October 01, 2008

Study: Psychoanalysis Is Better Than Other Psychotherapies

There's an interesting study out today in JAMA, a meta study asserting that psychoanalysis is more effective at treating complex mental disorders such as anxiety and borderline personality disorder than are other psychotherapies such as CBT. And by psychoanalysis the authors apparently mean the old-fashioned Freudian stuff, or long-term psychodynamic psychotherapy to the study authors who claim that:

"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.... [Results] indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96 percent of the patients in the comparison groups."

Not bad for a treatment paradigm that has been almost completely eclipsed by medications and other psychotherapies over the last 30 years or so. In fact, psychoanalysis is so out of favor, even in counseling circles, that it is virtually untaught these days to young therapists and medical students in psychiatry and has pretty much become a historical artifact.

Or as one researcher told the New York Times:

"Dr. Barbara L. Milrod, a professor of psychiatry at Weill Cornell Medical College, who like Dr. Gerber is a clinical practitioner of psychodynamic therapy, said further research was crucial as a matter of survival for a valuable treatment.

"'Let’s be real,' Dr. Milrod said. 'Major medical centers have been shutting down psychodynamic training programs because there isn’t an adequate evidence base.'"

Another added:

"'If you define borderline personality broadly as an inability to regulate emotions, it characterizes a lot of people who show up in clinics, whether their given diagnosis is depression, pediatric bipolar or substance abuse,' said Dr. Andrew J. Gerber, a psychiatrist at Columbia. For some of those patients, Dr. Gerber said, 'this paper suggests that you’ve got to get into longer-term therapy to make improvements last.'"

Obviously, meta studies aren't direct measures of effectiveness per se and some of the small studies grouped in this larger study go back to the early 1960s. And, since psychoanalysis is highly individualized in the hands of each practitioner, I would assume that researchers offer various cautions about over-interpreting the study's data.

Nonetheless, score one for Freud. And couch salesmen everywhere.

Posted by Philip Dawdy at October 1, 2008 09:47 AM
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Comments

John M. Grohol at PsychCentral looked more closely than you did, and saw it somewhat differently: Psychodynamic Psychotherapy Gets Some Research Respect

Posted by: cbtish at October 1, 2008 10:10 AM

this sort of therapy is as good as the therapist...but there is no doubt in my mind that long term psycho-dynamic therapy can be extremely powerful and in some instances as in cases of extreme trauma, sometimes the most effective means of healing. I'm sure the reason it has fallen out of favor is largely because it's not paid for by insurance.

Short-term therapies are covered.

having said that, the worst experience I've ever had with a mental health professional was with a sadistic Freudian Analyst...so like I said, it's very dependent on the practitioner...

Posted by: Gianna at October 1, 2008 11:22 AM

The Times conflated psychodynamic with psychoanalysis. It was the former cited in the study. Psychodynamic psychotherapy means therapy in which issues in the unconscious are considered important as well as the relationship between therapist and patient. It would include Freudians, Neo-Freudians, Object Relations, Adlerian, Jungian. In short, those approaches which are not behavioral and which do consider the unconscious important.

Any therapy is only as good as the therapist as there are no magic tools for us to use.

Posted by: Cheryl Fuller. PhD at October 1, 2008 02:22 PM

I don't need these studies and it's a shame psychoanalysis lost it's credibility due to the Big Pharmas omnipresence in anything related to emotional problems.
I met two depressed women.
One of them is really depressed and was in the mental institution to see a psychiatrist to send her to psychoanalysis.
She was really depressed but she said she doesn't want drugs. She only wants something to help her sleep.
I've just met another woman that lives in my building - yep, I meet people and I can tell, i don't know how, that they are suffering depression. I can see something on the face, strange -.
She refused to take anti-psychotics. She was diagnosed bipolar and she was brave enough to tell the psychiatrist that she was not to going to go back to her office any longer. She met another psychiatrist that told her she was not bipolar, and she isn't.
She found balance searching and prescribed herself.
That's what the arrogance of psychiatrist are doing to people. (I withdrew Effexor by my own.)
After dooing some research she is taking citaloplan and wellbutrin by herself.
She is not feeling great but she is working and living her life. She wants to do therapy.
People are eager to talk about their problems but all roads leads to psychiatrists and people don't even know where to find therapy.
Yes, Freud and the couch salesmen are going to be very happy. :)
But good psychoanalysts don't use only Freud. He is the base but with a great help of some others.
I've been on psychoanalysis for 20 years.
Just reached the end and I'm really grateful to the work we did.

Posted by: Ana at October 1, 2008 04:58 PM

not sure if this says more about psychodynamic therapy (which i give little credence to, to say the least) or having a long-term therapeutic relationship

the psychcentral article, which another commenter linked to, did a good analysis of this study

Posted by: lourde at October 1, 2008 07:48 PM

"I've been on psychoanalysis for 20 years." What a great line. And it goes for me too, 22 years total with a range of psychodynamic neo-freudians, gestalt therapists, one feminist therapist, a Lacanian, another object relations expert and they all basically borrowed from these and other disciplines. Those therapists were so extremely sophisticated about the human condition, all prioritized arts and letters, and all treated me for trauma/dissociation before there was even a PTSD classification or treatment protocol.

CBT? Not so much.

Posted by: flawedplan at October 1, 2008 10:18 PM

Well, I'd have thought that both approaches (Freud-type and CBT-type), were of equal value, because, when all's said and done, one can't fix a problem (CBT), until one knows what the problem is (Freud). There's too much guesswork going on; that's the problem I think.

