Tag Archives: jonathan shedler

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

 

 

Leave a comment

Filed under Uncategorized

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.

Leave a comment

Filed under Uncategorized