Dodos In Rehab: What’s Effective Therapy (part two)

Shedler’s comprehensive research informs us that psychodynamic practices are not only effective, but arguably more so than its rival models. The effect sizes he reports following numerous meta analyses are consistently higher than those attributed to cognitive behavioral therapy, and furthermore, the effect sizes linked to psychodynamic approaches increase over time; that is, from short-term follow up studies to longer-term follow up studies. This suggests that in-depth psychodynamic therapy sets in motion a set of changes for people that acquire momentum over time, and are ongoing.

Yet these findings don’t speak to the issues that I presented to that frozen audience in the community mental health setting–that audience, comprised as it was with overworked souls more typcially compelled to hear rote trainings in which smug pedogogues pitch bullet-pointed treatment manuals: the evidence-based droning about quantifying treatment goals and codifying methods. The irony, Shedler asserts, is that many who work under the banner of CBT actually practice methods at least derived from psychoanalysis. In my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, I allude to this curious trend. Writing anecdotally, I reference several terms, like “splitting”, “denial”, “failure to thrive”, and “containment”, which are used regularly in settings purportedly driven by a CBT philosophy, but which have a psychoanalytic pedigree. Shedler implies that many practitioners are unwittingly using psychodynamic language and methods; which sounds a bit like rock musicians who aren’t aware of the blues roots of their craft. He cites a study by Ablon and Jones (1998), who interviewed experts in CBT and psychoanalysis, asking them to define their models such that use of objective tools like the so-called Q-sort assessment (blind raters, listening to audio tapes of sessions, tracking specific interventions) could be understood. The psychoanalytic experts cast the umbrella psychodynamic process as follows: allowing for an unstructured dialogue, the identification of recurrent themes, linking feeling states to past experiences, and giving attention to intrapsychic defenses, and to “unacceptable” feelings. I can see in my mind the disdainful head shakes of those who think this a waste of time; something only the privileged might pay for. The CBT experts in the study emphasized a more specific focus in therapy–a process actively structured by therapists taking on didactic, teacher-like roles. They give advice, discuss goals, and focus generally on current life stressors or (in the case of those mandated into tx.), objectives assigned externally: far more popular with industry onlookers looking to streamline methodology.

But get this: the investigators measured therapist adherence to models without regard to what therapists believed they were applying: Beck’s treatment model, apparently. Upon reading verbatim transcripts, investigators of this study tracked the following variables: quality of therapeutic alliance; addressing cognitive distortions by patients; patients’ experience of emotion; gaining awareness from previously implicit meanings and feelings. The thing is, only one of these variables truly belongs to the canon of cognitive behavioral therapy–addressing cognitive distortions. Therapeutic alliance and the importance of establishing therapeutic alliance is a concept that has been written about in psychoanalytic literature for decades. Implicit process? Practically synonymous with the unconscious. And BTW: only one of these variables, focus on cognitive distortions, was associated with poorer treatment outcomes. Oops! Regarding the ambiguous term “experiencing”, there is a fascinating breakdown of meaning by researchers: Shedler refers to the experiencing of feelings to distinguish it from a defensive expression of feeling, or an absence of feeling. A person can, for example, be speaking of him or herself and their life, and be doing so truthfully, but also intellectually; that is, without emotion. Also, a person can be speaking emotionally, but focused upon external phenomena, and thus be blocked from learning how events relate to self. The premises of psychodynamic treatment call for people to integrate thought and emotion, reflect upon self and other, and to recognize needs and viewpoints of self and other in such a manner that holds each in equilibrium–neither subordinate to the other, ultimately.

These were among the things I hoped to stir in my patients/clients when I worked in community mental health. They were the variables of treatment success I suggested to newer therapists as I later became a clinical supervisor. Roughly, and anecdotally speaking, these were the outcomes that were clearly sought by the consumers of all this dross we call therapy.

* Ablon, J., Jones, E. (1998) How expert clinicians’ prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive behavioral therapy. Psychotherapy Research, 9, 71-83.

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