JAMA: Effectiveness of Long-term Psychodynamic Psychotherapy

The most recent article of JAMA features a meta-analysis on long-term Psychodynamic Psychotherapy which boasts impressive results.

Leichsenring F, Rabung S. The effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA. 2008;300(13):1551-1565.

According to comparative analyses of controlled trials, LTPP showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, a between-group effect size of 1.8 (95% confidence interval [CI], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups (P=.002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across various and particularly complex mental disorders (range, 0.78-1.98).

This is wonderful for the field of psychology because it will push CBT and other more structured therapies to be more creative in considering psychodynamic psychotherapy as having worthwhile attributes. Maybe there will even be studies that incorporate a combination therapy...a girl can dream right?

There is also a great editorial on the article in the same issue:

Psychodynamic Psychotherapy and Research Evidence: Bambi Survives Godzilla?
Glass JAMA.2008; 300: 1587-1589.

Freud warned that all cases suffer from being explained

My supervisor recently lent me the book, A Safe Place by Lester Havens. I am finding so many passages from this book that fill me with a sense of relief. The common pattern between all of these passages so far is that they talk about the behind the scenes interaction of the therapist and patient. For instance, Havens suggests that "as long as therapists depend upon patient's accounts of their problems, we are in danger of seeing things the way the patients do." He goes on to describe how really demanding people rarely view themselves as demanding: they feel entitle to what they receive, and perhaps expect more. Another example is perhaps that shy people seldom see themselves as being shy, instead they worry about being an oppressive force on others. My first reaction to this was, "of course!" However, I have rarely thought of interpreting a clients presentation to me in this way consciously. In thinking about someone describing themselves as a modest, shy, or demanding in a session, I can see how one way to react would be to merely acknowledge the lack of insight they seem to have to their situation and fit their dysfunctional thought patterns into a model that explains the err of their ways, however I also see that there is a skill that comes from being able to recognize the discrepancy, listen for similar associations, and formulate ways of interacting with the patient that may allow them the freedom to determine, for themselves, how they recover what they may have lost, or even define something new.

I believe that any decent therapist incorporates the second, more psychodynamic approach, when interacting with a client, but it is not something that was discussed in my CBT-oriented program. It all makes good sense and perhaps others don't need to see the words written out on the page like I do, however my interpretation of the absence of being taught the basics of therapist-client interaction was that it just was not important to delivering CBT. Perhaps it was just my expectations of what my clinical training would be like and the type of intellectual conversations that we would have in our coursework, but I feel grossly unprepared to describe the skill that I have learned in conducting therapy outside of my ability to follow a manual.

Starting from scratch?

My initial training in Cognitive Behavioral Therapy (CBT) was great. I learned from the best and saw a few people get some relief from pretty distressing symptoms. However at the end of this training I couldn't help but ask the question "is it really true that you can relieve psychological symptoms forever without learning and understanding how these symptoms were formed in the first place?" And if not is CBT merely a therapeutic collusion with patients who want a quicker fix? It is these questions (which may only reflect my naivete, I'm open to this) that attracted me to psychodynamic theory and why I decided to leave my information processing comfort zone to see for myself. I just began a clinical training in short-term psychodynamic therapy, which I'm currently finding both incredibly exciting and overwhelming. The excitement stems from both the intellectual stimulation, as well as the level of comfort and respect that I feel with and for the people training me (and in such a short time). The overwhelming sense comes from the fact that the theory has been presented in a biased manner throughout my clinical coursework and most of the people in my field of research aren't even aware that people still conduct this type of therapy. Not to mention the fact that I have to read each page of the suggested readings a minimum of two times.

I plan to post my thoughts and ideas on the theories and concepts that I read about, as well as my thoughts on my training experience, sessions, and supervision to help me process this experience and perhaps answer some of the questions that I have.

Any words of advice?