TCPR: Dr. Shedler, you recently published a widely cited article reviewing efficacy studies of psychodynamic psychotherapy (Shedler J, Am Psychol 2010;65(2):98–109). What was your conclusion?
Dr. Shedler: I examined results of multiple meta-analyses published in top tier, peer reviewed journals. The findings were clear and consistent: effect sizes for psychodynamic psychotherapy are at least as large as those reported for other therapies that are promoted as “empirically supported” or “evidence based.” Also, the benefits of psychodynamic therapy are lasting. Patients not only improve, but continue to improve even after therapy ends.
TCPR: One interesting aspect of your article was your discussion of the diagnostic process. For most psychiatrists, evaluating a patient involves coming up with a DSM diagnosis and finding a medication appropriate for that diagnosis. How is the psychotherapeutic approach different?
Dr. Shedler: There are noteworthy exceptions, of course, but for most patients, DSM categories are a poor and extraordinarily limiting way of understanding emotional suffering. First, most patients simply don’t come to us packaged in clear-cut DSM-IV categories. Comorbidity and personality dysfunction are the norm. Second, DSM assumes it is helpful to view emotional suffering in terms of “disease,” like influenza or diabetes or ringworm. It fosters the fiction that you can treat emotional pain as some kind of encapsulated disease entity that has little to do with the person who is having the pain. However, most of the problems that bring patients to our offices are woven into the fabric of their lives. It is not so much a question of what the person “has,” but rather of who he or she is—his or her way of being in the world.
TCPR: So this is a different way of viewing psychiatric disorders—not matching up a patient with a diagnosis, but spending more time understanding the patient as a person.
Dr. Shedler: Yes. It is rarely helpful to move from a DSM diagnosis to a treatment decision—as many practitioners are now trained to do—without understanding the meaning of the person’s difficulties and the larger psychological context that gives rise to them. Psychiatric diagnoses are just summary descriptions of collections of symptoms. They provide useful shorthand for summary communication with other professionals, but they are not explanations and they rarely facilitate understanding. It would be more helpful to think of depression, for example, not as a “disease” but as the psychic equivalent of fever. Fever is a nonspecific response to an enormous range of underlying conditions, from the common cold to leukemia. Diagnosis does not end with taking the patient’s temperature. Once we know the patient has a fever, we ask why. Depression is likewise a nonspecific response to a wide range of underlying disturbances. If we are going to be effective, we need to know what is causing the “psychic fever.”
TCPR: Can you give us an example of this principle in action?
Dr. Shedler: A resident and I saw a patient in our clinic who was in his 30s, who had been in psychiatric treatment for 15 years with little if any benefit to show for it. He suffered from chronic depression and came in asking for medication changes. The resident and I met with the patient and reviewed with him what was going on in his life, the trajectory that had gotten him to where he was, and his thoughts about what might help him to feel better. The patient said, “I have had psychotherapy before, it doesn’t work for me.” However, as we talked further, it became clear that the patient had never engaged in a meaningful psychotherapy process. He had been on one medication after another, and he had had an alphabet soup of brief evidence-based psychotherapies thrown at him. But he couldn’t say anything about what he had learned about himself in any of those therapies, nor could he say anything meaningful about the relationships he had with any of the therapists.
TCPR: But this patient thought he had spent years in therapy. So, as psychiatrists, how do we determine whether a person has had a real robust trial of therapy?
Dr. Shedler: If a patient has had meaningful therapy, he will be able to discuss it in a meaningful way. You can ask the patient, “Tell me about your previous therapy. What kind of relationship did you have with the therapist? What did you discover about yourself?” In this particular case, what was striking was that this intelligent patient did not even grasp the concept that psychotherapy involved a relationship between two people. He thought of therapists as simply “providers” who dispensed various techniques and interventions.
TCPR: So what happened with this patient?
Dr. Shedler: We invited him to tell us how he understood his depression—his view of what was making his path through life so painful. Shockingly, no one had asked him this before. The patient had spent about nine months in therapy making “small talk” and steering around emotionally meaningful topics. Once he began to open up, he revealed that in his private thoughts, he was hypercritical of virtually everyone. He would meet somebody, hone in on a perceived flaw, then condemn them and write them off. It emerged that he didn’t just regard others this way, he viewed himself through the same lenses. He was constantly condemning and excoriating himself. At that point, we were able to make an interpretation along the lines of: If you treat people badly, berate and abuse them, it hurts. That is equally true when the person you mistreat is yourself. The resulting hurt is what you have been calling depression. So the meaning of his experience shifted from a descriptive label, “depression,” and became a window into his inner experience and an understanding of something vitally important about himself. That was actually the beginning of therapy.
