Hi Stephen et al.: You could well be right about that, and I agree with you
that the data are still preliminary. But a few points:
(1) You note that "a classic psychodynamicist would sooner marry his mother
than do that [incorporate behavioral principles], knowing how dangerous mere
symptomatic treatment is."
That is indeed true of some of the real "old-timers," but some thoughtful
modern psychodynamic folks, like
Bob Bornstein and Drew Westen, have no problem with incorporating behavioral
techniques. Also, some of
these individuals appear to regard behavioral techniques as important and
sometimes even necessary, although not sufficient,
for treating anxiety disorders, mood disorders, and the like (I do not
necessarily agree with them on this score, however).
(2) Leichsenring et al. did compare short-term psychodynamic therapy with
treatment-as-usual (TAU), which is sometimes
thought of as an approximation to an "attention placebo" condition. They
found higher effect sizes for psychodynamic treatments compared with TAU,
but the number of studies was very small (and the nature of the control
conditions probably quite heterogeneous, although it's hard
to know without reading the original articles, which I haven't).
(3) The question of what constitutes "real placebo" (see Stephen's message)
in this literature is exceedingly complex and not easily answered.
As Grunbaum and others have noted, there is probably no "single" or
"correct" placebo condition in psychotherapy outcome research.
The selection of the appropriate placebo condition depends on what one
posits to be the specific vs. nonspecific ingredients of the
treatment one is testing. For example, the choice of a placebo condition
for a behavioral therapy would almost certainly be quite different for that
for
client-centered therapy. In the latter case, an "attention-placebo"
condition consisting of an empathic, genuine, and accepting listener
(which might be a defensible placebo for an exposure-based behavior therapy)
would actually be theoretically problematic, as the ostensible
"specific" conditions in client-centered therapy are precisely those that
most behavioral therapists would regard as nonspecific.
I'm far from an apologist for psychodynamic therapy, but I do think that
we should maintain an open mind regarding the data, while continuing to
ask tough questions along the lines that Stephen has posed (I do sometimes
worry that the traditional antipathy of psychoanalysts to data, as exemplied
in the Adam Phillip's NY Times column, may sometimes make us react
reflexively against any implication that psychodynamic treatment could be
efficacious). Also, I think the arguments here (e.g., the selection of an
appropriate control condition; see above) are exceedingly complex and don't
lend themselves to straightforward answers, as they depend in part on one's
theoretical conception of active treatment ingredients. I don't envy
psychotherapy outcome researchers.
...Scott
----- Original Message -----
From: <[EMAIL PROTECTED]>
To: "Teaching in the Psychological Sciences" <[email protected]>
Sent: Friday, March 03, 2006 11:11 PM
Subject: Re: Psychotherapy claims
On 2 Mar 2006 at 11:00, Scott Lilienfeld wrote:
As for the claim regarding short-term
psychodynamic treatments, several recent meta-analyses have shown
promising research support [snipped hedges following this statement]
One recent meta-analysis on this front is by Leichsenring et al.
> (2004, Archives of General Psychiatry: The efficacy of short-term
psychodynamic therapy in specific psychiatric disorder: A
meta-analysis). The Abstract is reproduced below...
I thought I'd take a quick look (which means you can't criticize me
because I have an excuse). I discovered that I have full access to
ithe article, not sure why. You can try at:
http://archpsyc.ama-assn.org/cgi/reprint/61/12/1208
Anyway, the most significant bit is in the abstract.
First, the description of "short-term psychodynamic therapy" [STPP]
includes this: "The focus is on the patients' experiences here and
now, including their symptoms". Shades of Hans Eysenck! If I was
taught that there was one difference [ok, two] which distinguished
behaviour therapy from psychodynamic therapy it was that behaviour
therapy emphasized the here and now and treated the symptom, not the
allegedly deep-seated underlying cause. So this certainly supports
Scott's suspicion that STPP incorporates behaviour therapy
principles. A classic psychodynamicist would sooner marry his mother
than do that, knowing how dangerous mere symptomatic treatment is.
But the real kicker is how the data were analyzed. The clue is that
the 17 studies included in the meta-analysis were "randomized
controlled trials", not "randomized, placebo-controlled trials", a
significant difference. In fact, their large effect size for target
problems (1.39) was based on before-after comparisons, not
comparison with an equally-credible placebo treatment. So while their
meta-analysis may have shown that STPP works, it provides no evidence
that it works better than a placebo.
In place of a placebo group, they identified four of the studies as
having a wait-list (i.e. do nothing) control. Sadly, this number was
too small for statistical analysis, although the effect sizes before
and after no treatment (paradoxical 'tho that may be), although
positive, were small. So it appears that STPP works better than
doing nothing (something I've never disputed). But it hasn't gone
mano a mano with a real placebo, and as far as I'm aware, those that
have, have failed to show that they're better. So STPP doesn't seem
too promising to me.
At this point, I'd also like to mention that I agree with Jim Guinee,
who noted in a recent post (quoting Hans Strupp), that even if
psychoanalysis is no better than listening to a friend, at least it
provides (at some price!) that friendship. I have no problem with
that either. I recall a book some years ago with the revealing title,
"Psychotherapy: the Purchase of Friendship". But what gets me is
that no psychoanalyst would ever admit this, claiming instead that it
is their arcane knowledge and profound insight into the workings of
the human psyche that uniquely qualifies them to do psychotherapy.
Then they write stuff like that silly piece in the NY Times we've
been discussing.
Stephen
-----------------------------------------------------------------
Stephen L. Black, Ph.D.
Department of Psychology
Bishop's University e-mail: [EMAIL PROTECTED]
Lennoxville, QC J1M 1Z7
Canada
Dept web page at http://www.ubishops.ca/ccc/div/soc/psy
TIPS discussion list for psychology teachers at
http://faculty.frostburg.edu/psyc/southerly/tips/index.htm
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