Efficacy of dynamic psychotherapy

The following post is an adaptation of an argument I presented on Sacramento Street Psychiatry, my blog on the Psychology Today website.  As usual, I welcome your comments. Western medicine's great strides are largely due to understanding etiology (the biological basis of disease), defining a nosology (a system of categorizing diseases), and testing treatments aimed at these nosological entities, not at individual patients. Take 100 healthy volunteers, swab their throats with Streptococcus, and perhaps 88 will soon develop strep throat. Both our knowledge of bacterial infections (etiology) as well as repeated empirical observation of similar cases leads us to conclude that Streptococcus causes a recognizable condition called strep throat (nosology). Once patients are diagnosed with strep throat — once their conditions become exemplars of this disease category — experiments can be done to show which treatments relieve the condition. Western medicine is the accretion of such knowledge.

Hypotheses about disease categories, and about treatments aimed at these categories, can be tested using randomized controlled trials (RCTs), our most powerful statistical method to assess the effect of independent variables. As in the rest of medicine, evidence supporting the efficacy of psychopharmacology, as well as manualized psychotherapies such as CBT, depends on sorting patients into nosological categories such as "major depression," applying different treatments to comparison groups, and finding statistically significant group mean differences.  In psychology such a research approach is called nomothetic; the goal is to identify general laws of behavior.

However, another kind of knowledge is important too. Why didn't the other 12 subjects get strep throat? Is it the same reason for all 12, or is the answer different for each of them? Looking at what makes people unique, as opposed to members of a category, is called idiographic research in psychology. This is the nature of psychodynamic theory and treatment, and why it resists the usual RCT approach to research. Patients who present for such treatment rarely fit neatly into a category such as "depressed." They vaguely say their lives aren't working well for them, or that their relationships are unsatisfying in a particular way. They lack meaning and purpose in life.  They get a "funny feeling" when dealing with competition. Their boss triggers authority issues.  They can't trust their spouse's fidelity. And on and on.  Such complaints are not exemplars of a nosological category. We may not know what causes schizophrenia or bipolar disorder — we have no etiological understanding of any psychiatric disorder, one reason they are called "disorders" and not "diseases" — but at least these labels reflect a coherent nosology.  Not so with the presenting complaints of most psychotherapy patients.

Psychodynamic therapists and psychoanalysts find little of value in the nomothetic approach. DSM-IV and similar nosology sheds no light on the particular patient in the office, with his unique history, dreams, fears, hopes, etc. The psychoanalytic/dynamic perspective is to understand the uniqueness of that specific patient, and to promote unique helpful changes that may have no relevance to any other patient seen in the practice.

This is not to discount the importance of the nomothetic approach where it applies. If a patient's condition is exemplary of a nosological category, it should be treated that way.  Doing so allows us to use powerful research tools to separate bias and wishful thinking from real treatment effects.  If a patient presents with major depression, bipolar disorder, or schizophrenia, nomothetic research can and should guide treatment. In such cases, psychodynamic therapy must stand or fall on the same RCT basis as other treatments.  The evidence base for manualized psychotherapies such as CBT, IPT, and a few others is stronger than for dynamic psychotherapy. If someone is seeking relief of major depression, pure and simple, I am happy to refer them to a CBT therapist, and have done so on a number of occasions.  It would be nice to be able to claim strong evidence for the efficacy of prescription antidepressants as well, but unfortunately this is less clear.

CBT and other manualized therapies for specific conditions are much easier to study than dynamic therapy for ill-defined complaints. So it's really no surprise there are more such studies.  Idiographic research methods, e.g., pre and post measures in single-case designs, have been used to study dynamic psychotherapy, both whether it works and how. But nomothetic researchers consider this "weak science": There are no control groups — no groups at all, actually.

The bottom line is that dynamic psychotherapy has different goals than CBT or medication.  It doesn't aim to treat a nosological category such as major depression.  Since it isn't based on a nomothetic treatment model, RCTs are the wrong assessment tools to use.  Idiographic research methods may be statistically weaker than their nomothetic counterparts, but they are the best that this domain of inquiry allows.  (Seligman argues that naturalistic surveys have their place too.)  Dynamic psychotherapy is based on a rich theoretical foundation that has been scrutinized and refined for the past century. But ultimately it comes down to the individual and the unique mix of discomforting feelings and troubling thoughts that led him or her to reach out for help.

