What evidence for psychotherapy to develop

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A critique of outcome research in psychotherapy, and a proposal that more weight should be put on the ability fo therapists and clients to continue in relationships for as long as therapy remains active and mutative

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  • Famous study that puts psychotherapy under the microscope: is it more than placebo? Leads to vilification and vengeance that has continued every since, plus the use of survival analysis. But is this appropriate? Much of psychiatry has used this method.
    Also what goes around, comes around.
  • I am working on the association of CNVs on chromosome 15 and atypical psychosis in ASD
  • Prestigious journal but forgot to analyse control group
  • Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415.
  • Neurobiology reinforces placebo effect
  • Later developed phase idea:
    Early phase, acute distress/ Middle phase Chronic distress (but of course this might be social rearrangement)/ 3rd phase ‘characterological’
  • Protagoras (blue) the first sophist or wisdom professional/ retailer vs. Socrates (red) the friend of philosophy, or the amateur, who thought that there was an ultimate truth
  • Advertizing has biassed drug prescribing and created a spurious sense of differential potency. Now Layard advertizing has done the same. But the evidence is rather less grand, in both cases
    Drugs, and psychotherapy, may differ only in side effects.
  • Advertizing has biassed drug prescribing and created a spurious sense of differential potency. Now Layard advertizing has done the same. But the evidence is rather less grand, in both cases
    Drugs, and psychotherapy, may differ only in side effects.
  • What evidence for psychotherapy to develop

    1. 1. www.existentialacademy.com 1 WHAT EVIDENCE WILL WE NEED IN FUTURE FOR PSYCHOTHERAPY TO DEVELOP? Digby Tantam Member, IGA (London) Clinical Professor of Psychotherapy, University of Sheffield Senior Visiting Research Fellow, University of Cambridge Honorary Consultant Psychiatrist, Sheffield Health and Social Care Trust Director, Existential Academy “Exoriare aliquis nostris ex ossibus ultor ! (Let someone arise from my bones as an Avenger!)” Virgil, Aeneid, IV 625
    2. 2. Eysenck, H. (1952). The effects of psychotherapy: an evaluation. Journal of Consulting & Clinical Psychology. 16: 319-324. • A kind of meta-analysis of published data • Disabled or admitted to hospital often involuntarily after at least 3 months illness. ‘Severe neurosis’ unspecified. After is at least 2 years • No distinction between treatment and maintenance
    3. 3. Problems raised by this particular study have been considered ever since: Use of appropriate controls Standardization of method (‘manualization’) Clarity about parameters e.g. length of follow up Separation of treatment and prevention (or maintenance) But first and foremost is what is the outcome of psychotherapy – Early intervention – Maintenance • What is this? 3 www.existentialacademy.com
    4. 4. • “(1) if there is no adequate study of psychoanalytic therapy showing a better improvement rate, then there is no firm evidence that the therapy is therapeutically effective. • (2) A review of existing studies showed that indeed there did not exist any such adequate study. • (3) Consequently, I concluded that there was no evidence of therapeutic success for psychoanalysis (or more general methods of psychotherapy, which I also analysed in a similar manner)” www.existentialacademy.com 4
    5. 5. Letter to Garfield Library, University of Pennsylvania • As far as I personally am concerned the outcome was that I was ostracised by the clinical fraternity, had efforts to establish alternative methods of treatment (behaviour therapy) blocked by psychiatrists, was refused research grants by embattled psychoanalysts on grantgiving bodies, and was generally treated as an outcast and a pariah...Efforts were made to terminate my appointment, and quite generally I was made to feel that one does not oppose the Zeitgeist with impunity, however correct the argument. Exoriare aliquis nostris ex ossibus ultor !” The Psychologist, 23 (9), 736 Sept 2010 • “He (Hans Eysenck) developed a superb descriptive model of personality that has scarcely been bettered and contributed numerous ingenious theoretical insights. However, he took his eye off the ball by trying to exceed the fame (and citations!) of Sigmund Freud with comparably grandiose speculations. If only my father had focussed his research more on behavioural genetics rather than wasting his time tilting at an endless succession of windmills!” www.existentialacademy.com 5
    6. 6. Leichsenring et al, JAMA 6
    7. 7. Kirsch, I., B. J. Deacon, et al. (2008). "Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration." PLoS Medicine 5(2): e45. www.existentialacademy.com 7
    8. 8. www.existentialacademy.com 8 What IS a Caucus-race? said Alice; not that she wanted much to know, but the Dodo had paused as if it thought that SOMEBODY ought to speak, and no one else seemed inclined to say anything. Why, said the Dodo, the best way to explain it is to do it. (And, as you might like to try the thing yourself, some winter day, I will tell you how the Dodo managed it.) First it marked out a race-course, in a sort of circle, (the exact shape doesn't matter, it said,) and then all the party were placed along the course, here and there. There was no One, two, three, and away, but they began running when they liked, and left off when they liked, so that it was not easy to know when the race was over. However, when they had been running half an hour or so, and were quite dry again, the Dodo suddenly called out The race is over! and they all crowded round it, panting, and asking, But who has won? This question the Dodo could not answer without a great deal of thought, and it sat for a long time with one finger pressed upon its forehead (the position in which you usually see Shakespeare, in the pictures of him), while the rest waited in silence. At last the Dodo said, EVERYBODY has won, and all must have prizes. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415. Luborsky, L. and B. Singer (1975). Comparative studies of psychotherapies. Is it true that "everywone has one and all must have prizes"? Archives of General Psychiatry. 32: 995-1008.
