(This article is a review of psychotherapy-related workshops and lectures at the American Psychiatric Association’s May 2014 conference. It involves content originally published at mindcafe)
The APA has a reputation for often being too biologically focused; however the psychotherapies were certainly well represented, and even appeared to show a level of maturity and pragmatism in how they were presented. Summers & Barber held a workshop providing an overview of the evidence base and use for psychodynamic psychotherapy. Much was made of the issue of therapeutic alliance, and echoing Bordin’s 1979 statement of ““… we can speak of the working alliance as including three features: an agreement on goals, an assignment of task or a series oftasks, and the development of bonds.” Rather than simple motherhood statements, these were directly represented in Barber’s 2000 study identifying that the therapeutic alliance independently predicted improvement in an 88 patient study on depression, amongst several other studies. What was most remarkable was their idiosyncratic contribution to the field in terms of considering formulating cases around six key concepts, or “Core Psychodynamic Problems”. These ranged from a fear of abandonment to panic anxiety, and notably each core problem was structured around a well-established school of thought – from ego psychology to object relations. In doing so they presented a structured approach to eclectic dynamic psychotherapy, which is not a mean feat.
This tendency to pragmatic integration continued with Glen O Gabbard’s lectures regarding the evidence base and sensible approaches to the psychotherapies. One of his first lectures involved a significant level of apologies for the Association-enforced title of “How I became Me”, and his legendary humility showed in how he simultaneously apologised for being asked to discuss his own biography, but provided a valuable insight into the development of a psychotherapist and an educator. There was a note of concern, though, as he admitted to observing that psychodynamic psychotherapy had a shrinking role in the public sector, and numerous questions from the audience comprised basic patient-related questions from trainees, suggesting the limited access that many American trainees had to supervision. A later lecture discussed the increasing neurobiological correlates with psychotherapy, such as insights into procedural memory and the evidence of improved serotonergic transmission following successful therapy.
A key point was Gabbard’s review of the therapies for borderline personality disorder, and how he pointed out that there were now six independently designed therapies that all had Level II evidence for effectiveness in BPD. He queried why this was, particularly given the grossly different theoretical models they utilised, but offered the suggestion that all the therapies built on therapeutic alliance, and provided patients with a plausible means of understanding themselves, which itself may be where the change came from. The notion of plausibility of an intervention rather than the inherent higher “truth” of the psychotherapy would have been heretical in recent times, but it was surprising to see it repeated by multiple proponents throughout the conference.
Gunderson, who had workshops and multiple lectures regarding his approach to borderline personality, also took the pragmatic stance, particularly pointing out that effective engagement of a personality disordered individual was possible without highly specialised training, and in itself yielded better outcomes. He presented newer research showing improved functioning with his “Good Psychiatric Management” treatment method, formerly called “General Psychiatric Management”. One admires his restraint in not referring to it as “Gunderson Psychiatric Management”.
On the other end of the spectrum was Kernberg and his associates describing object relations theory and its implications. A workshop on narcissistic personality disorder was notable for the mysterious omission of any case studies verifying the reintegration of the personality, which is supposed to be the hallmark of the object relations approach. Whilst it is easy to denigrate a therapy that took (as per the proponents at the workshop) about 10 years to yield change, Kernberg’s lecture on Love and Anger demonstrated that the object relations model provided a beautiful means of conceptualising the human mind. Accuracy and independent verification are separate issues, but the art of psychiatry in terms of understanding the un-understandable continues.
At the end of the conference, an academic forum attended by Gabbard had a wry note at the excellent turnout to the review of personality disorders, particularly at such a late stage in the conference. Discussing obsessive compulsive personality disorders and key features of treatment, he was notably critical of Item 5 on the DSM-IV (and now DSM-V) listing. The same enthusiasm for treatment however came with himself and subsequent speakers, particularly a remarkable resident program with intensive dynamic psychotherapy.
The conference as a whole left myself with a renewed enthusiasm and willingness for open reflection regarding psychotherapy and how it works. There has not been any doubt as to whether it works, but the doubt as to why it works has been previously ignored. The improved willingness to confront this issue from multiple leaders in the field is reassuring. On the other side of the globe, Mary Taggart’s keynote address at the RANZCP’s congress in Perth identified attachment and mentalisation as common features associated with improved patient functioning, regardless of modality of therapy. It was fortuitous, as one considers that a good therapeutic alliance is essentially good attachment that facilitates mentalisation. Perhaps we are approaching a paradigm where psychodynamic psychotherapy is actually dynamic.
1.) When evaluating the progress of a psychotherapy (whether you are delivering it or not), one can determine its effectiveness by how well the therapist engages the patient, and how likely the patient feels that the therapy makes “sense”.
2.) If providing dynamic psychotherapy, consider using Summers & Barber’s “Six Core Psychodynamic Problems” approach in order to suggest with theoretical modality is most likely to help understand and benefit your patient. (“Psychodynamic Therapy: A Guide to Evidence-Based Practice” from Amazon Kindle)
3.) If not providing dynamic psychotherapy, consider using Gunderson’s “Good Psychiatric Management” approach as a simpler but still evidence-based means of reducing negative events. (ISBN-10: 1585624608)
4.) Do not stick too slavishly to any single theoretical modality, as this can interfere with the therapy outcome – a dynamic approach using multiple theories is always better.