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The Wisdom of Psychopaths
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A remarkably important event has just occurred in the world of psychology: A leading, peer-reviewed journal has published the strongest evidence yet that psychodynamic psychotherapy -- “talk therapy” -- works. In fact, it not only works, it keeps working long after the sessions stop.
Full disclosure: We report this not as disinterested observers, but as psychotherapists and researchers on the process and efficacy of therapy. Our book, “Handbook of Evidence-Based Psychodynamic Psychotherapy,” summarized the body of research through last year and another will follow late this year. Still, we can state as fact: The movement to establish an evidence base for psychodynamic therapy has taken a giant new step forward.
This new academic paper reports positive findings about the form of therapy that began with Sigmund Freud and has historically been utilized more than any other psychotherapy treatment. What does modern psychodynamic psychotherapy look like? Its distinctive features include several basic building blocks: A focus on emotion and relationships; identification of recurring themes and patterns; discussion of past experiences; a focus on the therapy relationship; exploration of attempts to avoid distressing thoughts and feelings; and exploration of fantasy life.
Overall, the paper found, psychodynamic psychotherapy demonstrates efficacy at least equivalent to other psychotherapy treatments commonly labeled as “empirically supported” and “evidence based.” And in fact, it notes, psychodynamic therapy's "active ingredients" are shared by many other forms of therapy as well.
The paper heralds a turnaround thirty years in the making: Practitioners of psychoanalysis and psychodynamic psychotherapy were notoriously late to the research enterprise. Through the late 20th century, they eschewed the need to enter the rigorous academic world of process and outcome research, claiming that gathering observable data from psychotherapy sessions could not apprehend the essence of treatment that is based on unconscious meaning.
That stance made it ever harder for psychodynamic psychotherapists to convince insurance companies to pay for their services, especially long-term treatments. It also made psychodynamic psychotherapy look somewhat backward compared to schools of therapy that actively did gather efficacy data, such as cognitive-behavioral therapy, a treatment which focuses on patients' irrational beliefs.
In recent years, however, for reasons of self-interest and consumer interest, those attitudes have changed, and psychodynamic clinicians and researchers have engaged in research with growing force. They are measuring treatment variables such as empathy and the therapeutic alliance, the compact between patient and therapist about goals and methods of the therapy. They are also studying physiological markers such as galvanic skin response: they measure skin conductance on the patient and the therapist during sessions, and the greater the concordance between the two, the higher the level of empathy.
Additionally, research from neuroscience is beginning to offer implicit support to the mechanisms of action of psychodynamic psychotherapy. Initial findings, for example, suggest that as patients learn to regulate their emotions, that change is reflected in the prefrontal cortex, the seat of executive function.
The new paper by Jonathan Shedler, an associate professor of psychiatry at the University of Colorado School of Medicine, appeared in the journal American Psychologist. It carefully analyzes the results of randomly controlled trials -- the gold-standard for scientific studies -- of psychodynamic psychotherapy treatments for a wide range of psychological disorders.
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7 Comments
Add CommentFinally, somebody did the work that was needed to show what we have already known. Bravo!
Reply | Report Abuse | Link to thisThis is a wonderfully interesting article, and Im glad that it gives the larger public an awareness of this whole body of research. From my vantage-point as a therapist, one of the things the authors make reference to thats most interesting is the notion of how common factors appear operative in various schools of psychotherapy. Id love to see Scientific American do a piece on this issue within the field. Meanwhile, thanks for publishing this!
Reply | Report Abuse | Link to thisThis is a wonderfully interesting article, and I’m glad that it gives the larger public an awareness of this whole body of research. From my vantage-point as a therapist, one of the things the authors make reference to that’s most interesting is the notion of how “common factors” appear operative in various schools of psychotherapy. I’d love to see Scientific American do a piece on this issue within the field. Meanwhile, thanks for publishing this!
Reply | Report Abuse | Link to thisWell, I wouldn't say it what WE have already known, if we place the WE in the larger context of everyone. There is a large contingent of the general populace who disagrees with the efficacy of talk therapy..."you're seeing a therapist? What are you, crazy??"...having empirical evidence behind it makes it a bit more "valid".
Reply | Report Abuse | Link to thisNow, when we consider a world where Kevin Trudeau can convince millions of people they can cure their own cancer with some herbs, empirical evidence isn't generally considered valuable, but it can help those who are on the fence in dealing with reality. :)
Besides, it's not good science to say something works without empirical evidence!
Spoonman - Exactly my thoughts. I'd say that this article affirms what psychotherapists already believed, anyway! Not that I have any real knowledge of the subject, but I've always been very skeptical of it: this article did not change that.
Reply | Report Abuse | Link to thisAs a Psychodynamic Psychotherapist I am excited about this paper. Not enough research about PP but this paper says it all!!
Reply | Report Abuse | Link to thisLyn Ezekiel
The idea that some critics (presumably CBT disciples) “dismiss the value of the research entirely because the efficacy studies are for mixed disorders rather than for a specific disorder” is ludicrous.
Reply | Report Abuse | Link to thisConsidering that DSM-IV has no established scientific validity or reliability calls into question the validity of all research based on DSM-IV criteria. Are they truly measuring what they are trying to measure? is my understanding of validity. Reliability pertains to the results being reliably reproducible. Validity itself is dependent on reliability.
It is not for want of trying. The APA has attempted to establish validity and reliability for the DSM-IV but has been unable to. Basically, people can get ten different diagnoses from ten different practioners. Moreover, once an accurate diagnosis (which is often characterized as an all important goal to proper treatment) there is no empirically demonstrated single treatment model showing consistent efficacy for these supposed categorical disorders.
As a mental health practioner DSM-IV diagnostic categories are useless in helping to understand the etiology of an individual's psychological problems or treatment. I have never encountered one patient whose symptoms were restricted to the categorized constellation of symptoms equating to a specific mental disorder (five symptoms, yes, four no) described in the DSM-IV and which have no correspondence to anything in nature. The universe just doesn't work this way.
In my experience, all mental disorders are mixed disorders. Indeed, more often, the medical model causes narrow symptom based thinking and treatment that excludes learning the underlying source of the problem. Like fevers, psychological maladies have many different sources but similar presentations. One can take ibuprofin to treat a fever. However, I would suggest that if the fever lingers, treating the underlying source would be better course of action.
Moreover, the common variable across psychotherapy models and the best predictor of outcome is the quality of the Therapeutic Alliance. Psychodynamic psychotherapy methods inherently, if unintentionally, place more emphasis on initiating and preserving the alliance (a genuine interest in the individual and understanding the idiosyncratic sources of their suffering as opposed to symptom focus, respect for complexity, empathy, emphasis on the therapeutic relationship and transference and attachment impediments that inhibit establishing and maintaining a productive working relationship, the unconscious wishes and fears revealed in fantasy and interpretation or, in other words, helping a patient create a narrative--creating language for experience--which allows, as humans think in language, the patient to think and feel about their experience—mindfulness--which allows for greater emotional regulation and control) all foster therapeutic alliance.
Neuroscience is, in fact, confirming many of the constructs of psychodynamic theory.