The Skeptical Sleuth

It seems to me that the biggest problem in researching so-called "long-term psychodynamic psychotherapy" is less statistical than practical. How do we define "psychodynamic psychotherapy"? Certainly not as follows: "The authors defined LTPP as having at least 40 sessions and continuing for at least one year." The problem is that what we call psychodynamic psychotherapy varies immensely from practitioner to practitioner, and even from case to case. So what are we really measuring? Certainly, psychodynamic psychotherapy should not be defined on duration alone. A psychodynamic approach can be taken in brief, time-limited treatment too (much less than 40 sessions). Simply seeing a patient for 40-50 sessions per year for a couple of years does not define psychodynamic psychotherapy. Psychotherapy cannot be defined by frequency or duration of sessions, but rather by what takes place in the consulting room. What exactly is going on in those sessions? Are the psychotherapists inclined more to Freud, Jung, Rank, Adler, etc.? Are they psychoanalysts? Are they "pure" psychodynamic practitioners, or do they eclectically weave in existential or other orientations as well. (For example, I practice what I call "existential depth psychology.") My point is that, especially when it comes to depth psychology or psychodynamic psychotherapy, there is no one standardized approach to it. What the psychotherapist brings to the table is crucial, and varies tremendously from clinician to clinician. So where is the reliability in such studies? I believe we would need a much more detailed and sophisticated definition of psychodynamic psychotherapy applied in order to meaningfully measure its efficacy as compared to other treatment approaches.

The discussion in the blog is largely made on the basis of one study, granted it was a meta analysis, however one study none the less. A criticism of one study does not an argument make.

I also think the mantra of psychology lately is CBT and meds, CBT and meds, CBT and meds. We are quick to be critical of the cost of talk therapy, but we are not so quick to ask the unpopular questions about the drawbacks of medicating so many people.

Finally, because of the popularity of CBT/meds many studies focus on researching this intervention. Far fewer studies focus on LTPP than other methods of treatment. A lack of evidence because an intervention is not often studied is not the same as a method being ineffective.

I am tired of arguments that focus on costs while insurance and pharmaceutical profits soar.

I think the jury is still out, epidemiologically, on the efficacy of long term therapy. The study that begs to be done is to compare a control group of folks on a therapy wait list, to a group of people who simply talked for an hour a week for a year with an untrained person called "therapist", to a group who talked for an hour a week for a year with a trained person called "therapist."

Good piece.

Dr. Diamond writes:

"Simply seeing a patient for 40-50 sessions per year for a couple of years does not define psychodynamic psychotherapy. Psychotherapy cannot be defined by frequency or duration of sessions, but rather by what takes place in the consulting room."

As someone who has been in therapy, in my opinion this is exactly right. Many different things happen within the definition of "psychodynamic psychotherapy" and those differences are crucial for outcomes.

Perhaps it is impossible for scientists to be as objective and fair and open minded as what would ideally be best for science. This could be said for both sides of this argument (CBT and non-CBT researchers). The passion that drives us to research certain issues or theories make it near impossible for us to be dispassionate about the results.

Perhaps it is impossible for us to be as objective and fair and open minded as science demands of us ideally. The passion that gets up to research these theories make it next to impossible to make dispassionate interpretations of the results. This, I feel, is the case on both sides of this argument (CBT and non-CBT researchers).

Behaviorism and Cognitive Behavior Therapists have long attacked the usefulness of the therapeutic relationship and insight, and often use biased research to support their anti-psychodynamic claims. They will argue that psychodynamic theory and treatment (which includes not just behaviors and cognitions, but also feelings, development, history, family dynamics, traumas and the unconscious) is not scientifically supported. When there is scientific support, they claim that it is flawed science.

Sometimes studies do warrant concern, but the methodological concerns are true of most outcome research, or as in this criticism- it is a false claim. Falk Leichsenring and Sven Rabung have responded in the professional journals that the criticisms are unfair and based on a mis-reading of their work. And even when they did re-analyze the data in the manner suggested, they got similar results (as expected). People who are bright but not psychologically minded will always be threatened by psychodynamic insights.

