A very well written post. I can’t tell you how frustrated I am (and a little resentful) that prior to my current therapist, I’ve only received supportive psychotherapy and psychodynamics for my Social Anxiety Disorder instead of CBT. Part of the problem was that I was ignorant of Social Anxiety Disorder and neither my psychiatrists nor clinical social workers told me of their diagnosis (except for the second psychiatrist but he kind of hinted at it). I finally realized I had it when I watched youtube videos from Social Anxiety sufferers.

The only evidence-based treatment I gotten was SSRIs (paxil and later lexapro) but of course, it wasn’t enough for me and it left me with anorgasmia when I took them. Luckily, I’m now receiving Group CBT in a hospital outpatient clinic. I’m now very hopeful that I’ll overcome it!

Great post! I like the passion you have for putting the right therapy with the diagnosis. As someone who sat in therapy for 8 years talking about but not healing my trauma I can attest to how unhelpful that was!

I wonder how you would treat PTSD — with CBT only? What’s the best way to use CBT technique and approach for healing trauma? And what other modalities would you suggest in tandem with CBT. I found CBT helpful in terms of coping but not in resolving and relieving my trauma.

If you would like to, I’d be very interested in you guest posting on my healing PTSD blog: http://blog.healmyptsd.com.

Confusing post. Your first reaction, sure. Yes, there are well tested therapies and your therapist should know what they’re doing and be able to explain it to you.

But your second point is that you’ve had training? I’m not understanding the relevance in relation to the what the post is supposed to be about.

Oh well, I’ll take my leave scratching my head.

Cheers!

Hello to Carlos and Michele: thanks for your kind words. I am pretty passionate about getting the right care for people. It frustrates me that so many psychotherapists insist that what they do is somehow deep and mysterious. We know that the collaboration between the client and the therapist is critical, but that is not the only part of psychotherapy that works. antiSWer, the 2nd point of my blog is that training in evidence based therapy has been available for years. The fact that so many people are getting treatments that aren’t based on science is quite sad.

Hmmm. I’ve also read studies that suggest the therapeutic alliance to be more important than the therapeutic method employed. How do those studies support the validity of using standardized methods?

You have a valid point-therapists should keep up with current research–no disputes to the central point. But the connotations in what you wrote article sort of dismiss the large grey areas.

The problem with statistical research is that it assumes all human beings are alike. While we may have common denominators-such as bipolar, borderline, OCD, and all the rest, which are addressed by some studies, all the numbers in between that represent human nature comprise a spectrum no smaller than infinity.

So if therapy becomes a science-how can one address all the infinite, unique possibilities? We are all so different. If a study shows CBT helps a certain condition 70% of the time, what does that say for the 30% who did not benefit? Someday, will they not be able to find the appropriate therapy that suites them best? Should a therapist just blindly use the method that helped the 70%, ignoring the needs of the 30% who did not benefit because of statistical results?

Your article has ‘hints’ of adverse bias against psychoanalytic based methods. Do any practicing psychoanalysts today really believe in penis envy? Maybe some; I wouldn’t know. But just ask anyone who has recently discovered or benefited from psychodynamic therapy about their experience wasting years and money on CBT, ask them how they feel about their psychotherapist’s personal, artistic methodology.

One size fits all approaches do not apply to human beings, in my opinion. A human being is not a statistic.

Lots to think about here…

This short PC article is relevant to this discussion:

http://psychcentral.com/blog/archives/2007/04/03/intensive-psychotherapy-helps-bipolar/

Someone posted a comment in the PC forum about medicare only allowing cbt or interpersonal therapy. Because of the source, i’m not sure if this is fact, but i see turning therapy into a science-in terms of basing treatments on statistics-as problematic. People who would greatly benefit from psychoanalysis would be left out in the cold and never experience recovery because of some statistic/empirical evidence that classifies people in groups instead of individuals.

There are many problems comparing psychotherapies–such as how to operationalize and control for the human factors such as therapeutic relationship. Many studies do so by comparing different theraputic approaches that all provide therapeutic alliance such as supportive therapy, interpersonal therapy versus CBT. In one interesting study reported in the American Journal of Psychiatry (2009), Dr. Falk Leichsenring compared psychodynamic psychotherapy (his preference) to CBT for people with Generalized Anxiety Disorder. The study was designed to balance the factors such as number of sessions and amount of time in session. There are few such studies. This one found overall CBT helped people with GAD more than psyhchodynamic therapy. Research studies can’t answer all of our questions about therapy and humans, but it can inform and guide those of us who struggle with what works. Please, if any one knows of specific studies that look at how psychodynamic therapy has helped people with OCD–we’d seriously like to have the reference. Take care.

