by Michael D. Anestis, M.S
Over the past year, we have written a number of articles on PBB in response to an article published in the American Psychologist by Jonathan Shedler. These articles have prompted a number of interesting back-and-forths both here and in other forums and we are awaiting the publication of our response to Shedler's article in the American Psychologist (Anestis, M.D., Anestis, J.C., & Lilienfeld, S.O [in press] The devil is in the details: Are the conclusions of Shedler [2010] consistent with the evidence? American Psychologist). I anticipate that this conversation will continue off and on for quite some time.
Recently, I learned that Scientific American has published an article by Dr.Shedler in which he reiterates the points to which we have replied here and in our published comment. Today, I would like to respond to that article with a few quick points, a series of references, and a number of links to past conversations we have had on related topics. I look forward to hearing your thoughts on this, regardless of whether or not you agree with our conclusions.
First off, here is a link to the article in Scientific American. I recommend that you read that to arrive at your own conclusions before reading my thoughts on the piece.
And now on to my replies:
- First and foremost, here are two articles we have written that directly respond to Dr.Shedler's original article. In these PBB postings, we summarize problems with the data used to drive the conclusions in Dr.Shedler's article. Ultimately, our point is not that psychodynamic psychotherapy does not work, but rather that much more evidence is needed in order to arrive at such conclusions, as data comparing it to CBT actually speak to a much different reality.
- With respect to the Scientific American article, one of the most problematic issues is the gross mischaracterization of CBT. The idea that emotions are ignored or shunned in CBT sessions is, quite frankly, asinine. Some CBT therapists may do this, but that is because they are bad therapists, not because CBT tells them to do it. Horrific psychodynamic therapists routinely make errors at least as problematic. Considering that dialectical behavior therapy (DBT) is often referred to as a form of CBT (an, in fact, is included as a form of CBT in studies included in the analyses cited by Shedler) and DBT has entire modules devoted to emotion regulation and distress tolerance, the idea of emotions being ignored in CBT is entirely untenable. For a good description of how CBT works, I would recommend the following resources:
Bob Leahy's blog
American Institute for Cognitive Therapy
Beck Institute for Cognitive Therapy and Research
Association for Behavioral and Cognitive Therapies
- The notion that the therapeutic alliance is a driving force in psychotherapy is often stated, but the data paint a much more complicated picture. Now, nobody is saying it is wise to have a poor alliance, but there are plenty of reasons to believe that the alliance is far from the most important variable in determining treatment outcome, particularly in treatments for which the alliance is not something routinely called attention to during sessions. The work of Robert DeReubis of the University of Pennsylvania and Tony Tang at Northwestern University are particularly notable on this front. We have touched on some of their studies on PBB and the following two articles summarize them relatively concisely:
- Attempts to link the popularity of CBT to insurance companies and to liken CBT to the work of the pharmaceutical industry are absurd. The data supporting the efficacy and effectiveness for various forms of CBT for a range of mental illnesses are undeniable. CBT is not perfect and, for a number of diagnoses, it is not the best or only option. That being said, the evidence base supporting CBT far exceeds that of psychodynamic psychotherapy, so efforts to dismiss its utility on the basis of its imperfection completely negate any argument that psychodynamic psychotherapy is a viable alternative. It may very well be, but the evidence simply does not support that notion. Regardless, psychologists who support the use of empirical evidence to drive practice do not have the advertising money or political sway of pharmaceutical companies. Attempts to portray psychodynamic psychotherapy as some form of outsider to the insider game of CBT are akin to billionaire children of congressmen selling themselves as a breath of fresh air and a voice for those who have no connection to Washington, DC as they campaign for office using limitless funds accumulated through a life of lobbying and nepotism. The degree to which psychodynamic psychotherapy still dominates the general population's understanding of clinical psychology renders such ideas completely indefensible.
- The notion that CBT only touches on surface level issues while leaving core issues untouched is not supported by any form of evidence. Furthermore, the notion that panic attacks in panic disorder, non-suicidal self-injury and suicidal behavior in borderline personality disorder, anhedonia and hopelessness in depression, binge eating and purging in bulimia nervosa, and the legion of other targets effectively treated by CBT are somehow of little importance is mystifying to me (and to the countless individuals who have suffered from such symptoms and benefited from such interventions).
I look forward to hearing your thoughts on these points and hope that you will contribute to the conversation here and elsewhere, regardless of your stance. Either way, however, my hope is that contributions to the conversation will be based upon facts rather than anecdotes and evidence rather than philosophy.
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If you would like to learn more about this or other topics discussed on PBB, we hope you will consult our online store for scientifically-based psychological resources.
Mike Anestis is a resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University
