Remember the Soul?
Depth therapy found to be equally or more effective than cognitive behavioral
Posted April 14, 2010
Soul: The complex of human attributes that manifests as consciousness, thought, feeling, and will, regarded as distinct from the physical body; a person's emotional and moral nature, where the most private thoughts and feelings are hidden—Encarta Dictionary
Once upon a time, beginning perhaps with Carl Rogers and Rollo May, psychotherapy was about expanding consciousness and finding meaning in life. Then there was a change. I associate it with an International Conference on Psychotherapy in Mexico City in the 1970s, at a break-out session on the future of psychotherapy with a dozen other psychologists, including at least one future president of the American Psychological Association. The worry was that when insurance covered mental health, psychiatrists (M.Ds.) would be the favored providers unless psychologists approached psychotherapy differently. Like doctors, they needed specific, preferably brief treatments with clear indicators of a cure.
Today good therapy is said to be brief, focused on a diagnosis, standardized, and evidence based, which is equated with cognitive behavioral therapy. There is more than a hint that it is unethical to practice any other way. However, in the February-March 2010 issue of the American Psychologist, Jonathan Shedler of the University of Colorado Denver School of Medicine has an article, "The Efficacy of Psychodynamic Psychotherapy." It is a meta-analysis of 160 outcome studies, finding effect sizes for psychodynamic therapies that are equal or larger than those produced by cognitive behavioral therapy. Some studies found that the benefits also lasted longer, and when transcripts of sessions were analyzed blind, the cognitive behavioral therapists who were most successful were actually using psychodynamic methods. These 160 studies were in peer-reviewed journals ranging over many years. Why is cognitive behavioral therapy still seen as the superior, evidence-based method? As Shedler mildly states, it "may reflect selective dissemination of research findings."
Shedler lists the characteristics of psychodynamic therapy: A focus on emotions, and on the past, especially childhood attachment; a lack of agenda, encouraging patients to discuss anything, including dreams; exploration of attempts to avoid distressing thoughts; interest in recurring themes and patterns; and emphasis on relationships, including the therapy relationship. In other terms, this is depth therapy, exploring the unconscious, an anathema right now in clinical psychology.
Cognitive behavioral therapy is still an excellent place to begin treatment and for many may be enough. It is "top down," using the cerebral cortex to control the lower, older parts of the brain that produce emotional responses, some of which we do not want. Most self-help methods are also top down, asking us to repeat self-affirmations or focus on the positive. This approach sometimes fails*, mainly when the problem began early in life. (Insecure attachments from childhood occur in 40% of adults.)
Most people place the blame on themselves for not using these methods well enough. In fact, some individuals do better with a "bottom up" approach that uncovers the overwhelming emotions that have been dissociated. At the core of these feelings we find the undervalued self, often serving to dissuade us from approaching any experience that could repeat the original trauma. Altering these defensive responses can require years of security in a consistently kind therapy relationship. Occasionally that could cost almost as much as a college education, but for some it may have a much greater impact on both happiness and income, for themselves and their children and children's children.
Positive Self-Statements: Power for Some, Peril for Others, Joanne V. Wood, W.Q. Elaine Perunovic and John W. Lee (2009), Psychological Science, 20, 860-866