The study you referenced compared SHORT TERM psychodynamic therapy with CBT, with the mean # of sessions approx. 29. The prevalent factor that improved less with STPDT as opposed to CBT was ‘worry’. A population of 50 some people, excluding those with prior depression w/in the past year….both groups of therapists had to use manuals – CBT therapists are used to using manuals and trained in their use, while the PD therapists generally do not use manuals (because each person they treat is unique)..okay I’ll stop.

My main diagnosis was GAD. Now, in PD therapy, I don’t really have one (except when one must be chosen to submit to the insurance co.). I found psychodynamic therapists (can only speak for the ones I have known) do not use the DSM diagnosis in terms of formulating a person’s needs or categorize people into those narrow labels. Diagnoses change all the time, but how they overlap heavily adds much more complexity, which I think is another factor that leads to difficulties with making valid conclusions from comparing therapies.

I wonder if those who end up in psychodynamic therapy have more complex problems to begin with? Not in studies, but in the non-study world?

What has really helped me in terms of psychodynamic therapy was the opportunity to access and work through emotions that have been repressed all my life. This was the missing element from years of other therapies. I’m middle aged now, and am very saddened I was so clueless all those years about the different types of therapy, while I was engaged in those that made not one iota of difference in my life (even though the therapists were supportive and nice to talk to).

I really wish one of my psychiatrists would have suggested psychodynamic therapy (I had never heard of it prior to one year ago). People should be educated as to what their options are. Not one P-Doc suggested I try a different therapeutic approach than CBT. Now, with the information on the internet, it is so much easier to investigate your options. Before I had internet access-I did not even know there were so many different types of therapeutic approaches! Not everyone uses the internet for medical information..and even so, P-Docs should inform patients of these options at some point during one of our 15 minute medication appointments.

But I do think experience makes a huge difference. A therapist may be taught a certain method and realize it doesn’t work and change their approach. My current PD therapist/MD told me that long ago, he revised his techniques originally taught through psychoanalytic training. I weigh a therapist’s 30 plus years of experience with the nature of human relationships much greater than what a student might learn from a graduate program. That’s just my personal belief and preference though. Converting the many theories to clinical practice is primarily how I see the art in it all…..a skill acquired through experience. The downside is mistakes are likely to be made through some of these learning experiences…

At any rate, I’m glad to see studies comparing therapies, pleased to see others reporting on them and welcome the chance to discuss them…so thanks for your article!

Thanks for your thoughtful response and it’s wonderful that a psychodynamic theraputic approach has worked well for you. I believe that many of the theoretical differences are really semantic differences. Psychotherapy integration has its own journal. So people in the field are certainly talking about theories. Take care.

The problem is not the efficacy of different kinds of therapy. The problem is insurance.

That sentence is hyperbole to make a point, and here’s my point. If a human wants to dump, pour, or invest tens or hundreds of thousands of dollars into a psychoanalysis or long-long-long term therapeutic relationship, that is the person’s prerogative. I could see where for some folks, with a brilliant analyst and a probing analysand mind, that could be a fantastic intellectual and emotional exercise. I can even see where anecdotally (as opposed to statistically) it could provide a “cure.”

The problem is, where does insurance and government funding via Medicaid enter into it? Especially with the 2010 advent of mental health parity, what is the responsibility of the larger insurance pool participants to pay for such an analysis or relationship? Freud said that the point of psychotherapy is to turn neurosis into ordinary human misery. How much misery should be tolerable, and how much of your misery should I be responsible for paying for to alleviate? How miserable ought I be before I ask you to help fund my care?

No answers here, just questions. Great post and excellent comments.

So true. I don’t know many insurance companies that will fund psychoanalysis several times a week for many years. That’s the reality for most of us.

I agree that there should be more focus on proven techniques. But there are often underlying issues to the symptoms. I think that a good therapist can help identify some of the underlying issues as well over time. Not just the head-ache but what is causing the headache.

Raymond Bokenkamp
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@Raymond: True, but these goals are not incompatible!