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A Tale of Two Therapies

Can too much 'evidence' be a bad thing for psychotherapy?

​At the turn of the 20th century, Sigmund Freud pioneered modern psychotherapy in the form of psychoanalysis. He believed that talking to a therapist could help patients work through repressed conflicts driving pathologies such as depression, neurosis, and anxiety. But by the late 1900s, psychoanalysis had fallen from favor. Critics accused Freud of relying too heavily on what were seen as unscientific interpretations of patients' dreams and streams of consciousness.

In the decades since, so-called neo-Freudians or post-Freudians have recast psychoanalytic principles while retaining Freud's practice of unearthing the past to expose unconscious conflicts. But others have staked out their own ideas, arguing that psychotherapists need a better way to scientifically test their treatments. This new emphasis on experiments—what came to be called "evidence-based psychotherapy"—spawned the notion that some therapies are more scientific than others, a contention that has etched deep divides within the psychology community.

Now expanded access to mental health care under the Affordable Care Act gives the label of evidence potentially even more power. Evidence-based therapy is increasingly sold to patients on multiple fronts, said Jonathan Shedler, a psychologist and professor at the University of Colorado School of Medicine. He believes designating certain therapies as "evidence-based" can affect what type of research gets funded, how insurance companies justify spending, which treatments physicians recommend, and how the public perceives psychotherapy in general.

One concern that Shedler and others psychologists have is that over-emphasizing neat experiments of standardized treatments detracts from the ultimate goal of psychotherapy: making sure patients get the best intervention, rather than the one that lends itself to scientific research most easily. Rigid, controlled conditions tend to focus on outcomes that are easy to measure, such as symptom relief, instead of abstract benefits such as personal growth and fulfillment, said Shedler.

Some psychologists also believe that the uniform therapies studied in research are too artificial to draw conclusions about real-world therapy. "No two minutes of any human interaction are identical," said William Stiles, a retired psychologist and professor emeritus of Miami University in Ohio. "This sort of responsiveness is essential clinically, but it wrecks the scientific logic of outcome studies."

The main approach to claim the scientific mantle is cognitive behavioral therapy (CBT), a strain of modern psychotherapy that diverges hugely from Freud's ideas. Since then, CBT has become an industry standard and is often the default treatment doctors recommend for conditions such as depression or anxiety disorders. Many celebrities, including J.K. Rowling and the Dalai Lama, have publicly spoken out in support of CBT.

Cognitive behavioral therapy arose from experiments done in the 1960s by Aaron Beck, a psychiatrist at the University of Pennsylvania in Philadelphia. At the time, Beck was a psychoanalyst looking to empirically study his field's methods. He analyzed the dreams of depressed patients, expecting to find anger and hostility as predicted by Freud. But instead of validating psychoanalysis, Beck concluded that Freud's theories did not hold. Wanting to design a more empirically testable and effective psychotherapy, Beck developed CBT.

CBT practitioners believe that faulty thinking patterns, or cognitive distortions, cause people to adopt unhealthy behaviors. Rather than looking to the past, CBT providers focus on behavioral changes that patients can make to resolve present-day problems. As a result, CBT is highly instructional: therapists work with patients to set agendas and assign homework. A CBT practitioner might treat a depressed patient by helping them create a plan for waking at a reasonable hour, making a friend at work, or going out during the week.

Meanwhile many other therapists practice a form of psychotherapy resembling Freud's, called psychodynamic therapy. Psychodynamic therapists rely heavily on individualized relationships they develop with each patient. To treat someone with depression, a psychodynamic therapist might help the patient identify and dissect painful childhood memories. While CBT tends to be short-term, often lasting just eight to twelve sessions, psychodynamic therapies tend to be much longer, often lasting at least forty sessions or a year.

Scientific research on CBT has proliferated from its inception. "CBT evolved from academic learning theory," said Stiles. "A lot of the early contributors were academic scientists, used to designing research and publishing, and they built a norm of data-gathering and scientific reporting into the treatment paradigm. Psychodynamic therapy grew from clinical practice and hasn't had that ethos."

Whereas research on psychodynamic therapy has only come into the picture in the past decade or so, thousands of studies done over the last 40 years have shown that CBT can effectively treat an impressive range of conditions, including depression, anxiety, posttraumatic stress disorder, and addiction.

But many psychodynamic proponents argue that evidence-based assessments might lead psychologists to dismiss potentially useful therapies that simply haven't been studied enough.

"Absence of evidence doesn't mean evidence of absence," said Michael Thase, a psychiatrist and professor at the University of Pennsylvania. Psychologists can't conclude a therapy doesn't work just because it lacks supporting evidence, he cautioned. Studies show that CBT works for suicidal patients, for instance, but that doesn't necessarily mean other therapies don't also work—their effectiveness just hasn't been demonstrated yet.

It would be professional suicide to study therapies that resemble real-world therapy, which might last a year or two.

There's academic incentive to study CBT over psychodynamic therapy, said Colorado's Shedler, because studying brief therapies allows researchers to perform and publish more experiments. "It would be professional suicide to study therapies that resemble real-world therapy, which might last a year or two," he said, and this research bias might encourage insurance companies to neglect long-term therapies.

Many insurance companies do impose a limited number of psychotherapy sessions before evaluating whether or not to renew a patient's coverage, said Christine Padesky, a CBT practitioner based in Huntington Beach, California and co-author of the book Mind Over Mood. But she believes that fits well with the CBT model. "Insurance companies want to see an organized plan," she said, "and that's what CBT is all about—having a plan based on evidence of what works."

There's validity to the pragmatism of researchers and insurance companies, said Judith Beck, a psychologist who co-founded the Beck Institute for Cognitive Behavior Therapy in Philadelphia with Aaron Beck, her father. "Let's say you have two people who are depressed," she said. "One gets a short treatment and gets better. The other has two years of treatment and perhaps gets better. So which of those treatments is best?"

Shedler, however, fears that as insurance companies and doctors increasingly refer patients to CBT rather than other forms of psychotherapy, people who don't get what they need from CBT will be turned off to therapy as a whole. "When they leave treatment they don't say, 'CBT didn't work for me,' they say, 'therapy doesn't work,'" he said. "So we're actually cutting off the opportunity for a lot of people who really could be helped to get help."

Beck has her own gripes with the field's evidence obsession. She thinks some psychotherapists perform shoddy versions of CBT so they can slap an "evidence-based" label onto their practice. "A lot of people who self-identify as cognitive therapists don't carry out therapy in a way I recognize," she said. "They don't even do the basics."

Shedler is concerned that the term "evidence-based" has led to "a kind of McCarthyism," where people who question evidence-based therapies are seen as anti-science. "If the words 'evidence-based' have become a form of branding for short-term, manualized treatments, we already have a problem," said Shedler. "Now we can't actually have a meaningful, honest dialogue."

"Researchers are being cut off from the feedback that comes with practicing in the real world, and from a tradition of clinical knowledge and wisdom that's accrued over a century," he said. "I think it's the most destructive thing that's ever happened to this field."