I feel an urge to reply to Janet Low’s critique, and have my own little rant about psychoanalysis along the way.
The gist of Low’s argument is that evidence-based practice is a “shibboleth” that removes the human experience from psychiatry, and that its nadir comes in the form of cognitive-behaviour therapy, which chases an impossible (but pleasing to policymakers) goal by trying to be a cheap, quick and scientific form of psychotherapy. Low says:
Evidence-based practice is a policy maker’s dream, a wish of what science would be: totally free from human contamination, utterly beyond question, and absolutely clean.
Straight away, I’m going to say that I think Low has immediately misrepresented evidence-based practice. EBP doesn’t just rely on the hard sciences with no place for human values. EBP includes the use of qualitative social research methods like ethnography, case histories or focus groups that do allow room for individual expression and meaning.
EBP isn’t about excluding human experience. It’s simply about ensuring that before a clinician does something to a patient, there’s some degree of evidence that it’s liable to work. I don’t think there’s anything sinister in that. In fact I’d say it’s utterly essential to patient safety.
I’ll probably sound like a massively cynical old bugger by saying this, but my own opinion is that the reason psychoanalysts like Low hurl such vitriol at evidence-based practice is because there’s very poor evidence that their own massively expensive remedy is likely to do any good. Psychoanalysis puts in years of work, often for very little gain, and at times can make the client worse rather than better.
Some of her critique of cognitive-behaviour therapy is valid. Yes, it’s certainly true that CBT is attractive to policymakers because it’s cheap and quick. What’s the Dept of Health more likely to fund? Ten-session courses of CBT or years and years of psychoanalysis? And yes, often that results in unrealistic expectations of what such a short, sharp intervention can achieve.
But that’s not to say that CBT isn’t necessarily helpful. Also, there’s a thinly-veiled undercurrent to Low’s argument. She doesn’t quite say it explicitly, but the point she seems to be trying to make is, “Instead of funding CBT, the government should be funding psychoanalysis”. (Another psychoanalyst, Darian Leader, has made a similar critique of CBT, with the same not-so-hidden undercurrent.)
Low also shows herself to have something of a cheek by criticising CBT for bringing politics and economics into the equation. So there’s no economics involved in psychoanalysis? Imagine you agree to be analysed. You have three or four sessions of analysis a week for several years. In my provincial backwater a private psychotherapy session would be cheap at £45 an hour. Go to London, and you could easily be paying £100 an hour and upwards. Given the sheer number of sessions involved, you’re talking about some pretty huge sums of money. I’ve come across people who have spent years in psychoanalysis, and as far as I can tell the only discernable effect is that they’ve gone bankrupt.
I’m not saying all psychoanalytic ideas are worthless. I find certain aspects of psychoanalysis - particularly attachment theory - to be clinically useful. However, I have to admit that I strongly dislike psychoanalysts as a profession. They just strike me as a self-referential, self-perpetuating cult, a little weird and more than a little paranoid. (For an insider’s view of the unpleasant underbelly of the psychoanalytic profession, I recommend Jeffrey Masson’s book Final Analysis) They draw people in to spend years and years subjected to a dubious therapy for little benefit while sucking large amounts of cash out of their wallets. Kind of like the Church of Scientology, but without even some decent UFO stories.
I’m clearly in a grumpy mood today. Argue among yourselves whether I need CBT, psychoanalysis or merely a nice pint of the foaming stuff.
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January 13, 2008 at 9:55 pm
TheShrink
Psychodynamic psychotherapy is expensive, involved, folk get worse before they get better (so risks escalate) and takes an age. It’s clearly not a psychological treatment that can be widespread, treating most folk with mood problems or adjustment disorders or loss events.
For folk who’ve been okay, become unwell, then profit from a therapy to get better, CBT is currently the treatment of choice.
For folk who’ve not been okay, who’ve been unwell for years, they can profit from a therapy to get better, psychodynamic psychotherapy has some utility for these folk, some of the time.
The evidence base (in any form) is poor.
