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November 24, 2013 at 3:53 pm · · 0 comments

The George Washington University Announces Incorporation of Psychoanalysis

From James L. Griffith, MD

Chair, GWU Department of Psychiatry and Behavioral Sciences

On the evening of October 11, we will celebrate the incorporation of the Washington Center for Psychoanalysis into our George Washington University Department of Psychiatry and Behavioral Sciences as a new academic division. This is a momentous event for the WCP and our department, the fruition of negotiations that began in earnest two years ago but had been periodically discussed for over two decades. The new affiliation between the WCP and our department is the only affiliation between a psychoanalytic institute and a psychiatry department that has occurred in recent history. Na-tionally, there have been three psychoanalytic institutes embedded within departments of psychiatry at Columbia University, New York University, and Emory University. In 2003, the Menninger Institute navigated a move to Baylor University after continued existence at its longstanding Kansas home became untenable due to changes in national health care economics. Unlike the Menninger move, creation of our GW-WCP affiliation has not been driven by duress, but by the promise of new vistas for joint educational and research programs that can fulfill core missions for both.

The rarity of psychoanalytic institutes within university departments of psychiatry can perhaps be explained by the emergence during recent decades of psychopharmacology and the descriptive diagnostic systems of DSM-III, -IV, and -V as dominant forces shaping the evolution of American psychiatry. A more important question, however, is why a rapprochement of psychoanalysis with academic psychiatry makes sense now. From my perspective, three reasons stand out.

First, the past 50 years of psychotherapy outcome research have firmly established that psychotherapy is among the most highly effective treatments in all of medicine with an effect size of approximately 0.8 in meta-analyses inclusive of multiple kinds of clinical problems and diverse patient populations. However, the active elements that contribute most to this effectiveness are those that engage a patient’s subjective experience, such as the mobilizing hope, emotional at-tunement, and building a collaborative therapeutic alliance. Psychoanalysis and psychodynamic psychotherapy remain our major therapeutic methods for understanding, witnessing, and responding to a patient’s subjectivity.

Second, psychoanalysis is an important method for conducting inquiry that tracks patterns of a person’s lived experience within contexts of family, workplace, community, and culture. As such, a psychoanalytic perspective can add a depth of understanding to clinical treatment, psychiatric education, and the medical humanities.

Third, the emergence of cognitive and social neuroscience provides methods for the scientific study of phenomenological observations that psychoanalysts have drawn from their patient’s lives. Psychoanalysis, always strong in generating hypotheses but weak in empirically testing them, has gained a new route back into the world of medical science. Psychoanalytic methods lend themselves to mixed methods research in which functional brain imaging, the methods of empirical cognitive and social psychology, and psychoanalytic inquiry simultaneously can examine the same human behaviors, discovering “the patterns that connect” as Gregory Bateson would put it.

As a departmental Chair, I hope that the presence of the WCP will solidify a national identity for our psychiatry department as a center of excellence for psychotherapy practice, training, and research. In our mid-Atlantic region, we want to be the psychiatry department to which patients turn first when psychiatric symptoms have become treatment refractory or carry medical co-morbidities, because our clinicians can provide complex treatment programs that seamlessly integrate somatic, psychotherapeutic, and family or social interventions. However, our best accomplishments likely will be in medical education. WCP members on our clinical faculty already make vital contributions to teaching and supervising our residents and medical students. We anticipate new opportunities for residents to study within the educational programs of the WCP. We likewise hope that the resources of our department, medical school, and university open new opportunities for students and fellows of the WCP. We are excited that the WCP is now part of our department’s identity as we face future challenges and opportunities together.

October 2, 2013 at 3:54 pm · · 0 comments

Where is the Evidence for Evidence-Based Therapies?

Expert clinicians know better than to follow treatment manuals

Published on October 2, 2013 by Jonathan Shedler, PhD in Psychologically Minded

A study from a prestigious psychology journal recently crossed my desk. It found that clinicians who provide Cognitive Behavior Therapy or CBT—including the most experienced clinicians—routinely depart from the CBT techniques described in treatment manuals. “Only half of the clinicians claiming to use CBT use an approach that even approximates to CBT,” the authors wrote.

The finding is not surprising, since there is no evidence that treatment manuals improve outcomes, and therapists in the real world naturally adapt their approaches to the needs of individual patients. Their practice methods also evolve over time as they learn through hard-won experience what is helpful to patients and what isn’t.