Therapy for therapists

Tara Parker-Pope of the New York Times blog Well featured my prior post, on the feelings some patients have as they imagine whether their psychotherapists have been in therapy themselves.  My post was about patients' fantasies, not the reality of therapy for therapists.  Nonetheless, many of the comments argued for the great value of such therapy, and one or two expressed amazement that such therapy is not universally required.  I agree that psychotherapists have much to gain from personal therapy, and in this follow-up post I'll offer some reasons why. Is therapy required in order to become a therapist?  In the U.S., generally not.  According to Geller, Norcross, and Orlinsky [1]: "In most European countries, a requisite number of hours of personal therapy is obligatory in order to become accredited or licensed as a psychotherapist.  In the United States, by contrast, only analytic training institutes and a few graduate programs require a course of personal therapy."

A "training analysis" is required to become a psychoanalyst.  I.e., one must be analyzed oneself.  However, in the U.S. personal therapy is not required to practice other schools of psychotherapy, nor to obtain licensure in mental health disciplines such as psychiatry, clinical psychology, etc.  Specific training programs within a discipline may require it, and certainly a large number of programs recommend personal psychotherapy for their trainees.  Indeed, many strongly encourage it by offering referrals to therapists, low-fee therapy, time off from training to attend therapy, and so forth.  In a 1994 survey of psychologists by Kenneth Pope and Barbara Tabachnick, 84% reported having had psychotherapy themselves, although only 13% had attended a graduate program requiring personal therapy for therapists-in-training [2].  Whether by mandate, urging, or independent choice, many practicing psychotherapists can claim experience in "the other chair."

At the most commonsense level, a therapist who knows what it is like to be a patient may be more empathic, and may anticipate unstated feelings more readily than a therapist without this first-hand knowledge.  For example, vacation breaks can feel extraordinarily disruptive to patients, a fact that can be taught in lectures or textbooks (or blogs), but may not be fully appreciated until it is experienced oneself.  Transference in general is better understood experientially than learned academically.  Even non-analytic therapists can benefit by recognizing transference and other common "real-time" emotional reactions, conscious and unconscious, in their patients or clients; these can affect rapport, treatment adherence, and so forth.  Psychodynamically informed practice is a hallmark of psychiatry, even when psychodynamic treatment is not offered.  The same, I would argue, is true of other mental health disciplines.  Psychologists conducting CBT and clinical social workers leading support groups should know about psychodynamics too.  And the best way to learn dynamics is experientially, in one's own psychotherapy.

The argument is even stronger for therapists who practice traditional psychodynamic therapy, where transference and countertransference are essential treatment tools.  As I wrote last year, it takes self-knowledge to use countertransference therapeutically. Without this self-knowledge it would be impossible to sort out the patient's issues from one's own.  In seminars for psychiatry residents, I point out that our field has no blood test or brain scan to directly measure thoughts and feelings in the interpersonal space.  Our own feelings, countertransference broadly defined, is the sensitive instrument we bring into the consultation room.  The therapist's own psychotherapy "calibrates the instrument" so he or she can better trust its readings when applied to patients.

To me, this is the main reason to recommend therapy for therapists.  In addition, others have argued that it normalizes and destigmatizes being in therapy (assuming the therapist discloses his or her personal therapy to the patient); that it improves one's performance as a therapist non-specifically, by relieving stress and tension; and that it may give the therapist "a valuable perspective on what works and what doesn't." Several commenters on the NY Times blog believe the therapist's own therapy encourages humility, and may decrease errors based on hubris and unexamined countertransference:

We are to be one of the self monitoring professions, responsible in a unique way as the stewards of our treatment with our clients.... Having our own issues worked with ... goes a long way toward ensuring a unique quality of care.

I would be very wary of a therapist who had never sought therapy for him or herself. To me it would smack of an "I don't need it — it's for messed up folks like you" attitude.

I am also frequently shocked by the stories my patients will tell me about being in therapy with someone who clearly hasn't worked on their issues. It can be very damaging to a patient...

A personal psychotherapy does not guarantee that a therapist will be caring, non-abusive, technically proficient, or effective.  But there is little in psychotherapy, or in life, that is guaranteed.  Psychotherapeutic work, particularly the psychoanalytic and psychodynamic varieties, seems closely tied to the therapist's self-knowledge and willingness to self-reflect.  If we are to use our own perceptions and reactions as sensitive instruments in the consultation room, we are well-advised to take good care of the equipment.