Evidence Based Medicine (EBM) has differnet levels of evidence, from the excellent type 1a evidence (metanalysis, pooling data from lots of randomised controlled trials) to the less excellent type 4 evidence (expert opinion, i.e. someone or some group saying it’s the right thing to do). Psychodynamic psychotherapy lacks a lot of good quality EBM and relies mostly on weak EBM, if it relies on evidence at all.
That caveat aside, what is the current EBM available to guide us on talking therapies? And, to be kind, let’s focus on personality and relationships (since that’s what psychodynamic psychotherapy is supposed to be good at, and CBT weaker at).
The British Journal of Psychiatry published a paper in 2000 by Bateman and Fonagy that looked at 1814 scientific papers about this, but found only some 80-odd to be up to standard. Results weren’t encouraging for most folk, “In summarising studies of out-patient treatment, it should be noted that there is relatively little compelling evidence that individuals with personality disorders and low levels of functioning can be successfully treated on an out-patient basis“.
Although not looking for CBT evidence, “Most evidence supports long-term cognitive—behavioural approaches, and psychodynamic orientations with Cluster B patients.” CBT rears it’s head as successful again, eh?
So, use of psychodynamic approaches as an out patient was shown to be ineffective.
What about living and breathing it, in a therapeutic community? Spend £12,000,000 on centres of excellence to get good results? Sadly not. “None of the interventions for the treatment of severe personality disorders is entirely satisfactory.” Living in such a therapeutic world isn’t brilliant at helping folk, either.
Stone’s paper from 1993 said that, “Psychoanalysis and related methods work best within the anxious/inhibited group [of patients]” but CBT was better at effecting behavioural change.
Psychodynamic psychotherapy increasingly is becoming a bit of a niche intervention. Delivered with 1:1 therapy to hospital in-patients over years it has shown to have some use. Delivered in out-patients it hasn’t. So how wide spread should it be?
When I want a talking therapy, I want CBT. And I want it from secondary care since IAPT and other community models professing to deliver CBT are often suboptimal at it. Proper CBT by proper therapists, unsurprisingly, gives proper outcomes.
January 13, 2008 at 10:52 pm
Mandy Lifeboats Adrift
Got here.phewee!
I guess I have tried to understand the higher interllectualities of it all. But having tried to suss the difference between stork and margarine…..I fell back down the hole to the bottom rung…which is all about care that works for me.
Selfish mare that I am, and please bare with me, in my self indulgance. Or not…your choice.
As I posted in last comment. (lifeboat)..the bottom line is about taking what is on offer. Not just cause there needs to be an element of working together with people, whose job it is to provide care support, but sometimes something is better than nothing (as a short term plaster…to provide some hope). Long term…well the effects talking therapies have had on me speak volumes int he fact I am not really any better than I was in the past. Could go into another debate about being better than I was in work but right now I couldn’t argue that from high ground as am feeling like a lump of aged poo. Although try gettign me up at 7.30 with a view to getting to work onpublic transport and you might have a psychotic on your hands.
anyway, it should be about choices and not about choices between something that is slightly okay ish for a while or bugger all.
And the block is economical…as in to provide the sort of support people (long term non responsives) like myself need is not going to wow the tax payer. And the tax payer is who the goverment are trying to wow whilst dismantling the NHS. A game of double bluff that Jo Public seems to be swallowing right now. And I guess looking after loonies is not a priority. I don’t blame people, it just doesn’t help me much.
boo hoo….back to the choccy and will endeavour to make next post witty and more endearing..either that or stroppy and sod em all.
January 13, 2008 at 11:08 pm
Smellyhelly
Surely all you need is love?
January 14, 2008 at 12:46 am
Mandy Lifeboats Adrift
P.S. Prefer the new slogan.
Think I might be an existing Asylum Seeker. Depends what is meant by Asylum.
All you need is love, understanding, knowledge, money, connections and lots of chocolate.
Right, I am outta here before someone slaps a section on me.
January 14, 2008 at 7:28 am
zarathustra
All you need is love, understanding, knowledge, money, connections and lots of chocolate.
