Psychodynamic Therapy vs CBT SmackdownI have a soft spot in my heart for psychodynamic psychotherapy. While its science generally lags behind its more modern cousin, cognitive-behavioral therapy (CBT), it’s the “old timey” therapy based upon theories …

18 Comments to
Psychodynamic Therapy vs CBT Smackdown for Anxiety

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  1. “Virtually of the measures employed showed significant improvement on anxiety and depression measures”

    Virtually all of the measures…?

  2. Affect change? I would say effect change. In my experience, none of it really works, but maybe that’s because I couldn’t afford quality mental health care.

  3. I think it’s probably good to use a mix of both. At least it was helpful for me. I’m not sure I would have responded to a therapist who used strictly CBT.

  4. “This study demonstrates that psychodynamic psychotherapy is an effective alternative for the treatment of generalized anxiety disorder, when compared to the more commonly-used CBT. The researchers encourage more studies like this one, and I couldn’t agree more. It’s a timely reminder of the value of the different types of psychotherapies available, not just the kind that might be in vogue at the moment.”

    I also agree that there has to be more randomize clinical trials comparing these two treatments not only for GAD but also other psychological disorders. However, I’ve gotten a bit annoyed because I felt like you’re treating the study as if it proves that Psychodynamics Psychotherapy is equally effective as CBT for GAD. Even though you informed us that CBT was superior in regards to reducing trait anxiety and worrying (which I find to be very important in regards to GAD), I get the feeling that you reduce its importance by your last paragraph. Personally, I think the study still shows that CBT is superior to Psychodynamics. Even though, the latter will reduce the severity of GAD all around, it seems CBT can do far more.

  5. “I also agree that there has to be more randomize clinical trials comparing these two treatments not only for GAD but also other psychological disorders.”

    Whoops! Meant to say “Randomized Controlled Trials!”

  6. I’m curious what the power of the study was given such a small sample size. Depending on the effect sizes (I haven’t looked at the full paper, so I don’t know), the results could also be accounted for as a false negative.

  7. I hope that they follow up with the group again at six month intervals for a few years. 6 months is a short time to make conclusions. I’d also like to see studies like this with a variety of mood disorders.

    In my own personal therapy and working with people with mental illness, I find that a combination works well…I am biased toward psychodynamic. I find that CBT does not work well for me as I find that it works better to form a trusting open relationship. I find that CBT and EMDR are disconnected to the patiet.

  8. My wife and I wrote about this article on our website as well. The efforts on the part of the authors to actually compare the two treatments to one another was a great service to the field and more studies attempting to do the same would be invaluable. Comparative treatment studies are a wonderful thing.

    At the same time, caution is required in interpreting these results. As another commenter mentioned already, CBT outperformed psychodynamic therapy in the reduction of the primary symptom of GAD: worry. GAD is characterized by free floating worry and if one therapy is superior at reducing that symptom, that’s a big deal.

    I was actually quite surprised by the generally strong performance of psychodynamic therapy in this study, which goes to show how much more value we get from data than we do from our own subjective expectations and philosophies. At the same time, caution needs to be used in drawing the conclusion that a single study in which one therapy outperformed the other in reducing the primary symptom of the mental illness being treated indicates equivalence across the two forms of therapy.

    Thanks for writing this summary.

    http://www.psychotherapybrownbag.com

  9. Dear John–I’m sure you don’t remember me as we haven’t been in touch for several years.
    I’m still producing programs for On Good Authority, my newest one being on The Therapeutic Relationship, and I’d like to quote your latest post in my introduction. It is a terrific review of this research!
    Thanks so much for this very fine service.
    Barbara

  10. Random selection is surprising. when u are going to assess the effects of something else then, groups must be made on the bases of the problem, severity etc.
    anyway its encouraging that both rivals are parallel.

  11. You believe in psychodynamic therapy? Just like believing in reiki, EMDR or some other useless treatment. Freud was wrong. Psychodynamic therapy should be retired, and people should stop wasting time and research dollars on it. Move on and find real cures for mental illness, and not “treatments”.

    CBT is another suspect in this morass of pseudoscience that is called “psychology”. One can not quantify terms like “improved”. If I wait a few months, no matter what happens– I might be “improved” if I thought people were treating me for something. Until I see a study using “sham CBT” (as if something like that could even be invented) I think all psychology is nothing more than reiki in a different wrapper–believe in something, and you get a nice placebo effect. Nothing more, nothing less.

  12. Skeptic says: ‘Move on and find real cures for mental illness, and not “treatments”’.

    Well, I agree with you in that most mentally ill people do not seek treatment, but rather bring their victims into treatment.

    But first we would have to find a good definition for ‘mental illness’ before curing people of it, and that is very relative. I’d say about the same number of mentally ill people who seek treatment, or a cure , and those who do not suffer in the least?

    But aside from that, I am surprised about the outcome of the research. I would have thought that psychodynamic psychotherapy, including psychoanalytic psychotherapy, creates anxiety, and I cannot even imagine what it would do to someone who is already anxious to begin with.