[1] Geller JD, Norcross JC, and Orlinsky DE, The Psychotherapist's Own Psychotherapy: Patient and Clinician Perspectives, Oxford University Press, 2005.

[2] Pope KS and Tabachnick BG, "Therapists as Patients: A National Survey of Psychologists' Experiences, Problems, and Beliefs" Professional Psychology: Research and Practice, 25(3), pp 247-258.

"Have you seen a therapist yourself?"

Recently a patient asked whether I'd ever been in therapy myself.  Without answering his question directly (see my post on psychotherapist disclosure and privacy), I replied that many of us have, and asked what it meant to him.  It would be a bad sign: "How can you help if you need help too?"  We went on to discuss his feeling that being in psychotherapy marked him as defective or deficient.  He would naturally prefer a therapist who did not share similar defects and deficiencies. Many patients take the opposite view.  They believe a doctor who knows what it's like to be a patient can better empathize with them.  So this patient's concern stood out in my mind — he truly feels his psychotherapy is a mark against him, a kind of declaration or admission that he is damaged.  I later reminded myself that professionals — and others, everyone really — regularly use services offered by others in the same field.  Lawyers have their own lawyers, doctors see their own doctors.  Chefs eat meals made by other chefs, barbers get haircuts from other barbers.  The only problematic examples that come to mind are when the condition being treated is shameful or morally repugnant, or when the condition could directly affect the service being offered.  Examples of the former: police officers who require the "services" of other police officers after committing crimes, and clergy who need spiritual or moral counseling for their own transgressions.  Examples of the latter: a neurologist with brain damage, and a business consultant who cannot maintain his or her own business and needs outside help.  How does this apply to psychotherapists, and what light does it shed on patients' feelings about seeing therapists themselves?

The need for psychotherapy feels to many people like a sign of defect/deficiency/damage.  In speaking with patients I often highlight the "need" in that sentence, and contrast it with "want" or "could benefit by."  Some patients make themselves feel worse by telling themselves they "need" therapy, when it would be just as accurate to say they are apt to benefit by it, or even that they desire it.  I don't believe it devalues psychotherapy, or psychiatric medications for that matter, to note that they're frequently optional.  Most depression improves on its own eventually, and people may choose to muddle along in life dissatisfied, angry, or in a series of bad relationships.  Remembering that psychotherapy is a choice may take some of the shame out of it.

That's only part of it, though.  No one worries or cares if one's proctologist also needed to see a proctologist at some point, even though proctological conditions feel shameful to many people.  In addition to shame, there is moral repugnance associated with mental illness, even, or perhaps especially, the apparently milder problems that lead people into psychotherapy.  Often unstated is the notion that one chooses to be emotionally weak, distraught, hotheaded, or whatever, and that this choice is selfish, unfair to others, or otherwise immoral.  Moreover, that seeking professional help to "snap out of it" or pull oneself together is self-indulgent and akin to laziness.  While the idea isn't totally groundless — there is some choice in how to act, and even how to feel sometimes — it assumes far too much conscious choice.  Most troubled patients would give anything to be happier, at least consciously.  In returning to my patient's question, perhaps he would not trust a doctor who willingly made himself dependent on others to help steer his life back on course.  It may feel as morally suspect as the corrupt police officer or clergyman: a character flaw in the traditional sense.

Alternatively, there may be concern that a psychotherapist who needed therapy ("needed" in scare-quotes as noted above) cannot perform well as a therapist.  This would be analogous to the brain-damaged neurologist or the business consultant whose own business is failing.  The logic may be pragmatic:  A psychotherapist should have his or her own life in order before claiming to be able to help others.  Or it may be fear that residual pathology lurking in the therapist may be harmful to the patient.  Or it may be a transferential need for an idealized, faultless therapist.  Each of these can be addressed as it arises.  We each have our blind spots, and can help others without necessarily being able to help ourselves.  It is better to have sought treatment for potentially hurtful pathology, than to have ignored or denied it.  No therapist is perfect.