And a cool pair of trainers, naturally.
January 14, 2008 at 7:36 am
beakie
Yes, z, EBP uses qualitative sources of evidence but they are way down the hierarchy, joining “expert opinion” and just a smidge above the anecdotal. I tend to agree with Janet Low, that EBP is largely seen as science free from all the mess and baggage humans bring, when in fact even the most stringent RCT is subject to human contamination.
CBT has successfully engineered a few RCTs to shore up its image, something psychoanalysis has failed to do. However, I wonder how many of them are really up to snuff. Certainly, from my reading, CBT in psychosis seems to be researched by the same old faces coming to the same old conclusions - a tad incestuous, but still able to be presented as “gold standard” proof that it’s whizz-bang brilliant stuff, mr Government minster.
Me, I suspect I wouldn’t want any talking therapies at all. I don’t trust ‘em. Most therapists seem like snake-oil salesmen to me.
January 14, 2008 at 1:50 pm
E
Darian Leader makes a similar point in comment free “A dark age for mental health” 13/10/07
http://www.guardian.co.uk/comm.....58,00.html
He argues that the “evidence” on which the claims for the efficacy for CBT are made comes from evaluation techniques which are devised by the makers of the therapies themselves and are designed to avoid the complexities of human suffering He quotes Paul Verhaeghe, professor of psychodynamics at Ghent University who says that CBT trials follow the medical model with two groups of patients with similar profiles who then receive a standardised treatment in an attempt to rule out the influence of the therapist.
Prof Verhaghe then makes the point that there is no such thing a patient with a similar profile or symptoms to another and that each persons experience of mental illness is unique. He then goes onto say that therapy relies on the unpredictable input of the therapist and removing this factor means that we no longer have therapy but something else. What exactly is unclear but my own experience of assessing people with mental illness mirrors this and I have long wondered about the validity or even usefulness of psychiatric diagnoses.
I have always thought that what ever therapy was being practiced the most important factor is the relationship between the therapist and the patient. Frankly as long as this is right the patient could be stood on their head spitting 2p pieces for all the difference receiving one type of therapy over another makes. .
My other beef is the validity of what passes for “evidence” especially in what passes for research these days. Whether it is drug companies massaging the results from clinical trials for this or that anti depressant much of what passes for evidence is frankly not worth the paper it is written on. Most trials of depression treatments rely on one rating scale or another to introduce some measure of objectivity to the trial. But as Prof Verhaeghe points out each persons experience (of mental illness) is unique. The results from any rating scale have to be subjectively analysed by the person using the scale which brings you back to square one and an entirely subjective measure of success. I am reminded of the following cartoons.
http://www.thejabberwock.org/blog/2/dilbert5.png
followed by
http://www.thejabberwock.org/blog/2/dilbert4.png
January 14, 2008 at 3:18 pm
Mr Ian
Being a reductionist.. we’re all going to die.
Or is that a fatalist?
I did a talk on EBM/EBP/EBN(ursing) for some post grad students. I had an hour… we covered soooo much, and someone even snook a social worker into the session. Tried to make it of practical value in the workplace rather than talking theory, which was just as pointless.
Anyhoos… back to the point…
All this EBB(ollox) has taken treatment by the nob and slung it up against the wall. Ijn so doing, it’s nuts have become a little battered also. What am I wittering on about now? Not sure, just wanted to get a phallic metaphor in first before I lose my thread that I haven’t started yet.
Treatment X. Has no evidence.
Does not mean X is no good.
Treatment X may be very good (or bad) but the research on it is done badly. Still does not mean X is no good.
Treatment X is applied by gibbons and chimpanzees who think they are doing it right, but actually, are not. Does not mean X is no good.
So before we do research on Treatment X, we need to do research on those who use Treatment X. Most places just accept ‘oh he’s got a PhD, he can do anything’, which is dog shite. Or we do enough research on X to offer some validity.
Unfortunately, every research I see seems to state: Could do with more research.