    9. 9. www.existentialacademy.com 9 Psychotherapy works to remoralize through its placebo effect. Theory is what commends it to clients, not an explanation of its actions
    10. 10. www.existentialacademy.com 10 MARGINS OF PLACEBO EFFECT ARE THE MARGINS OF PSYCHOTHERAPY But these are fuzzy So behaviour change, habit change, symptom suppression, training, and education are like lemon juice and pips: worth separating but not so easily done because in nature they are intermingled
    11. 11. www.existentialacademy.com 11 Acute distress Chronic distress Characterogical change
    12. 12. SHEDLER, J. (2010). "THE EFFICACY OF PSYCHODYNAMIC PSYCHOTHERAPY." AMERICAN PSYCHOLOGIST 65(2): 98-109. “As noted earlier, the goals of psychodynamic psychotherapy include, but extend beyond, alleviation of acute symptoms. Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility. Symptom-oriented outcome measures commonly used in outcome studies (e.g., the Beck Depression Inventory [Beck et al., 1961] or Hamilton Depression Rating Scale [Hamilton, 1960]) do not attempt to assess such inner capacities (Blatt & Auerbach, 2003; Kazdin, 2008). Possibly, the Dodo bird verdict reflects a failure of researchers, psychodynamic and non- psychodynamic alike, to adequately assess the range of phenomena that can change in psychotherapy. 12 www.existentialacademy.com
    13. 13. SHEDLER, J. (2010). "THE EFFICACY OF PSYCHODYNAMIC PSYCHOTHERAPY." AMERICAN PSYCHOLOGIST 65(2): 98-109. “As noted earlier, the goals of psychodynamic psychotherapy include, but extend beyond, alleviation of acute symptoms. Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility. Symptom-oriented outcome measures commonly used in outcome studies (e.g., the Beck Depression Inventory [Beck et al., 1961] or Hamilton Depression Rating Scale [Hamilton, 1960]) do not attempt to assess such inner capacities (Blatt & Auerbach, 2003; Kazdin, 2008). Possibly, the Dodo bird verdict reflects a failure of researchers, psychodynamic and non-psychodynamic alike, to adequately assess the range of phenomena that can change in psychotherapy. 13 www.existentialacademy.com
    14. 14. • Exoriare aliquis nostris ex ossibus ultor !” • Aeneid, IV 625). “Let someone arise from my bones as an Avenger." Virgil Aeneid, Iv, 625 • Said by Dido (Carthage) of Aeneas (Rome) • Who won? • Rome, not Carthage • Clever though: a quote from Sigmund Freud, The Psychopathology of Everyday Life (1901) www.existentialacademy.com 14
    15. 15. www.existentialacademy.com 15 THINGS THAT CHANGE IN PSYCHOTHERAPY…AND THAT MIGHT PROVE USEFUL EVIDENCE FOR PSYCHOTHERAPY Defences? Character or personality? Quality of personal relationships? Love? Cognition? Work? Well being?
    16. 16. www.existentialacademy.com 16 DEFENCES Militaristic metaphor Bond and Vaillant study showed only disorganized vs. organized defences were predictive Does this improve on “messed up”?