Matt

Posted by: Matthew Holford at October 2, 2008 02:39 AM

Wasn't the entire point of psychoanalysis supposed to be to "cure" people? Didn't psychanalysis predate the idea that mental illnesses were incurable, permanent medical diseases that required 20 years of treatment, in other words, acute, not chronic?
Isn't the idea of people being born with bad personalities that are genetic diseases considered modern by folks who are into the biological model because it's a very, very new idea, born of the same eugenics movement that gave us Nazi's, as opposed to the intellectual tradition that produced Jung, Fromm, Rogers, etc?

Posted by: Sally at October 2, 2008 07:02 AM

flawedplan,
I find CBT a useful little tool in my toolbox. But it's touted everywhere as a panacea for PTSD. Not so, at least among the survivors of severe and/or sadistic abuse I know--which are many.

CBT does almost nothing to help me with my emotions. The notion that I, who was trained from birth to ignore my own feelings, sensations, perceptions, etc, am going to be able to listen to my own self-generated "refutations" and take them seriously is ludicrous. It's the old "I don't want to join a country club that will admit me" thing.

To think my disempowered inner voice will outweigh the Greek chorus of disapproval I carry inside betrays a total lack of understanding of my inner life. And I find the guys (and they're mostly guys around here) who practice this stuff to be impervious to any world view but their own. They're arrogant, sneer at other treatment modalities in a most unprofessional manner and generally treat patients who ask questions like dirt under their feet. They're RIGHT, you see. And don't you forget it.

What has helped me--a lot--is to fill my life as much as possible with people who actually LIKE me. And to escort to the edges of my life those who do not. Hearing those refutations (which are, after all, merely a healthy world view) coming from the lips of others who like me, and whom I like and whose opinions I value, validates my feeble inner voice. Who knows? Perhaps someday I'll really be able to outvote the Greek chorus and believe I'm okay. I'll have to live a long time, though, because the level, quality and length of operant conditioning I endured will take a long time and a lot of effor to undo. No mere formulation of "tapes" is going to do the trick. It amazes me that psychology, a profession which came up with the concept of operant conditioning and which allowed that guy to abuse baby monkeys mercilessly in the seventies in the name of science, totally denies the effects of both in PTSD survivors. I find that breathtaking. And I am outraged to think those poor baby monkeys suffered in vain to please the sadism of one abusive man and his henchmen students.

Of course, one bunch of people I had to escort to the door of my life were the CBTers. I don't need arrogant jerks in my life condemning me because I don't "think right".

I do use CBT in many small ways, as a reminder sort of thing that helps with some behaviours. It's not the Big, Fat Cure it's billed as, though. Just another useful little tool among many.

Posted by: Sherry at October 2, 2008 08:52 AM

I have been "in therapy" for most of my adult life. It will never cure anything (READ: it can never change the trauma that I endured as a child, over long periods and multiple situations). But it helps me cope day to day. People who know me are often curious/disapproving when they know how long I've been in therapy "when are you going to be done??" That includes medical professionals who have asked that question as well. I appreciate others' concern that I not develop an inappropriate dependence, but it would be quite all right with most folks to think about taking meds for the rest of my life. (Been the meds route, will never do that again, not if I want to live). Therapy is my med.

And yes, it depends greatly on the skill and integrity of the therapist, and finding someone who supports my goals and who meshes well with me. Not all of them have. Some have been ineffective, to say the least. Then there was the sick psycho who convinced me that having a sexual relationship with him would cure me. But there have been good and gentle, professional and safe therapists along the way too. And for that I am grateful.

Posted by: I at October 2, 2008 09:15 AM

I,
Wow. I can so relate to what you said, especially the first paragraph.

Sadly, sometimes you simply cannot put the toothpaste back in the tube. For some of us PTSD is a chronic condition which learn to manage over time. Our medical system doesn't do very well with any chronic condition. As a rehab counselor I saw many, many people rejected by their medical doctors for the crime of not getting better. People with chronic pain were especially ill treated.

Thanks for writing.

Posted by: Sherry at October 2, 2008 11:24 AM

I, you raise an interesting point about people being concerned about your being in therapy for the rest of your life who would not question your being on meds for the rest of your life.

Posted by: Sally at October 2, 2008 11:26 AM

A couple common misperceptions about psychoanalytic approaches:

Wasn't the entire point of psychoanalysis supposed to be to "cure" people?
when all's said and done, one can't fix a problem (CBT), until one knows what the problem is (Freud).

Couldn't be more wrong, but does go to the heart of the hostility between Freudian and CBT devotees.

Psychoanalysis is not so much about "fixing" as it is about enlightenment. That's why it was so popular with the bored and wealthy during its heyday. Therapy is an exploration, rather dark at that, and when all is said and done the client graduates with a doctorate degree in herself.

Posted by: flawedplan at October 3, 2008 12:56 AM

Enlightenment is something I can get behind, as is exploration, it's the idea that enlightenment and/or exploration or only valid and/or necessary when treating a medical disease that I don't like as much as I don't like the idea that a problem is only a problem and pain is only pain if these things are "genetic medical diseases."

Sherry, I think you're spot on about CBT. Used to be it was humanistic vs. behavioral, but now with the biomed freaks in the battle, I forgot how much I and my professors in the day disliked CBT and came down on the humanistic side.

Posted by: Sally at October 3, 2008 08:34 AM

Sally, perhaps we could start with this.

Posted by: flawedplan at October 3, 2008 12:26 PM

Did you see the recent article in The Skeptical Inquirer called The Bipolar Bamboozle? Just curious what you thought if you did.

Posted by: wrongshoes at October 3, 2008 06:38 PM
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