    Cognitive Therapy, well it would make sense that it at least doesn’t make you anxious, as it doesn’t stir up much of the unconcious?

  13. I’m not at all surprised by this study, although I can’t deny that my feelings on it are colored by personal experience. I’ve suffered from anxiety and depression for several years, and have tried both of these methods of treatment.

    The CBT didn’t work for me at all–I was frustrated by the fact that the therapist just assigned me to do exercises without really exploring the reasons behind why I was feeling anxious. It felt like I was treating a single symptom rather than the disease, and I saw almost no improvement from CBT treatment.

    Once I started psychodynamic therapy and was able to come to terms with the reasons for my anxiety, I saw a significant improvement in my mood and decrease in number of panic attacks. I can’t describe how much it’s helped me.

    Both methods can work, but it depends on the specific patient and circumstances of their disorder. It’s good that both are out there so people can figure out what works for them.

  14. Also, in response to Skeptic:

    Mental illness is difficult to define clearly, and there are some disorders (schizophrenia, personality disorders) for which we simply do not have “cures.” This shifts the focus of therapy to, yes, “treatment”–helping the patient manage their symptoms to the highest degree possible in order to function.

    In fact, there have been studies conducted comparing CBT with what you call “sham CBT” (patients being instructed to perform similar mental exercises as in CBT, but exercises with no therapeutic benefit). CBT consistently outperformed the placebo treatment by a significant margin. So yes, therapy is effective–I’m surprised there are still people out there attempting to deny it.

  15. I’m not surprised at all. A lot of studies show that bonafide therapies are equally effective. Of course, you have to look a bit to read these studies. You won’t find them in journals of CBT. But you will find them in peer reviewed journals… The only question is: ‘what works best for who?’. All the bonafide therapies have a lot of potential, but it’s ridiculous to impose CBT to everyone, like it happens nowadays in some countries, like GB.

  16. Okay, I am biased toward psychodynamic therapy. I really appreciated the comment from Miek (December 21st):

    “All the bonafide therapies have a lot of potential, but it’s ridiculous to impose CBT to everyone, like it happens nowadays in some countries, like GB.”

    I understand evidence-based practices are important; empirical research is important. But perhaps I do not trust my (very basic, I’ll admit) education in statistics as much as some do – I don’t believe anyone can realistically control for the level of empathy of the therapist, the intuitive nature of the therapist, the cognitive style of the therapist, the hundreds of variations one can practice through eclectic adaption that any particular therapist learned over time, etc. You really cannot even effectively control for the diagnosis of the patient – 10 different therapists will give 10 different diagnoses. People have traits of personality disorders, but many of the same do not meet the DSM criteria. This does not mean such traits do not influence the outcome of research studies.

    People who have had parental attachment issues, I believe, can sometimes benefit more from psychodynamic therapy (from antecdotal observations aside from my own). Another thing that is not usually controlled for – patients very motivated to change maladaptive behaviors – who can dissect their lives and get to the core of their inner motivations; insight, curiousity, whatever. Its not that CBT patients cannot have those traits, its that some of us psychodynamic patients maybe cannot deal with the more superficial aspect of CBT? I mean, I have to understand everything. I NEED to know my unconscious motivations for the behavior itself before I can change it. Psychodynamic therapy, once a week like CBT, is the only thing that can and has elecited more than marginal recovery for me. I also do not want drugs to mask the inner problems. There’s a big difference with addressing inner motivations and being taught to continue to repress and then (attempt to) redirect inner motivations, imo.

    I’m only a patient; I know relatively little about therapeutic orientations. However, I do know I wasted $1000s on CBT for years, not knowing a different “type” of therapy existed-until I discovered psychodynamic therapy as a result of my own personal research (thanks to the internet-before this technology existed, I would have never known about the different orientations). I was shocked to discover I gained more insight from 4 weekly sessions of psychodynamic therapy than all the years of CBT. Shocked out of my skin.

    Just one example of how CBT was a failure for me: I used to have GAD real, real bad. During one point in my life, I started overeating to deal with the anxiety. For some reason, at the time, it was the only thing that stopped the severe anxiety although I never had an overeating problem before. Anyway, the CBT therapist suggested, among other things, I take my plate of food and eat on the stairs of my house to change my motivations or relation or whatever with the food. Well, if I had the willpower to force myself to sit on the stairs while I eat food, I’d have the willpower to not let myself overeat in the first place!! This illustration is exactly how CBT was for me, all those years. Ridiculous…

    For me, personally, to change, knowing what was important was what was causing the anxiety itself, what caused my maladaptive behavior. I mean I guess I could continue to repress emotions, redirect my thoughts all I want, but the inner core issues and unconscious emotional motivations would still remain inside me, unaddressed, no matter how hard I tried to redirect my intellect to change my behavior.

    Antecdotal information is important, I guess its just an opinion I hold true. What Katrin said may be true for her, but each time CBT tried to help me with GAD, I had panic attacks and could not even talk about it. While PD therapy can unleash many emotions, I never had a panic attack while discovering the cause of/discussing my emotional reaction, while mostly transference based, with a psychodynamic therapist. The difference in discovering the source of anxiety itself, rather than trying to intellectually redirect it, was astoundable.