Any or all of these concerns about the therapist may also apply to the patient himself.  Being in therapy may make a patient feel ashamed, or morally bad or wrong.  It may highlight a fear of incompetence or harmfulness.  It may clash with a need to be perfect.  Asking the therapist "Have you seen a therapist yourself?" may be an easier way for the patient to broach sensitive feelings about his or her own participation in therapy.  This seemingly simple question can carry a lot of meaning, and if explored in detail, can help a patient understand himself better.

Talk doesn't pay: Comments on the NY Times article

I'd like to take this opportunity to comment on the article that appeared in today's New York Times: "Talk doesn't Pay, So Psychiatry Turns to Drug Therapy."  Gardiner Harris writes about psychiatry's shift from talk therapy to drugs, and profiles psychiatrist Donald Levin of Doylestown, PA (a suburb of Philadelphia), who felt financially unable to maintain a psychotherapy practice, and therefore shifted to a high-volume, medication-only practice.  It is clear that both the doctor and the journalist consider this a sad state of affairs.  Dr. Levin is quoted as saying: "I’m good at it, but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.” That comparison is apt to rile my colleagues who are serious and careful psychopharmacologists.  But Dr. Levin is right:  Most medication management in psychiatry is tediously straightforward.  Which is why it is mostly done by primary care doctors, not psychiatrists.  In the U.S. most antidepressant and antianxiety prescriptions are written by non-psychiatrists.  (And even antipsychotics lately, but this is a different and far more worrisome issue.)  It seems to me that any self-respecting psychiatrist who limits his or her practice to psychopharmacology, i.e., medication management only, should add some value over a visit to a family doctor, internist, or pediatrician.  Either the cases seen should be harder, e.g., "treatment resistant," or the doctor should offer something more nuanced and sophisticated, or more comprehensive.  If so, such a psychiatrist will not be "the ape with the bone."  Unfortunately, my experience suggests this is the exception, and that the shift to medication management has been borne of expediency and financial pressure in many cases, not an earnest scholarly focus on advanced psychiatric medication strategies.  And for this reason, the critique that our field is increasingly populated by dumbed-down medication technicians is not the throwaway line it would otherwise be.

In saying this, I invite a rebuttal.  If psychiatrists who give meds should add something over other med providers, what do psychiatrists who conduct therapy add over other therapists?  The answer is a more comprehensive viewpoint, one that takes into account medical and bodily issues, drug interactions, and similar matters.  And the option to prescribe medications when these are needed in addition.  If we cannot add this value, we should not charge more than other therapists.

Since I have a mostly-psychotherapy practice myself, I took note of several points made in the article.  Most glaring is a starkly misleading statistic.  Harris cites a 2005 government survey showing that just 11 percent of psychiatrists "provided talk therapy to all patients."  I'm not sure why that surprises anyone.  I'm a huge advocate of psychotherapy, yet I don't recommend, much less provide, it for everyone.  It's a treatment — it's expensive, it takes a lot of time, it's often uncomfortable.  I only provide psychotherapy when I predict it will help, and when my patient agrees to it.  While I believe it would be helpful for many patients I see, I nonetheless still treat a minority of patients with medication only.  In my view, one of the best things about being a psychiatrist is that we have a variety of tools.  While I find dynamic psychotherapy more intellectually interesting and humanly engaging than writing prescriptions, I'm glad I can do both.  The 11 percent statistic is meaningless.

Another potential confusion in the article are the widely disparate fees cited, with little explanation.  At one point Harris writes: "A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session."  At least here in San Francisco, this is considerably less than either service is typically worth, even accounting for payment caps by health insurers.  Not to mention that psychotherapy is traditionally 50 minutes, not 45.  But then Harris writes about "a select group of [New York] psychiatrists [who] charge $600 or more per hour to treat investment bankers," and later notes that a nearby colleague of Dr. Levin charges "$200 for most [therapy] appointments."  The truth in my experience is that no psychiatrist starves by being a psychotherapist, even though there is more competition from other disciplines and the overall income may be less.  Talk does pay, just not quite as much.  When psychiatrists complain about comparatively low psychotherapy income, it makes me wonder why they didn't become surgeons.  Seriously, from what I gather surgery is very engaging, very satisfying, and very lucrative.  It sounds much better than doing half-hearted, half-assed psychiatry just for the income boost.