See my article: http://www.mmpi-info.com/psychology-publications/scientific-renaissance-...

I'm responding as a layperson, offering my insight as a long-term consumer of various psychological/psychiatric services over the course of my adult life. I have been exposed to psychodynamic therapies, CBT/DBT, a multitude of medications and, most recently, ECT. I have suffered from depression since the age of fifteen, and although I went through more than a decade of inpatient hospitalizations, I'm grateful that I am now a successful professional. I don't have a particular allegiance to psychodynamic therapy, but I must say that the obsession with immediate symptom-resolution is misguided. In fact, the few fantastic longer-term therapeutic relationships I've had helped me maintain at "baseline," often during periods when I was in grave danger of getting progressively worse. When I was engaged with these therapists (most of whom I would categorize as eclectic), the fact that I refrained from destructive behavior for periods of time was a great form of progress; although my symptoms, per se, may not have been greatly alleviated. The most (and I don't say this lightly) destructive evidence-based modality I've been in engaged in is Dialectical Behavioral Therapy. I languished for years, not getting better, and eventually got worse. The focus on simply teaching skills in a didactic manner and reviewing a mood chart in individual sessions was, for me, barely useful. My questions: when is the relationship itself, in fact, the curative factor? Why only seek to match diagnoses with therapeutic modalities when, it seems to me, learning and personality styles may be equally or more important? And, for those of us who have many years of major psychiatric problems, when is focusing on maintenance a worthy-enough endeavor?

The other problem I've seen is the artificial binary between medication and psychotherapy. I recently (this week)tried ECT and after two sessions, have begun to feel better for the first time in years. I've been to some of the best psychiatric institutions in New York, and this was never offered: it was medication after medication, and CBT/DBT. I don't doubt that CBT/DBT can be highly effective, but for whom and for what reasons? I'm definitely an advocate of longer-term therapy. Maintaining the "status-quo" rather than decompensating is a worthy-enough reason for me to advocate for this. And I have found a wonderful therapist who employs some CBT techniques, but it's the relationship itself which has been quite curative so far. Those of us who are lucky enough to have been able to engage in effective longer-term therapies (and I'm not talking about the worried well) need to continue to speak up.

I have been in LTPP for eleven years. Some people would think that this is ridiculous and a waste of money. For me, though, it has saved my life. I started therapy at a time when I was addicted to alcohol and drugs. I was 23 years old. I had been suffering from severe recurrent (nearly constant) depression since I was 12 years old. I started medication when I was 17 years old just prior to spending 6 weeks in a psychiatric hospital. I had PTSD and had previously had an eating disorder. Because of LTPP I have managed to stay sober for nearly 10 of the past 11 years, I have stopped other self-destructive things like cutting myself, I have not returned to disordered eating (had a problem for a short time after stopping drinking and drugs but was able to stop),and have become consistently less depressed. I still have difficulties with relationships and problems related to the PTSD and depression but with my therapist I am working on those, and am getting better. I have been able to complete college and work professionally. I live independently and pay my rent every month. For me, the cost of LTPP is more than worth it. I am living a life that I did not believe to be possible - one in which I am not constantly in distress and trying to seek a way to escape or contemplating suicide. My life is not constantly ruled by depression and addiction and PTSD. I have been on 26 medications over the years and none of them have been as effective in helping me change my thinking and behavior and brought me the peace that LTPP has. LTPP does not cause side effects like insomnia, loss of appetite, difficulty concentrating, drowsiness, liver damage, etc. that medication causes. I have had insurance companies that hardly pay anything for psychotherapy so I have gone into debt in order to pay my therapist - I only have done this because I truly feel that it is necessary for me. I think it must be very hard for researchers to measure effectiveness of LTPP in comparison to CBT (or some other therapy). For starters, you have the problem of every person being unique. You can't take 10 people diagnosed with severe depression and have them all respond the same exact way to medication so how do you think that all 10 people will respond the same way to LTPP or another therapy? Each person has a different life story. One therapist might be a good match for one person but not a good match for someone else. It is so hard to measure something when there are so many variables.