Development of Schools with charismatic leaders: often cult-like in character.
Development is by ... IAPT and CBT: Darian Leader. (2008). “It's a scandal!
Opposed by Dr Chris Fear
Overview y The alluring history of Psychoanalysis and the y y y y y y
psychodynamic legacy Psychodynamic approaches and the special relationship Psychodynamic approaches and the “special relationship” with psychiatry The decade of the brain... In which psychiatry lost its mind p y y Phenomenology has dramatically declined To be replaced by....what? Salvaging what is good? Empirical grounding
What type of question is this? What type of question is this? y .......it is essential for trainee
Psychiatrists to have a psychodynamic y p y y understanding of their patients y An empirical question, of course! An empirical question of course! y So what does the research say? y There is no research addressing this issue so instead need to consider other issue, so instead need to consider other forms of evidence.
The considerable contribution of The considerable contribution of psychoanalysis y In early days, the focus on phenomenology y Inspires the development of y Information processing y Psychopathology
y So, a key historical influence k h l fl
Evidence for efficacy y Research in psychotherapy is notoriously difficult to
do and few outcome studies have been attempted y The quality of evidence has been challenged. q y g y The very few comparison studies have tended to show equal efficacy between different psychotherapies q y p y p y There is considerable anecdotal “evidence” for There is considerable anecdotal evidence for
psychodynamic psychotherapy
The considerable contribution of Th id bl ib i f psychoanalysis y In early days, the focus on phenomenology y Inspires the development of y Information processing y Psychopathology
y So, a key historical influence
But: y It later becomes a restrictive orthodoxy y Neglects psychopathology outwith dogmatic positions y Development of Schools with charismatic leaders: often cult‐like D l f S h l i h h i i l d f l lik in character y Development is by splintering, death or “takeover” eve op e t s by sp te g, deat o ta eove y The recurring nightmare of Personality Disorder and “Axis II”
Psychodynamic Psychotherapy vs. Faith‐Healing y Based upon charismatic writing (bible, Freud, Jung) leading to y y y y y y
variety of schisms Relies on untestable dogma supported by self‐accrediting “priesthood” “cure” derived from quality of faith Treatment failures lack sufficient faith (“not psychologically minded”) Efficacy lacks scientific proof (so scientific method rejected as “invalid”) Effective self‐publicists with ability to repackage and reinvent Source of tremendous comfort to numerous believers and considerable self‐serving anecdotal evidence for effectiveness
Over‐dependence on private Over‐dependence on private g earnings y Most psychodynamic psychotherapy occurs in the
private sector y Has become an industry depending on marketing demand rather than evidence y Further undermines the integrity of psychodynamic psychotherapy
Issues of trust y Whilst majority of psychotherapists are trustworthy
there is a history of some therapists abusing their positions of power y The monitoring of the profession has been inadequate and this has undermined the trust of the profession y Some argue that the abuse of power is inherent in the model of therapy (Masson‐ Against Therapy 1988)
Different models of the Diff t d l f th understanding of the mind understanding of the mind y Biological/psychological/sociopolitical y Psychodynamic y Behavioural/cognitive y Neurochemical y Marxist y Buddhist y Christian y Why do we insist on trainees having a psychodynamic
perspective and not other perspectives?
y Even the different psychodynamic schools strongly
disagree with each other so there is no unified psychodynamic understanding of the mind
P hi t Psychiatry and the special d th i l
relationship y Medical psychotherapy M di l h h y Consultant psychotherapists y Did it become too easy to claim spurious expertise? y Up until quite recently, psychological therapy in
psychiatry pretty much synonymous with psychoanalysis and psychodynamic treatment. y Not only is it not going anywhere, but....
R il d Reviled upstarts: Jo Wolpe! (1958) t t J W l ! (1958) “Behaviour therapists not only say that they can cure phobic symptoms but that they also claim that it is possible to measure outcome” “There will be symptom substitution.” Phobias....a remarkable story of treatment development and translational research Generalises to anxiety disorders....e.g. Panic, OCD
Treatment Development through Clinical Science: l h h l l “Empirically Grounded Clinical Interventions” Theory
Outcome research
Clinical Practice (phenomenology) Experimental studies & psychopathology research
What killed the dominance of psychodynamic h k ll d h d f h d approaches in Psychiatry? pp y y y “The decade of the brain”: a period when psychiatry p p y y
lost its mind and gained......nothing at all. Should we turn the clock back? y Not in the light of Evidence Based Medicine
Cost effectiveness y If different forms of psychotherapy are shown to have
similar efficacy, why should psychodynamic understandings be given priority as psychodynamic psychotherapy is costly? y Overwhelming empirical evidence for effectiveness of cognitive/behavioural therapies in many psychiatric conditions. diti y Comparitive studies have been in very limited clinical circumstances. circumstances y NIHCE overwhelmingly recommends CBT for most conditions. conditions
IAPT and CBT: Darian IAPT d CBT D i Leader L d (2008) “It’s a scandal! Cognitive‐behaviour therapists not only say that they can cure almost every common psychological disorder and they also claim that there are outcome data to support this view. Governmental organisations agree too…”
Depth and comple it Depth and complexity... y Complex problems need complex solutions? y Why do we think that an approach which claims (but
fails) to help us understand and deal with simpler problems is going to help us deal with complex problems? y Personality disorder y DSM‐V (or VI) – unravelling the psychodynamic mess y “That Damascus moment” That Damascus moment
Babies and bathwater...... Mace and Binyon, Advances in Psychiatric Treatment, 2006 “Teaching psychodynamic formulation to psychiatric trainees trainees” y Recognising the psychological dimension y Constructing and illness narrative C i d ill i y Modelling a formulation y Naming the elements
Q estion Question: Is it essential for trainee Psychiatrists to have a psychodynamic understanding of their patients? p
A Answer: No N y Why would we insist on training in an approach that
has no practical benefit in today’s NHS? p y y But..... they should be trained in phenomenology and But they should be trained in phenomenology and
this linked to a good understanding of the evidence regarding psychopathology g gp y p gy y And.... they should be trained in psychological And they should be trained in psychological
