How Everyone Became Depressed

The rise and fall of the nervous breakdown

All Psychotherapies are not Equally Effective

CBT is better than psychoanalysis, at least for treatment of eating disorders.

Until now, I had believed the conventional wisdom, that all psychotherapies are equally effective, and that the therapeutic ingredient in psychotherapy was the caring exchange between therapist and patient.

But that’s evidently wrong.

The empathic, concerned exchange is still important, but in a recent, rigorous trial, cognitive-behavioral therapy (CBT) beat the pants off psychoanalysis, at least in the treatment of eating disorders. In the January 2014 issue of the American Journal of Psychiatry, psychologist Stig Poulsen, leading a team of researchers at Copenhagen and Oxford, reported that in the treatment of bulimina nervosa – binge eating and purging – CBT had done considerably better than psychoanalysis. This is an honest finding because the two lead researchers were analysts. 

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The researchers randomized 70 bulimia patients to either CBT or psychoanalysis and gave the analytic group two years of weekly analytic psychotherapy, the CBT group five months of treatment. They were then assessed at five months, and again at two years.

“A marked difference was observed between CBT and psychoanalytic psychotherapy," the researchers said. At five months, 42 percent of the CBT patients had stopped gorging and vomiting, only 6 percent of the analytic patients.

At two years the analytic patients had closed the gap only slightly: 15 percent of them were better vs 44 percent of the CBT group.

Bottom line: if you’ve got bulimia nervosa, you shouldn’t be seeing an analyst.

But we’ve known this for a long time. If you have anything more serious than diffuse unhappiness, you shouldn’t be in psychoanalysis because it has no edge over other psychotherapies that are much shorter, much less expensive, and now – evidently much more effective.

It’s astonishing that psychoanalysis has managed to stagger into the 21st century, and just barely. Almost no psychiatrists believe in it anymore, saved a handful of beached whales in New York and Los Angeles who don’t know how to do anything else and who, as a result of something called the Osheroff case, are obliged to prescribe whether they believe in “pills” or not.

There is still a psychoanalytic claque in some departments of psychology, though the field has raced way past them. Otherwise, where psychoanalysis survives is in department of literature. How does that make you feel as an analytic patient? That the people who most believe in your therapist’s magic are studying the uses of irony in Dryden?

Psychiatry today is overwhelmingly committed to biological models, although there is no drug treatment for bulimia nervosa. Is the swing to biology good?

Here we get to the fundamental problem in today’s psychiatry: Not only has the pendulum swung to the other side, it has swung right off the hook! The field is the highest prescribing specialty in medicine. Acccording to data from the National Center for Health Statistics of the US, in 2005 about 90 percent of visits to psychiatrists ended with prescriptions, compared to 69.4 percent of visits to dermatologists. (NCHS Advance Data, nr 387, June 29, 2007, tab 24, 33) Dermatologists, who live from drying and wetting skin lesions of various kinds with drugs!

So, you young women with bulimia nervosa, we may not be able to help you with a Prozac prescription – which everyone else gets – but maybe you’ll get one anyway because, quite frankly, there’s not that much we can do for you. Maybe refer you to a psychologist for CBT.

Well, yeah! Let’s try that!

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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