Tag Archives: evidence-based

The War of evidence-based psychotherapy: part two

 

Turnaround is fair play. That’s what it seems like when the champions of psychodynamic models like Jonathan Shedler caricature their CBT counterparts. As I’m no more in their offices as they are in mine, I don’t really know what they do or don’t do in their interventions, but I glean. I don’t glean that my CBT colleagues use workbooks like cookbooks, offering rote interventions that they either memorize or read from a sheet. Nor do I think that most CBT therapists interrupt when a client is speaking of family of origin material; that they scoff at such unstructured navel-gazing and inform clients that exploring the past is a waste of time. Many believe in a structured approach, one that mimics a teaching paradigm to some extent: passing out information worksheets, assigning homework…educating. I recall working in an agency that made copious use of defense analysis worksheets. Clients were meant to read along in a group or in one-on-one meetings, examples of typical defense mechanisms matched to illustrative phrases. They were meant to reflect and say, “I think I do that”, and so on, presumably so they’d learn to not exercise those habits in the future. I’d give lectures to groups on defense mechanisms, codependency—a host of topics I liked expounding upon—delivered bullet-point style, to individuals who appeared to lap up didactic material, to learn if not wholly integrate into their minds, because the learning they need isn’t academic. It simply isn’t. Anyway, the promulgaters of structured approaches think it necessary to, as they sometimes put it, set the limb (with information) before they encourage the broken patient to walk (meaning, explore). It was/is a catchy turn of phrase and powerful use of metaphor, only it doesn’t really work. The mind isn’t like a limb.

But ultimately, it doesn’t matter, this debate between proponents of CBT versus the range of psychoanalytically-derived therapies. It doesn’t matter because the establishment that drives mental health treatment has made its choice, based upon economics (the supposition that CBT is a more cost-effective approach), but justified publicly by invoking evidence-based research. Meanwhile, adherents of psychodynamic models ever hold space for a deeper, longer-lasting, sometimes abstruse and painful descent. Students of these models are on the workplace fringe unless working independently. They sometimes meet, in apparent secrecy, in ‘forums’ in hospital basements, Saturday morning church halls, to discuss their older theories like freemasons keeping one step ahead of orthodoxy. Analyst Wilfrid Bion wrote half a century ago that the role of the mental health provider was to be a container for the pathological patient who attacks his or her mind, and to operate without memory or desire so that an unfettered examination of projections and introjections can occur. His approach wouldn’t fly in most mental health agencies, psychiatrist offices today. He ethos is going to sound a lot different on a treatment plan than, say, “Client will use tools to reduce behavior X over the ensuing 90 days”, or “Take 30mgs of Effexor each day”.

The Bion line wouldn’t go on a treatment plan. It would scarcely enter a ‘team’ meeting, or a consult with a fellow professional. And it’s not because professionals don’t think there’s value in the approach of analysts like Wilfrid Bion or his latter day followers. That’s why the debate doesn’t matter, because it’s not really about which approach is better, but rather which approach is more plainly understood; about what can be quantified, studied, measured, published and disseminated widely so that insurance companies, program clinical directors, and possibly consumers—all looking to varying degrees for ‘evidence’ of what works or doesn’t work—can point to something tangible and say, “hey, this looks like it has substance to it.” It’s about what’s utilitarian, more readily conveyed across channels, such that teamwork, professional fusion—that popular if suspect notion of ‘being on the same page’—can transpire.

When I was a clinical supervisor in a mental health agency, back in the day, I used to assuage interns with non-conformist leanings that the external voices of what is evidence-based are not ‘in the room’ with them (though some try to be or think they are ‘in the room’). This ambiguous freedom comes with responsibility, to decide what’s right for a patient, which often means what ‘feels’ right for a patient, when in the dense meaning of a therapeutic moment. Those patients, the consumers of mental health services, rely upon a sage and flexible approach, and they stand to lose if providers simply conform to that which is prescribed. The notion of ‘what works’ in mental health is quasi scientific, semi-observable; the phenomena of desired outcomes in mental health tend to be thinly defined, and observable only over short durations, which doesn’t speak to the lasting and unknown changes that the consumer seeks.

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The War of Evidence-Based Psychotherapy

 

Work in a hospital or a community health agency of any kind and you’re likely to hear the term ‘evidence-based’ at some point, fairly early actually. Also, as a consumer of services you’re likely to have heard this term applied to clinical practices of various kinds, medical and not. In the field of mental health, this term, borrowed from medical science, has largely served as the cudgel of Cognitive Behavioral Therapy (CBT) advocates eager to promote their methods and mostly derivative theories to practitioners and third party payers (i.e: insurance companies). Since the late eighties, the ‘evidence-based’ tag has been used to assert or at least imply the superiority of cognitive behavioral therapy over traditional, insight-oriented or psychodynamic approaches to mental health. The strategy has been so successful that when people speak of ‘talk therapy’, the assumption (contrary to that of, say, two generations ago) is that a psycho-educational or cognitive-behavioral approach is being referenced.

