Friday, October 03, 2008

Psychotherapy: the meltdown continues

In 1952 the British psychologist H. J. Eysenck published a paper reporting the results of a massive study of mental patients, comparing those who received psychotherapy with those who did not. His conclusion was that available data "fail to support the hypothesis that psychotherapy facilitates recovery from neurotic disorder.” Not only did the application of psychotherapy, especially psychoanalysis, produce no noticeable improvement by comparison with the control group, it may even have worsened the condition of some patients.

Over the years psychotherapists have conducted a whole series of studies attempting to refute Eysenck’s conclusions. Repeatedly, we have been told that through this or that study depth psychotherapy has been vindicated--only to learn on further examination that the evidence proves no such thing. It is fair to say that there is still no solid, convincing evidence that the “talking cure” works any better than other forms of therapy. And of course because of the length of time involved, it is much more expensive.

As these dismal findings have finally sunk in, many universities and clinics have been closing down their institutes of depth psychotherapy. For better or worse, most practitioners now favor quicker procedures, usually involving prescription drugs. Yet the general public remains unaware of this meltdown, still eagerly snapping up books extolling the “boundless wisdom” of Sigmund Freud and other charlatans of that ilk.

An account of a new study, once again purporting to justify long-term therapy, has appeared in JAMA, the Journal of the American Medical Association, for October 1. Ostensibly, the results show that psychodynamic psychotherapy lasting for at least a year can be superior to shorter-term therapy for patients. However this is not true across the board, but only with a few specific chronic mental problems, such as anxiety and the so-called “borderline” personality disorder.

According to the JAMA press release, “[s]ome studies suggest that long-term psychodynamic psychotherapy (LTPP) may be helpful for these patients, according to background information in the article. LTPP is therapy in which emphasis is placed on more interpretive or supportive interventions, depending on the patient’s needs, and that involves careful attention to the therapist-patient interaction.”

Falk Leichsenring, D.Sc., of the University of Giessen, and Sven Rabung, Ph.D., of the University Medical Center Hamburg-Eppendorf, conducted a meta-analysis to examine the effectiveness of LTPP (lasting for at least a year, or 50 sessions) and whether it is superior to shorter psychotherapeutic treatments for complex mental disorders, including personality disorders, chronic mental disorders (defined as lasting at least a year), and multiple mental disorders. The researchers identified and included 23 studies for the meta-analysis (11 randomized controlled trials and 12 observational studies), involving a total of 1,053 patients receiving LTPP.

It seems, however, that rejoicing in the (shrinking) shrink camp is premature. According to a news account by Benedict Carey in the New York Times, “[e]xperts cautioned that the evidence cited in the new research was still too meager to claim clear superiority for psychoanalytic therapy over different treatments, like cognitive behavior therapy, a shorter-term approach. The studies that the authors reviewed are simply not strong enough, these experts said.”

Some qualified observers expressed surprise that JAMA would publish the article, because most review papers in major medical journals have hundreds of studies to draw on, not a mere 23.

The authors of the report left unaddressed the matter of cost effectiveness. What if, as appears to be the case, it is true that long-term therapy, including psychoanalysis, is simply too time-consuming and expensive?

Dr. Barbara L. Milrod, a professor of psychiatry at Weill Cornell Medical College, who is a clinical practitioner of psychodynamic therapy, said that further research is crucial: it is needed as a matter of survival for a “valuable treatment.”

Is it in fact valuable? It is now fifty-sex years since H. J. Eysenck laid down his challenge. Psychoanalysis and its congeners have had more than enough time to respond by proving that the techniques favored by their cult offer an effective form of mental therapy. Since they have signally failed to do so, consignment to the ash-heap of history appears to be inevitable.


Anonymous Anonymous said...

I've cited many psychiatrists (MDs with a scientific, evidence-based approach to therapeutics) that are critical of their own profession's inability to quantify the success of its various modalities. No "study" has shown psychoanalysis to be any better than placebo, and even that conclusion is suspect, since ALL datum are patient-centered intersubjective self-reports -- never a valid means for measure or scrutiny.

Prior to the "modern" therapeutic model, how did people survive their discontents? Did they have any? Or is psychoanalysis a profession in search of a disorder?

Today, the diagnostic bible of psychiatry is metaphysical multiple choice (five out of eight gets a named diagnosis) of 600 mental disorders. No one can compute so many algorithm possibilities, and all these hocus-pocus disorders can be distilled into less than ten classes.

Psychotropics are the sole exception, but then they are the same chemical agent used in people and therefore provide some stability across a complex intersubjective enterprise. Primary physicians, but not psychoanalysts, can dispense these agents based on simpler criteria than the DSM-IV.

In sum, non-medical psychological intervention has shown itself useful only in transitional difficulties, where a professional, distant person provides perspective. But that "person" could just as easily be a family member, a friend, or anyone capable of dispassionate advice.

11:31 AM  
Anonymous Anonymous said...

"But that "person" could just as easily be a family member, a friend, or anyone capable of dispassionate advice."

Absolutely. I've never used psychoanalysis, and could never imagine making use of it - especially as I've been most unimpressed by the calibre of the psychoanalysts that I've met in a social setting.

To be honest, I've a lot of sympathy for the view that says you might as well use a hypnotist. Or better yet, mesmerism! Seriously: who'd refuse a pass or two of sheer animal magnetism? (Oh. I forgot. Someone not in their right mind. ;) )

1:37 AM  

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