I’m glad Shrink put the 1a stuff up there, saved me having to rack my head for the nitty gritty but essentially, until such time as someone tells me it doesn’t work - I’ll use my own experiential research. After all, no one has actually researched the effects of mental health intervention against placebo - unless you look at the South American Inca’s who do not have an ICD-10 or asylums nor need for a Mental Health Act.
As for psychoanalysis / CBT - they all work, but only given:
The recipients receptiveness or positive sensitivity to the treatment
The providers competence in providing the therapy
The nature of the problem and the application of the process to resolving that problem.
If it’s not done appropriately, then it’s not the therapy it purports to be, however, it may still be successful.
All psychological therapies work; for some people, in some situations and when provided by some therapists. Even re-birthing will fit that descriptor, for someone.
My belief is, it doesn’t even have to have a theory to exist or to be good, let alone researched evidence-base. Because a lot of what we do is human, and is delivered by humans and reviewed by humans - and we all got our own evidence based opinion.
And finally… I was looking for a ‘re-birthing’ link but found this instead… which has nothing to do with EB stuff.. but made me laugh… (kinda Freudian tho)
Growing children organize fetal games, hitting, kicking and throwing around placental membranes (one, the football, even egg-shaped, that we rebirth through our legs), reenacting birth when passing them through upright legs or vaginal hoops. We likewise relive our birth when we celebrate Christmas as a rebirth ritual, complete with a placental tree and a Santa Claus–a chubby blood-red fetus going down his birth chimney attached to his placental bag–not to mention such thrills as bungee-jumping our rebirth at the end of a long umbilicus or throwing ourselves into mesh pits to be reborn at rock concerts.
http://www.geocities.com/kidhistory/ldfetal4.htm
January 14, 2008 at 5:13 pm
Mandy Lifeboats Adrift
Is this where I get to go 50/50, ask the audience or phone a friend?
as in to suss out how effective talking therapies are (in a wider context)?
If you wanna know what a hamburger tastes like best ask the people who eat hamburgers? Similar approach easily transferable to talking therapies.
And just cos they haven’t worked for me (thus far) doesn’t mean they won’t work for others or that there isn’t a therapy that can help.
It is more a case of boxes that I haven’t been able to fit in yet. If I was a Raggy Doll it would be Pace About ‘n’ Slump Petra.
January 14, 2008 at 5:46 pm
E
Asking someone who eats hamburgers what a hamburger tastes like only tells you what one tastes like to them. Likewise with talking therapies, if standing on your head spitting 2p pieces works for you then that’s what works for you, it might not work for me. My point being there is no truly objective view point when it comes to therapy which is what CBT practitioners claim.
January 14, 2008 at 6:13 pm
zarathustra
Taking the hamburger analogy a bit further, what do you do if 90% say they prefered a Big Mac but 10% felt they got more tasty goodness from a Tex Mex Spicy Double Whopper? Do you go with the 90%, considering the possibility that you might be in the other 10%? Also, what if there were also a sprinkling of people for whom all hamburgers tasted like cardboard, so they’d gone off for a salad instead?
Any psychiatric intervention (humanistic, cognitive-behavioural, psychodynamic, psychosocial, pharamacological etc) is basically a tool in a toolbox rather than a fix-all for every problem. The job of a skilled clinician is to work out which tool is suited to which task, otherwise you’ll be in a situation where you wind up trying to use a screwdriver to hammer a nail into a wall.
Analogies-a-go-go!
January 14, 2008 at 6:59 pm
E
“screwdriver to hammer a nail into a wall”
what’s wrong with that, works for me
January 15, 2008 at 7:50 am
beakie
Ah but some people only have the screwdriver in their toolbox, z, and go on and on about how brilliant the screwdriver is for every task around the home. They also publish papers evaluating the screwdriver; papers which are fashionably evidence-based enough to get the ear of the government, who then buy in screwdrivers for all and sundry whether they can use them or not, while leaving more expensive but perhaps better-suited tools in B&Q.
If you get my drift.
