Pterion]

One of the things you will notice is the high dropout rate of subjects in EBT studies. Are the people that remain in the study representative of the whole spectrum of the problem?

I haven't read recent research on this, but it is an excellent point. If the studies do not include "intent to treat" analysis one could argue that effect size is inflated. As Psisci has pointed out, many EBT's (and research protocols for that matter) don't necessarily reflect the profile of a real clinical population.

And I agree that there will be room for psychodynamically informed clinical practice, which I distinguish from classical psychoanalysis and from a theory base with rigid adherence to sexual development above relational development.

 

[clinpsychgirl]

One of the things you will notice is the high dropout rate of subjects in EBT studies. Are the people that remain in the study representative of the whole spectrum of the problem?

Your comment raises a good point...

While I'm not debating the issues regarding client barriers to treatment (high drop out rate; low SES) that occur in the EBT studies, I think it is important to recognize that in sound dissemination research, you target clinicians in "the real world." Usually you would compare the efficacy of an EBT with TAU (treatment as usual). The clientele at these agencies is what it is- as a researcher you don't influence that. And in the "real world," client drop-out rate is high.

This is a bit different than your "prototypical" (well funded) treatment outcome study in a research setting. Say the research designs a treatment of 12 sessions or so. Partipants must complete every session during a set period of time. Often times, partipants are reimbursed for participating in the study. Is the drop out rate lower in these studies? Ofcourse. Does that mean these finding are more clinically relevant??? NO.

Think about all of the benefits of treatment outcomes in a research setting:

*grant money supporting the training, clinicians, and in some cases, even the
clients
*a staff dedicated to this particular research project and its outcome (PIs,
psychologists, RAs, what have you)
*generally a staff that is trained in the same modality (say CBT)
*exclusion criteria- this one is huge- if you are doing a study to treat
childhood anxiety disorders, well what you will find is that the kids who
present with primarily with ADHD/ODD are out. How representative is this???

Now think about how this contrasts to the "real world":

*overworked underpaid clinicians
*typically not enough agency funding to train clinicians in EBPs
*supervisors/taff from a variety of theoretical backgrounds
*client barriers to treatment (e.g., low SES, single parent families, etc...this
would be related to the high drop-out rate you see in "real world" studies)
*complex clinical cases that you just don't see in the neat little research
studies with their exclusion criteria

So, we, as researchers/clinicians must exercise caution when analysing the validity of the results of treatment outcome studies done in the confines of a research setting. Results in research simply does not equal results in the real world- and for good reasons.

This topic generates a lot of interest for me... and I think it's vital that young professionals (and more experienced professionals) are aware of these issues. If anyone wants any additional information (citations, resources for more info, whatever) PM me. I'd be happy to discuss in greater detail.

 

[Logic Prevails]

Lisa4747,

To answer an earlier question, I can only say that I am in an accredited clinical psychology program. This program does not teach psychodynamic approaches but is open to let students learn them on their own and then supervise them. The faculty are thankfully a mixed bag, with mixed opinions and approaches that interest them.

I think it important to point out here that the words psychoanalytic and psychodynamic should not be used interchangably. In many ways, the newest psychodyanmic forms of therapy (and also the ones most likely to become "empirically validated") don't resemble at all Freud's psychoanalytic approach. Most of them are "time-limited", which often bring them down to the same treatment time as other approaches, and they leave out much of Freud's metajargon that didn't go over well with others in the past.

Check out Strupp & Binder's "Time-Limited Psychodynamic Therapy"
or
Davanloo's "Intensive Short Term Dynamic Psychotherapy"

Many people don't like the dynamic/analytic stuff because of the brutal history and the length of time that was involved. These newer approaches seem to avoid all of that and still keep the 'meat and potatoes' of what worked with Freud's ideas (defenses and whatnot).

 

[flanagan10]

Excellent point by Brad. Also read, Comparative Perspectives in Brief Dynamic Psychotherapy (Haworth Press, 1999) by Bill Borden. Another chapter (from an all around great book) is :

Bornstein, R. F. (2004). Reconnecting psychoanalysis to mainstream psychology: An agenda for the 21st century. In J. Reppen, M. A. Schulman, & J. Tucker (Eds), Way beyond Freud: Postmodern psychoanalysis observed (pp.1-19). London, UK: Open Gate Press\

Good luck!

 

[psychgeek]

At the risk of sounding kind of picky, there is an important distinction that seems to be unclear in this thread so far. Psychodynamic therapy is not the same as psychoanalytic therapy. While the two share the same theories regarding case conceptualization, the application of this theory is very different in the two approaches. While psychoanalysis is probably impossible to study in efficacy or effectiveness trials, psychodynamic approaches are more amenable to research. There is a small though strong body of literature demonstrating effect sizes for time limited psychodynamic approaches (like TLDP or IPT) that equals or exceeds those obtained from CBT trials.

There is no good basis to claim that either CBT or psychodynamic approaches are superior in general. Very few really good studies compare the two and the results from these studies are mixed.

CBT is not an EST in some sort of global sense. It is an EST for a limited number of disorders and populations. Most people you will see in your average community clinic don’t fall into these subgroups. For them psychodynamic approaches are just as empirically supported as CBT.

I am trained in both of these approaches and use them both with my patients. I don’t think either one is going anywhere because they both work.

 

[PsyDGrrrl]

Lisa4747,


Check out Strupp & Binder's "Time-Limited Psychodynamic Therapy"
or
Davanloo's "Intensive Short Term Dynamic Psychotherapy"

Many people don't like the dynamic/analytic stuff because of the brutal history and the length of time that was involved. These newer approaches seem to avoid all of that and still keep the 'meat and potatoes' of what worked with Freud's ideas (defenses and whatnot).

I agree, and also recommend Hanna Levenson's book on Time-Limited Dynamic Therapy. That's the model I was trained in and use.