An editorial piece for the December 2010 edition of the journal Psychoanalytic Psychotherapy makes for challenging reading. The authors strenuously criticise the indifference and resistance towards research that they see amongst many psychoanalysts.
Given the time, cost, and intensity of the demands placed on patients and therapists who enter into psychoanalysis, the fact that the field has neglected to perform appropriate assessments of whether or not the treatments we routinely recommend and deliver actually work is shocking.
The authors are not anti-psychoanalysis, both are staff members of the Columbia University Center for Psychoanalytic Training and Research. Part of their concern is for the diminishing prevalence and influence of psychoanalytic treatment, which they relate to the absence of sound evidence for its effectiveness. They dismiss those forms of evidence that are most often used by psychoanalysts and psychodynamic psychotherapists.
…clinical lore, collegial interaction, and direct observations by sole practitioners can appear superficially rational as a basis for determining the effectiveness of a treatment….
Psychoanalysts pride themselves on their awareness of the impact of fantasy and wishful thinking during their treatments, but minimize the impact of such factors on their subjective assessment of their own clinical outcomes.
In place of such subjectivity, the effectiveness of these treatments should be evaluated using randomised controlled trials based upon treatment manuals, so that the practitioner’s adherence to the treatment protocol can be assessed. Although some effectiveness studies have been published, it is claimed that many are flawed.
As I say, a challenging article, and one that leaves me with contradictory thoughts.
On the one hand I do feel the lack of a widely-accepted evidence base for the effectiveness of psychoanalytic psychotherapy. I do think that such a body of evidence is growing and I appreciate those studies that I see that add to this evidence.
However, I’m uneasy about the the insistence that randomised controlled trials provide the only trustworthy evidence of effectiveness. The work of John Ioannidis, for example, brings the reliability of such trials into question. In a study of 49 of the most highly regarded and frequently cited medical papers published in the last 13 years, his team found that 11 had not received independent verification, while of those that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. Two fifths of these key papers, when retested, were shown to be misleading, papers that were widely cited and referred to by physicians for guidance. (see my earlier post)
I’m also sceptical about the prospect of manualised treatment. For me psychotherapy is about an encounter between two people, with an attempt by the therapist to leave behind preconceptions and to see what use of him or her the patient or client wishes to make. Can a manual allow me to enter into that encounter without memory or desire? Although, I have to admit my ignorance of such manuals and how they are utilised.
And so I’m left with dilemmas that for now I cannot resolve. I want, for myself and for our profession, proof that this practice is effective, both for ethical reasons and to secure our place amongst recommended treatments. But I’m also not sure that the concept of treatment is the best way to describe this journey that I take with my patients. Certainly they come to me in distress and hoping for change. And, given the investment noted above, they deserve to find that our encounter is worthwhile and helps to bring about change. But I have doubts that this is best described in terms of a DSM diagnosis or the relief of a symptom.