January 15, 2008 at 8:49 am
zarathustra
Indeed. There’s a need for the debate to be balanced with something along the lines of, “Yes, the screwdriver is useful for a range of tasks. However, for other tasks a hammer may be more suited, and there may also be times when a combination approach of a hammer AND a screwdriver are needed. Therefore it’s important to have more than one tool in the toolbox.”
January 15, 2008 at 9:56 am
Jan
Oh, where’s Ben Goldacre when you need him?
January 15, 2008 at 10:28 am
TheShrink
Is this why the rehab unit, dealing with difficult experiences, has a workshop with a lathe?
January 15, 2008 at 3:09 pm
Jan
One assumes the lathe is for turning people’s lives around.
January 15, 2008 at 4:32 pm
zarathustra
Since CAMHS is probably the most psychotherapy-led of the different psychiatric specialities (at least, it is in the UK; over in the states they pump the little rugrats full of meds) I should probably say a few words about what’s in our toolbox.
Most therapy that’s offered is CBT, with also some systemic therapy (which is what used to be called family therapy) and some solutions-focused therapy.
We also have one psychodynamic therapist, who works mostly with attachment disorders. Attachment theory seems to be the main aspect of psychoanalysis that we find clinically useful. Interestingly, it’s also an area of psychoanalysis that one can find evidence for through cognitive science. So I’d say the idea that evidence-based practice can’t be applied to psychoanalytic concepts and interventions is utter cobblers.
January 16, 2008 at 8:18 am
Mr Ian
Whatever happened to talking to ya teacher/vicar/mate’s mum/dad?
In regards making a salad with a screwdriver I think the recognitionis needed that it’s the right tools for the right job by the right people.
January 16, 2008 at 7:15 pm
zarathustra
Absolutely Ian. More often than not the personal qualities of the therapist matter far more than the school of therapy they’re trained in. So talking to a local vicar who’s a good listener can easily be more therapeutic than talking to a highly qualified psychotherapist who’s a dick.
January 17, 2008 at 8:21 am
beakie
Of course, the best option would be to give the person with the leaky pipe or wonky picture frame the toolbox and get them to choose which one suits them best, then teach them how to use it themselves rather than having to call in the owners of the toolbox.
How much further can we stretch this metaphor before it snaps?
January 17, 2008 at 11:33 am
Mr Ian
But I would always choose the hammer to fix things - because it swings so nicely in my hand and seems the most manly thing to do. Wasn’t so effective for grating cheese tho.
Enter the Drug & Alcohol Team.
I did try a screw driver but I wasn’t sure which way to turn or how hard; and the harder I tried; the more the cheese looked like Jarlsberg; but didn’t taste like Jarlsberg.
Enter the psychologist.
I tried using a chainsaw once - but my greengrocer realised I was getting thru too much cheese
Enter the CPN
…and told me to get some cheese therapy.
So I got a professional to show me how to.
Enter the Psychoanalyst.
Now I have a samurai sword which slices much better, but I keep hurting myself on the darn thing - but at least the Japanese Sensai was a lot cheaper than hiring a fully qualified chef.
Which was all well and good, until I was sent to the chef for a CPA review
Enter the Consultant Psychiatrist
…and he told me I needed to stop using the sword; he took it off me and he gave me a cheesewire to cut with. Said that was the best tool for the job.
That was great, until I decided to have cheese and tomato sandwiches. The tomatoes didn’t take too well to the cheesewire - so I got the chainsaw back out again…..
Then I wanted grated cheese.. so I got the hammer out again..
The greengrocer saw me buying more tomatoes again and had a word with the chef.
The chef saw me and told me I was very bad and took the hammer and chainsaw off me - he told me to use a slim knife or a grater…
So now I have cheese with grated tomoato sandwiches.
And I use the slim knife to turn screws and hammer nails in.
January 17, 2008 at 12:15 pm
beakie
*sound of metaphor screaming for mercy*
January 17, 2008 at 12:41 pm
TheShrink
I’m confused.
Does this mean you can use a hammer to fix it, when you’ve got a screw loose?
January 17, 2008 at 1:50 pm
Mr Ian
Sure Shrink…
Enter Anti-psychotic Drug Rep