    The problem I have was eloquently stated by Miek. It would be so sad to see this artistic, perhaps unstandardized, profession die out – for everyone to be forced to do CBT on the basis that research, which cannot control for so many factors, indicates CBT is somehow “better” for patients.

    Please, let us, particularly those of us who have acknowledged our prior parental attachment issues, decide. Please do not push this type of therapy on us due to research statistics. That’s not fair to those of us who do not benefit from CBT-and end up wasting healthcare resources. Please do not let us all to be forced to accept the so-called proven methods like Great Britain does.

    Additionally, it will create even more social inequity among those of us with mental health issues – those who can afford the treatment of our choice, vs. those who will be stuck with issues that affect our ability to hold jobs, our relationships, the way we raise our children, our health, our life. If not addressed appropriately, it will or can continue to be passed down to our children. I know, being the only one in my family who ever graduated from college, the barriers to a socioeconomically productive lifestyle and obtainment of a decent life quality. My children now also know. If not for psychodynamic therapy, I do not believe I would have ever experienced a healthful, productive, quality life I now can obtain and sustain. PD made all the difference in the world to me. Please do not try to take this away from others. I already mourn for those who do not currently have this opportunity, and for those who will not have a choice in the future.

  17. It’d be intersting to see someone try to develop a questionaire that would seperate people who would be best served by CBT and people best served by PDT. A comparative study of people assigned a therapist/type of therapy with a questionaire versus people assigned at random wouldn’t be that hard to do.

  18. Measuring results in psychology is really hard, and, that’s why I like the way you formulated the conclusion: “This study demonstrates that psychodynamic psychotherapy is an effective alternative for the treatment of generalized anxiety disorder, when compared to the more commonly-used CBT.”

    Yes we should try out more solutions. I’ve seen some get better with hypnosis or qigong. But everyone calls you a quack if you even want to try that out.

  19. CBT is not a therapy but a set of skills that can be taught and help modulate symptoms. The whole edifice is built on an invalid precept – which is why the grand claims made for it don’t last over time. It gets short term results quite consistently, which wear off usually within a handful of weeks.

    Why?

    Well it declares that emotions are subordinate to thoughts. If only.

    Consider this thought experiment used in Philosophy 101 classes on ethics:

    There are 5 people tied to a train track with a train hurtling towards them. You can save them by pulling a lever which diverts the train onto another track. However, there is one person tied to that track.

    Ok – virtually everbody reasons that sacrificing one to save 5 is the way to go. Ho-hum.

    Now we have the same situation, five people tied to a track and this time no lever or second track. We do have a very fat man on a bridge over the track though. A lovely, kind avuncular figure, a pillar of the community and devoted father. His loving wife is beaming proudly as she takes his photo standing on the bridge. But here comes the train! Well you can tip old fatso over the handrail and his bulk will bring the train to a halt and save the five innocents.

    Do you?

    Well, probably. But it’s not so easy to say “Yes, lose one to save five” as in the first scenario.

    Why not? If we apply pure logic, restricting ourselves to the cognitive realm, these are essentially identical scenarios. Sacrifice one to save five – same both times.

    But people dont live in a purely cognitive realm. Humans are patently inherently irrational – as all major philosophers have conceded way back to Socrates. People have feelings. Bayoneting an enemy in the face is different to pulling a trigger on a sniper rifle from a mile away.

    The sheer conceit to believe you can think your way out of emotional problems is astounding. Not only do emotions always exert a influence, but their biggest pull is seldom even available to awareness.

    CBT is a bubble perpetuated by money men as it is of use to politicans who look like they’re doing something and can easily put a unit cost on treatments and calculate how many are typically required to get people off sickness benefits and back in the workforce.

    People relapse, usually within 3 months, and come back around to have the same experience. This is often logged as 2 successes instead of one abject failure.

    You can’t quantify human suffering, no matter how seductive Likert scales are.

    It’s bogus.

    • Couldn’t agree more, Thoreau. To be honest, I find the approach grotesque and overly simplistic; not really psychology but ‘ego-ology’.

      What particularly disgusts me is not the field itself (I have no objection to short-term cognitive techniques that are helpful) but the dogma with which CBT is currently being asserted, and how thoroughly they’ve courted the public.

      The part that offends me as a fellow researcher and scientist is how CBT is being sold to people as the only real evidence-based treatment, however, much of this evidence seems to be based on self-report questionnaires (is there anything more subjective in this world?) and how Likert-type scales are being processed by many as interval-level data. Interval data… like degrees celsius? To treat something so inherently subjective (and let’s not even go into the issue of a patient wanting to spare their therapist’s feelings and how that would affect reports) as self-reports with a small five-point scale as objectively measurable and quantifiable as degrees or metres I find scientifically offensive and a complete fabrication.

  20. I had a GAD without deppresion. CBT helped me, now i am healthy, in orded to overcome anxiety you must face your fears and get over them.

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