The scope of this article cannot detail all of the differences between the apparently warring factions, though I will point in what I think is the right direction. First of all, a negative suggestion: ignore Psychology Today. It dilutes issues, in my opinion, versus opening the reader’s mind. It does advertise my practice capably enough, however, so that’s all I’ll say about PT for now. Second: besides combing through the one hundred and twenty plus unheralded yet worthy blog entries on this site, readers might seek out the writings of one Jonathan Shedler, psychology professor at The University of Colorado and perhaps the foremost crusader of the last decade for the restoration of the psychodynamic therapy’s public and professional image. For at least that long Shedler has been an outspoken critic not only of CBT, but of its advocates’ tactics in marketing their method to providers, third party payers, and consumers. In Working Through Rehab, my 2013 excoriation of adolescent drug treatment, I cite Shedler’s 2010 American Psychologist article, “The Efficacy of Psychodynamic Psychotherapy”, which outlines the essential features of a psychodynamic (BTW: an umbrella term for psychoanalytically-derived models) treatment, and offers comprehensive evidence for its efficacy, contrary to the dismissive claims of CBT supporters. In his latest paper, “Where is the Evidence for Evidence-based treatment”, Shedler ups the ante with scathing condemnations of research practices of CBT advocates, more or less mocking their claims. The result makes for some entertaining reading, which I shall review here.

Tracing the history of the evidence-based (movement?), Shedler calls out the National Institute of Mental Health (NIMH) as the biggest culprit of ‘evidence-based’ misinformation, starting in the late eighties. Citing research that began a decade earlier than that, he points out that studies pertaining to treatment of anxiety and depression (the two most prominent conditions presenting in MH), indicate only minor differences between experimental CBT-treated samples and control groups on outcomes measured by the Hamilton depression scale; differences that carry statistical meaning (as in not the result of chance) but, as Shedler explains, lack significance in clinical terms, as in discernible contrasts in symptoms, presenting problems. Examining a recent study by Driessen et al. (2013), Shedler derides a method wherein 341 patients were subject to 16 sessions of manualized CBT. Though the method was proclaimed as effective, Shedler points out that only 22% indicated remission of symptoms, based upon assessments taken the day treatment ended. Shedler then points to studies suggesting that even such improvements evaporate after a short period of time and that 50% of CBT recipients seek treatment again after 6 months. And these findings beg other questions: what happened to the other 50% of patients? Did they improve significantly? Did they not improve and then give up on psychotherapy?

Moving on, Shedler generalizes his observations: the average patient receiving manualized CBT is still significantly depressed after a time-limited treatment episode; that benefits assessed after laughingly short intervals after treatment typically evaporate quickly; that most ‘evidence-based’ studies are ‘shams’, suppressing evidence that doesn’t fit preconceived agendas, publication biases extolling what he calls a “master narrative”; that criteria for patients’ participation in studies excludes those who present with more than one diagnosis, or those with personality pathology, to which (I think) most therapists would respond: wait…those are the people we see. Furthermore, Shedler complains that the so-called control groups don’t accurately represent alternative models of treatment; that while prominent or even celebrity practitioners administer the CBT treatment that is studied, psychodynamic methods are carried out by graduate students given minimal training, rendering a comparison of technique unfair. Finally, there exists in research circles what Shedler calls the ‘File drawer’ effect: the phenomenon of studies, or data within studies being suppressed, as in not published, and thereafter shelved (side note: like my Tommy article between 2012 and 2014). The missing data can be inferred from what is called a funnel effect of data, wherein small samples yield a wide range of values, versus large samples which yield a narrower range. The data is then plotted on a graph which resembles a funnel. Shedler demonstrates that gaps appear on such graphs pertaining to manualized CBT research, indicating ‘invisible’ data.

Incidentally, the term ‘manualized’ used and mocked by Shedler merits some comment, as does the rest of Shedler’s arguments, of course, though I’ll shelve most of my comments until part two of this essay, likely a week hence. Anyway, Shedler’s reference to ‘manualized’ treatment is a snide rebuke of therapies that appear to make use of workbooks, often co-written by practitioners and academics. I admit that I have a few of these manuals adorning my bookshelves, though I rarely use them. They contain examples of questions posed to patients about their conditions, designed to challenge problematic thinking; suggestions for a ‘reframing’ of a problem, or examples of homework assignments given—CBT chestnuts, I guess. The comedy in Shedler’s writing—his dismissal of ‘cookbook’ technique—verges on the nasty, but what’s significant is the background context: psychodynamic or psychoanalytic therapies/methods have been taking it on the chin for some time now; dismissed as “that Freud stuff” by pedestrian instructors, psychiatrists, peddlers of psychotropic medication, or ignoramuses positioned at various nodal points in the industry; people who pull the purse strings, or who have those peoples’ collective ear(s), who have been willing to stereotype, quite ruthlessly, the forefathers of our profession. Jonathan Shedler is one of the people at last bothering to fight back. So It’s 2016 and everyone and thing has its advocates. Including the unconscious, it seems.

 

  • I shall refrain from a list of references for this article, though each can be found via Shedler’s 2015 article, “Where is the Evidence for Evidence-Based Therapy”, available online

 

 

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