What evidence for psychotherapy to develop

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

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

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

• “(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)”

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!”

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.

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.

Psychotherapy works to remoralize
through its placebo effect.
Theory is what commends it to clients,
not an explanation of its actions

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

Acute
distress
Chronic
distress
Characterogical
change

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

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

• 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)

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?

DEFENCES
Militaristic metaphor
Bond and Vaillant study
showed only disorganized
vs. organized defences
were predictive
Does this improve on “messed
up”?

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

QUALITY OF SOCIAL RELATIONSHIPS
Strongly correlated with symptom scores
Relationship quality strongly correlated with
depression

RELAPSE PREVENTION
Attrition
Supervening life events

WELL BEING
Not symptom reduction
Kahneman
Life evaluation, a comparative measure linked to
mortality
Emotional wellbeing
Lack of suffering
Positive emotions

25
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.

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

The influence of special interests in selectively targetting drugs.
Selective publication

• 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.

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

• Drugs replace directions
for patients as well as
doctors

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

PERSISTENCE IN PSYCHOTHERAPY
Avoidance
Negativity as well as positivity
‘Free communication’
Addiction
Improvement and not deterioration during breaks

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 |__| |__| |__|

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
depression.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.

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What evidence for psychotherapy to develop

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