(This column is Dr. Einhorn’s article in the current Cappstone, the newsletter of the Chicago Association for Psychoanalytic Psychology. Dr. Einhorn is Chair of the Advocating Psychotherapy project at CAPP. To arrange for a presentation about psychotherapy, contact Dr. Einhorn through the website contact link.)
In this time of the prevalence of a one-dimensional medical model of mental suffering and treatment, and the increasing marginalization of psychotherapy as health care reorganizes under intense economic pressures, a colleague has advanced, and perhaps also hindered, the cause of advocating psychotherapy, in a recent column in the New York Times (9-29-13). Op-Ed contributor Brandan A. Gaudano, clinical psychologist at Brown University, writing on “Psychotherapy’s Image Problem,” begins by pointing out that “In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent,” despite the fact that “a recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.” “As well they should,” he continues, “…Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.” (entire article at: http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?emc=eta1&_r=1&/)
Dr. Gaudano attributes “the gap between what people might prefer and benefit from, and what they get,” to the fact that “psychotherapy has an image problem.” And what is that problem? “Primary care physicians, insurers, policy makers, the public and even many therapists are unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries–industries that, not incidentally, also have the money to aggressively market and lobby for those practices.”
So far so good. We heartily agree with Dr. Gaudano’s comments, which are entirely in harmony with the perspective of CAPP’s Advocating Psychotherapy project. But when it comes to identifying what constitutes effectiveness in psychotherapy, Dr. Gaudano is beating the drum of randomized controlled trials. “For patients with the most common conditions, like depression and anxiety, empirically supported psycho- therapies–that is, those shown to be safe and effective in randomized controlled trials–are indeed the best treatments of first choice.” Referring to a recent survey that he completed with his colleague Ivan W. Miller, for the November edition of Clinical Psychology Review, Dr. Gaudano states that “It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).”
“Psychotherapy’s problems come as much from within as from without,” Dr. Gaudano states. “Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which–like some old-fashioned Freudian therapies–should be abandoned.”
Here, I am afraid that some of Dr. Gaudano’s comments tend to muddy the waters about what psychotherapy is and how it can be of value, at the same time that he’s trying to clear them up. For example:
•The use of randomized controlled trials (RCT) as the “gold standard” of outcome study is misleading. RCT requires the standardization of patients into relatively pure diagnostic groups (depression, anxiety, etc., with careful pre-screening to have as close as possible to “pure” diagnostic groups) and therapies into methods defined by techniques (cognitive-behavioral, interpersonal, etc.), overlooking the individuality of patients, therapists, and patient-therapist pairs. Such clarity, simplicity and replicability are not found in the real world, in which patients are usually quite complex, therapists have to adapt whatever methods they are using accordingly, and the interaction between patient complexity and therapist adaptability often has more to do with outcome than diagnosis or treatment method per se.
•The largest contributor to outcome in therapy is quality of relationship between client and therapist (as Jonathan Shedler described in his overview of studies, “The Efficacy of Psychodynamic Psychotherapy,” in American Psychologist (Feb-Mar. 2010). This is not to dismiss the importance of methods and techniques, or the value of a well-stocked toolbag for therapists with more than a narrow specialization. But the methods and techniques are applied within a relational context, which has as much to do with their efficacy as technical skill per se.
•The practice of treating psychodynamic, cognitive, interpersonal, etc., interventions as if they are separate is misleading. I’ve never seen any successful therapy in which unconscious factors in the patient weren’t elicited and transformed, in which the patient didn’t learn to think and perceive differently, and in which the interpersonal life of the patient wasn’t in some ways altered for the better through interaction with the therapist.
•A key mistake, often repeated in the history of modern psychology, has been to reduce our understanding of human behavior and experience to the currently available scientifically accepted methods. “Science” does not mean “whatever we can study with RCT.”
•While it’s good to see psychodynamic therapy included in the winner’s circle of empirically proven methods, the emphasis on short-term therapy overlooks the need of many patients for longer-term work. Symptoms may be resistant to treatment, and can change into a focus on underlying existential issues as therapy proceeds; all of which can take a lot longer than 20 weeks.
•Dr. Gaudano’s assertion that empirically supported therapies are superior to medication still takes place within the medical model, in which mental and emotional disorders are disconnected from the facts and experiences of people’s lives. “Safe and effective” are statistical abstractions within this model. In practice, what is safe and effective for one person may not be for another; thus the lengthy caveats about problems with safety and/or effectiveness in medication advertisements.
As to “psychotherapy’s image problems,” psychoanalytic authorities and institutions have certainly contributed to them, but so have proponents of “empirically validated” treatments. In fact, just about every form of treatment in the field of psychotherapy has been heavily influenced by gifted authoritarian empire-builders and their followers, resulting in a mine field of claims and counterclaims, in which conviction based on reductionist thinking at the expense of wider truth, together with contemptuous dismissal of alternative paradigms, is the currency of the realm. There is no “one size fits all” therapy, or therapist, or method of determining efficacy.
This mine field is the main “image problem” of psychotherapy. The basic method of therapy, in which two people meet to discuss, and try to understand and resolve or improve on, the mental, emotional, and relational problems of one of them, during which they form a particular kind of working relationship which evolves if the work goes well enough–and each of those relationships is unique–continues to be more powerful than the ability of any theoretical model to explain.
Neuroscientific advances will contribute to our understanding of what’s happening in psychotherapy. Neuropsychologist Elkhonon Goldberg, in his The New Executive Brain, states that “even relatively brief but sustained cognitive activity is capable of affecting brain morphology and is detectable in neuroanatomically specific ways” (p. 239). Goldberg is talking about kinds of learning such as new languages or music, but the application to therapy is clear. All this work between patient and therapist, when effective, cultivates salutary brain changes in the patient; and perhaps also, to a lesser extent, in the therapist. Research in this area is already proceeding, although the methods and conceptual frameworks remain relatively crude. Such research, when it reaches maturity, has the potential to reformulate how we understand schools and methods of therapy.
In wider perspective, we can see that therapy and medication, mental and emotional disorders, have all evolved within our society, where rhetoric and practice in politics, education, economics, medicine, the military, religion, government, and business, are characterized by misleading oversimplifications, dogma and ritual mistaken for knowledge and truth, turf wars, cult-like processes, and successive fads; each claiming superiority until it, too, is debunked. And the people, including professionals as well as consumers in each field, tend to be blind to the process itself, caught up in the cycle of fads, one after another. Why should psychotherapy be any different?
What’s needed, across the board, is better information and better informed consumers and practitioners. Now that’s a long-term process; it will probably take more than 20 weeks. But contributing toward it, in whatever ways we can, is the goal of our little Advocating Psychotherapy project here at CAPP.