TCPR: But it took nine months. Most psychiatrists don’t have nine months to do weekly therapy.
Dr. Shedler: Who decided that? Many patients require time before they can begin to reveal themselves to us—or for that matter, reveal certain things to themselves. It seems to me that psychiatrists have the capacity to exercise personal choice. They may encounter pressure—economic and otherwise—to gear their practices around 15-minute med checks, but that doesn’t mean it is good care.
TCPR: What do you think about CBT techniques that are used for anxiety disorders? Psychotherapy for panic disorders tends to be a manual, menudriven approach, and sometimes it is said to only take a couple of sessions to work.
Dr. Shedler: There is a lot of empirical data on this. If we are talking about an otherwise psychologically healthy person with good relationships, good attachments, who is functioning well in other domains, then it is possible to treat an encapsulated symptom of, say, panic attacks relatively quickly. But that is not how most patients come packaged. We know both clinically and empirically that so-called comorbidity is the norm, not the exception—most patients, if we apply DSM decision rules, meet criteria for multiple axis I diagnoses, and at least some degree of personality dysfunction as well. So brief, manualized treatments are helpful for a small subset of relatively high functioning patients with uncomplicated panic disorder. Panic disorder is actually one of the conditions for which brief psychodynamic therapy has been shown empirically to be effective (Milrod B et al, Am J Psychiatry 2007;164(2):265– 272).
TCPR: How does psychodynamic treatment of panic or other kind of anxiety disorder work?
Dr. Shedler: A good starting point is the recognition that panic is fear. It does not occur in a psychological vacuum. Therapy involves exploring the patient’s inner experience in order to make explicit what is frightening—in order to bring it into the light of day. Generally, patients with panic disorder cannot readily tell us what is frightening. So we help them explore their inner worlds and put words to their fears.
TCPR: How is this different from the procedure of eliciting “automatic thoughts” in CBT?
Dr. Shedler: I think “automatic thoughts” is an area where there is some convergence between psychodynamic and cognitive approaches. Cognitive therapists speak of automatic thoughts, psychodynamic therapists speak of associations. In both cases, the intent is to help the patient attend to aspects of inner experience that otherwise escape notice. The difference is that in psychodynamic therapy, there is recognition that it may take a lot of work before the patients can put words to certain aspects of inner life. You can ask a person a question and get a perfectly truthful answer. And then if you ask, “What more comes to mind?” you get a different answer that is also true. You can continue in this manner, each time discovering additional layers of meaning.
TCPR: Please give us an example of a psychodynamic approach to a patient who has panic.
Dr. Shedler: One of my residents successfully treated a patient with panic disorder in a brief treatment of less than 12 weeks. The patient was an otherwise high functioning person. She experienced her panic attacks as arising “out of the blue.” We invited her to speak freely, without censoring her thoughts, and to follow them wherever they led. We began to notice that her thoughts consistently ran to dissatisfactions with her husband. And although she complained about him, she never expressed anger. We came to recognize that the patient was afraid of her own anger. You could say that she had an affect phobia. The experience of anger was unacceptable and terrifying to her. Panic episodes took the place of experiencing anger.
TCPR: So how was this addressed?
Dr. Shedler: Over the course of therapy, she began to recognize her anger, as well as the various things she had been doing to ward it off. She began to recognize that it was okay to attend to it and put it into words. It was not so dangerous after all, it did not destroy her, or her husband, or her therapist. She became more comfortable with this aspect of her experience. When she no longer experienced anger as unacceptable and alien, she began to better understand her emotional needs, and better communicate them to her husband.
TCPR: Interesting. Any final thoughts?
Dr. Shedler: If we view ourselves as “providers” whose role is merely to dispense interventions or medications, we cut ourselves off from the things that make this work rich and rewarding—the opportunity to create meaningful relationships, to truly know our patients, to play a role in their lives. The work is no longer a calling, it’s just a job. I think that’s bad for the soul—the patient’s, and the doctor’s as well.
TCPR: Thank you, Dr. Shedler.