As I wrote last year, dynamic psychotherapy is more than merely a treatment technique to place on a shelf alongside medications.  It is a perspective that informs our understanding of patients even when we do not offer this specific therapy as treatment.  Thinking about our patients dynamically can help us be better medication providers, better CBT (non-dynamic) therapists, better referrers to other professionals.  Psychiatrists don't have to be psychotherapists all the time, but we do need to think psychotherapeutically all the time.  The real tragedy highlighted by the NY Times article is not one man's devolution to an "ape with a bone," nor even a profession's.  It is the loss of intellectual curiosity — of knowing there is a better way, yet choosing not to pursue it.

Should therapists accept holiday gifts?

December brings the annual pleasures and challenges of holiday gifts and how to deal with them in dynamic psychotherapy. Although it is relatively easy to follow a simple rule about this, ideally a good deal of thought goes into a therapist's decision about whether to accept a patient's holiday gift. Below I will give a couple of examples of this from my own practice, and how psychodynamic theory guided my response. All beginning dynamic therapists are taught not to accept gifts from patients. This rule follows from the principle that the therapist should decline all gratifications from the patient aside from the fee paid. A therapist who is swayed by the patient's generosity, physical attractiveness, political connections, or other factors invites a conflict of interest in himself, and thus risks distorting the therapy in pursuit of his own needs and desires. Accepting a gift would be an example of this. Afterwards, the therapist may feel disinclined to challenge the patient, to induce anxiety or point out a contradiction. Conversely, the patient may feel the therapist should reciprocate the generosity, leading to disappointment and possibly anger when the therapist fails to do so.

Naturally, patients often do not know this rule, thus some arrive to a year-end session with a gift in hand. These gifts vary. Some are expensive, some less so.  Some are "for the office," others intended more personally for the therapist.  Some are homemade, or reflect something personal that had been discussed earlier in the treatment, while others are more generic.  Likewise, the nature of the treatment varies from patient to patient, from relatively supportive and concrete, to very "uncovering" transference-based therapy. Given these variables, there is room for some discretion in the no-gifts rule.

A number of years ago I treated a woman who painfully described feeling unvalued by others. Men only appreciated her because she gave them sex; her employer did not value her as a person, but only for her productivity. Our therapy was fairly psychoanalytic in nature. Arriving to a session around the holidays, she handed me a large, beautifully wrapped gift box. It looked store-bought and expensive.  I imagined she had taken significant time and trouble to purchase and bring it to me. With some apprehension I told her that we needed to discuss the gift before I could accept it. She was initially hurt by this. However, it soon became clear to both of us that her gift reflected her belief that I, like others in her life, did not value or appreciate her as a person — she hoped I would value the gift and therefore her. On that basis I thanked her but did not accept her gift, a decision she ultimately understood and agreed with.

It turned out very differently with another patient, an older Russian woman who saw me for supportive therapy. Around the holidays she presented me with a bottle of Kahlua, unwrapped if I recall. We had not been working with transference; I did not see how such a gift could damage our work. Also, it is customary in Russia to offer such gifts to one's doctors. I accepted the bottle with thanks, and pleased my patient. No harm done, and perhaps a bit of good in strengthening our working relationship.

Most dynamic therapies lie between these two extremes, somewhere in the midrange of the analytic-supportive continuum (more about that here). I have accepted inexpensive gifts in such cases, except when I sense that the offer is an unhealthy enactment, or that the patient is sidestepping a useful exploration. As is often the case in conducting dynamic psychotherapy, there is a balance between fostering a warm working relationship, versus encouraging reflection and insight.  In my view, a blanket rule of refusing all gifts is unnecessarily cold and inhuman for many patients, while accepting all gifts may appear "normal" but does not encourage reflection, and may introduce conflicts of interest.  The matter takes case-by-case consideration, neither unthinking acceptance nor unyielding refusal.  It should go without saying that I never expect to receive a gift; it's also helpful to note that most patients do not offer them.

Occasionally the opposite issue proves useful to explore: Whether the patient expects (or wants) me to give him or her a holiday gift.  As we all know at this time of year, both gift-giving and gift-receiving tap deep emotional aspects of our personalities, and sometimes highlight conflicts around themes of self-interest, self-sacrifice, guilt, generosity, reciprocity, and one's value in the eyes of others.  I do not offer my patients holiday gifts, but I do wish them, and you, Happy Holidays.