    17. 17. www.existentialacademy.com 17 PERSONALITY CHANGE Only reliable and enduring measures of personality are Big 5—openness, conscientiousness, extraversion, agreeableness, neuroticism (anxiety proneness)— none obviously linked to clinically relevant dimensions of personality change What we call personality is closely linked to current relationship quality, and may change in months or years Large spontaneous changes in personality e.g. attachment theory
    18. 18. www.existentialacademy.com 18 QUALITY OF SOCIAL RELATIONSHIPS Strongly correlated with symptom scores Relationship quality strongly correlated with depression
    19. 19. www.existentialacademy.com 19 RELAPSE PREVENTION Attrition Supervening life events
    20. 20. www.existentialacademy.com 20 WELL BEING Not symptom reduction Kahneman Life evaluation, a comparative measure linked to mortality Emotional wellbeing Lack of suffering Positive emotions
    21. 21. www.existentialacademy.com 24
    22. 22. 25 www.existentialacademy.com BEHAVIOUR ACTION ACTION Causes or reasons1 Justifications or Reasons 2 Tantam, D. (2002). "Reasons and psychological explanation." International Journal Of Psychotherapy 7(2): 165-173.
    23. 23. Can we learn from medicine? • Take, as an example, the so-called break through in the developmental of atypical antipsychotics • There is no clear evidence of advantages in terms of symptom control or likelihood of discontinuation (due to intolerable side effects and/or lack of treatment efficacy) MeReC (Rapid review) National Prescribing Centre • Crossley N et al. Efficacy of atypical v. typical antipsychotics in the treatment of early psychosis: meta-analysis. B J Psych 2010;196:434-9 www.existentialacademy.com 26
    24. 24. The influence of special interests in selectively targetting drugs. Selective publication www.existentialacademy.com 27
    25. 25. www.existentialacademy.com 28 • IAPT stands for ‘Increasing Access to Psychological Therapies’. It is a national Department of Health programme aimed to improve and increase access to evidenced based psychological therapies such as CBT. • Clinical evidence has shown that better access to therapies such as Cognitive Behavioural Therapy (CBT) can help treat depression and anxiety and reduce both time off work due to ill-health, and the claiming of Incapacity Benefits. Patients also prefer to receive talking therapies rather than medication alone. Lord Layard’s review of the economic and emotional costs of mental ill health demonstrated the financial benefits to providing psychological therapies to people suffering from depression and anxiety.
    26. 26. www.existentialacademy.com 29 Cuijpers, P., F. Smit, et al. (2010). "Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias." The British Journal of Psychiatry 196(3): 173-178
    27. 27. • Drugs replace directions for patients as well as doctors www.existentialacademy.com 30
    28. 28. Issue is not main effect, but persistence with treatment What are the factors that determine persistence/compliance? • Focus on preoccupying concern • Congruence of values • Emotional flavour • Tantam, D. (2003). "The flavour of emotions.” Psychology and Psychotherapy, 76, 23-45 www.existentialacademy.com 31
    29. 29. www.existentialacademy.com 32 PERSISTENCE IN PSYCHOTHERAPY Avoidance Negativity as well as positivity ‘Free communication’ Addiction Improvement and not deterioration during breaks
    30. 30. www.existentialacademy.com 34
    31. 31. GROUP CLIMATE QUESTIONNAIRE Date of group: Your number: If the statement on a line accurately describes how you felt at some time during the group, please tick all the boxes (there may be between 1 and 3) on that line. Active, extroverted, self-confident..……………………|__| Out-going, open, sociable.............………………|__|...|__| Leading in a friendly, democratic way.……|__|...|__|…|__| . .22 other items (total 26) . Passive, introverted, inhibited.....................………………………………….|__| |__| |__| |__| |__| |__| |__| U P F D N B FINAL SCORE |__| |__| |__| www.existentialacademy.com 35
    32. 32. www.existentialacademy.com 36
    33. 33. it’s time for disruptive innovation in psychotherapy In The Lancet today, David Kessler and colleagues evaluate the acceptability and clinical effectiveness of an internet-based psychotherapy programme for depres- sion.1Nearly two-thirds of those offered the programme completed five or more therapy sessions, a substantially higher rate than we would expect with in- person therapy. Clinical benefits were larger than generally seen with computerised self-help programmes, and similar to those with traditional in- person psychotherapy. Simon GE, Ludman EJ. It's time for disruptive innovation in psychotherapy. The Lancet. 2009 2009/08/28/;374(9690):594-5. www.existentialacademy.com 38
    34. 34. www.existentialacademy.com 39
    35. 35. www.existentialacademy.com 40
    36. 36. Thanks for listening Slides can be found at www.slideshare.net www.existentialacademy.com 41

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