In fact, studies show that when CBT is effective, it is at least in part because the more skilled practitioners depart from the manuals and use methods that are fundamentally psychodynamic. These include open-ended, unstructured sessions (versus following an agenda from a manual), working with defenses, discussing the therapy relationship, and drawing connections between the therapy relationship and other relationships.

So the research finding was no surprise. Something would be seriously amiss if experienced clinicians practiced like beginners, following an instruction manual like a consumer trying to assemble an appliance. What caught my eye was the authors’ conclusion that clinicians should be trained to adhere to CBT interventions “to give patients the best chance of recovery.”

The study did not examine therapy outcome, so the authors did not know which therapists were effective or which patients got better. They just presumed, in the absence of any information whatsoever, that departure from treatment manuals means poorer therapy. And this presumption— which flies in the face of the actual scientific evidence— slipped right past the “evidence oriented” reviewers and editors of a top-tier research journal. They probably never gave it a second thought.

The Big Lie

Academic researchers have usurped and appropriated the term “evidence based” to refer to a group of therapies conducted according to step-by-step instruction manuals (“manualized” therapies). The other things these therapies have in common are that they are typically brief, highly structured, and almost exclusively identified with CBT. The term “evidence based therapy” is also, de facto, a code word for “not psychodynamic.”

It seems not to matter that scientific research shows that psychodynamic therapy is at least as effective as CBT (see my original research article, The Efficacy of Psychodynamic Psychotherapy or for a popularized version, see Getting to Know Me: What’s behind psychoanalysis). Advocates of “evidence based therapy” tend to denigrate psychodynamic treatments (or more correctly, their own stereotypes and caricatures of psychodynamic treatment). When they use the term “evidence based,” it is often with an implicit wink and a nod and the unspoken message: “Manualized treatment is Science. Psychodynamic treatment is superstition.”

Some explanation is in order, since this is not how things are usually portrayed in textbooks or college classrooms. In past decades, most therapists practiced psychodynamic therapy or were strongly influenced by psychodynamic thought. Psychodynamic therapies aim at enhancing self-knowledge in the context of a deeply personal relationship between therapist and patient.

Psychodynamic or psychoanalytic clinicians in the old days were not especially supportive of empirical outcome research. Many believed that therapy required a level of privacy that precluded independent observation. Many also believed that research could not measure crucial treatment benefits like self-awareness, freedom from inner constraints, or more intimate relationships. In contrast, academic researchers routinely conducted controlled research trials comparing manualized CBT to control groups. These manualized forms of CBT were therefore termed “empirically validated” (the preferred term later morphed into “empirically supported” and more recently, “evidence-based”).

No research findings ever suggested that manualized CBT was more effective than psychodynamic therapy. It was just more often studied in research settings. There is a world of difference between saying that a treatment has not been extensively researched in controlled trials and saying it has been empirically invalidated. But academic researchers routinely blurred this distinction. A culture developed in academic psychology that promoted a myth that research had proven manualized CBT superior to psychodynamic therapy. Some academic researchers— those with little regard for actual scientific evidence—even began saying it was unethical to practice psychodynamic therapy because research had shown CBT to be more effective. The only problem is that research showed nothing of the sort.

This may shed some light on why the authors of the study I described above could so cavaliely assert that therapists should adhere to CBT treatment manuals to give patients the best chance of recovery—and how this scientifically false statement could sail right through the editorial review.

November 24, 2010 at 3:56 pm · · 0 comments

Getting to Know Me: What’s Behind Psychoanalysis

Psychodynamic therapy has been caricatured as navel-gazing, but studies show powerful benefits. (click here)

mind_2010-11Jonathan Shedler
Associate Professor of Psychiatry at the University of Colorado School of
Medicine and Director of Psychology at the University of Colorado Hospital
Outpatient Psychiatry Service

© Scientific American Mind, November 2010

October 24, 2010 at 3:55 pm · · 0 comments

Mental Health Insurance Under the Federal Parity Law

Most people in the United States have health insurance coverage, typically provided by their employer. Historically, many health insurance plans provided far less coverage for mental health services compared to physical health (medical/surgical) services. For example, a health plan might have covered only 50 percent of costs related to seeing a psychologist but 80 percent of costs related to seeing a primary care physician. (click here)