CONVERSATIONS IN CRITICAL PSYCHIATRY
Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.
Jonathan Shedler, PhD is known internationally as an author, researcher, and clinical educator. His 2010 article The Efficacy of Psychodynamic Psychotherapy won worldwide acclaim for establishing psychodynamic therapy as an evidence-based treatment. His research and writing on personality are shaping contemporary views of personality syndromes and their treatment. He is co-creator of the Shedler-Westen Assessment Procedure (SWAP), a clinician-completed psychological test for personality assessment and clinical case formulation. He is co-author (with Nancy McWilliams) of the Personality Syndromes section of the Psychodynamic Diagnostic Manual (PDM-2). He is a sought-after international speaker and provides clinical consultation to mental health professionals worldwide. Dr Shedler is clinical professor of psychiatry at the University of California, San Francisco.
Over the past 2 decades, Dr Shedler has emerged as one of the most articulate and prominent defenders of the psychoanalytic tradition of psychotherapy, and he has been on a mission to remedy the misconceptions about psychodynamic thinking that are rampant in psychiatry and psychology. His ire is particularly directed at the misapplication of “evidence-based” therapy, where assumptions of research protocols are being used to constrain clinical practice in ways that are not only unjustified but also harmful. I have found myself drawn to his ideas because he offers a distinct psychodynamic perspective on the ways in which decontextualized descriptive diagnoses, biomedical formulations, and manualized interventions have led to an impoverished view of human suffering. Dr Shedler is one of those rare individuals who can combine scientific rigor, clinical wisdom, and penetrating insight into the human condition, and are able to do so with refreshing honesty and great personal charm.
Aftab: I was fortunate during my psychiatry residency training to have a wonderful supervisor for my long-term psychotherapy patients. He was a psychiatrist and a psychoanalyst, and he helped broaden my clinical and conceptual horizons (Drew Clemens, if you are reading this, here’s a shout out to you!). I read Nancy McWilliams’ book on psychoanalytic psychotherapy, Psychoanalytic Model of The Mind by Elizabeth Auchinloss, On Dreams by Freud, Kohut's articles on self-psychology, essays by Aisha Abbassi, and so forth. Contrary to many older psychiatrists who had rebelled against “psychoanalytic dogma,” I was coming to this literature with a relatively untainted perspective and didn't feel the need to approach it with antagonism.
I was struck by how much “wisdom” there is in the psychoanalytic literature but also how difficult it is to translate that wisdom into contemporary scientific thinking in psychiatry. It felt like a living reminder of what Thomas Kuhn refers to as the “incommensurability” of scientific paradigms, that differences in concepts, methods, and target problems make it such that different scientific paradigms are “always talking at least slightly at cross-purposes.”1 You are well-familiar with the world of scientific research as well as psychoanalysis. How do you feel about the difficulty of communication between these 2 ways of thinking?
Shedler: I do not see scientific and psychoanalytic thinking as different ways of thinking. Good scientific thinking is critical thinking. Good clinical thinking is critical thinking. What are our assumptions? Can we articulate them? Can we justify them? What do we think we know and why? What would lead us to revise it? Scientists and practitioners should ask these questions. There aren’t separate ways of thinking. There is critical thinking and lack thereof.
The problem is that researchers and psychotherapists operate in different silos and often have little understanding of one another’s work—or the questions they consider relevant. Academic psychiatrists who pursue research careers may not have patients after residency, let alone practice psychotherapy. Academic psychologists may never work with a patient in their lives. Unless they get meaningful personal therapy, they cannot know what happens in psychotherapies of depth, insight, and relationship. Many researchers have trouble even conceptualizing psychotherapy as something with a purpose other than alleviating DSM symptoms. That is not its purpose.
One purpose of psychoanalytic therapy is to insert spaces for reflection where they have not previously existed and so create opportunities to know ourselves more fully, connect with others more deeply, and live life more congruently. Alleviating DSM symptoms is far down the list of what patients want from psychotherapy and what experienced psychotherapists focus on. That is not opinion; those are empirical findings.
So, why do psychotherapy researchers proceed from the assumption that outcome means DSM-based symptom checklists? There is no scientific reason we cannot operationalize the kinds of psychological changes patients want and experienced therapists work toward. Researchers make different assumptions. The result is psychotherapy research with little relevance to the practice of psychotherapy.
Aftab: A lot of psychiatrists who underwent training in the 70s and 80s have negative memories of their encounters with psychoanalysis. I have heard too many personal “horror stories” from psychiatrists I deeply respect to dismiss them as exceptions. In your view what accounts for this experience of mass discontent and disenchantment? What do you think are the major mistakes made by the psychoanalytic community that led to their “downfall” and loss of dominance in the profession? To what extent was it a misapplication of psychoanalytic ideas to severe mental illness such as schizophrenia (in the form of notions such as the “schizophrenogenic mother”)?
Shedler: The horror stories are real; I’ve heard them too. Actually, I’ve lived some of them. There is an apt quotation from Kevin Philips: “Any ideology that enjoys success first fulfills itself and then indulges in some hubris.” When psychoanalysis was the dominant paradigm, it indulged in some horrific hubris. Psychoanalytic training institutes were arrogant and insular. They separated themselves from other sources of knowledge and were openly disdainful of empirical research. Establishment psychoanalysis was the purview of MDs and psychologists were excluded. The medical authoritarianism of the time combined with the insularity of the analytic institutes and created a mix of superiority and dogma. It did not help that treatment and training took place in secrecy. Under those circumstances, abuses were inevitable.
Psychoanalysis is still paying for the excesses of decades past, probably deservedly. But the backlash against psychoanalytic knowledge is also impoverishing our thinking in the mental health professions. We are losing vitally important ways of understanding and alleviating human suffering. Fundamental, timeless truths are being lost or trivialized. One fundamental truth is that none of us fully know our own hearts and minds, and what we don’t know can hurt us. An aim of psychodynamic or psychoanalytic therapy is to help us know aspects of self that were previously unknown, so we can become better and more whole versions of ourselves. (For a jargon-free introduction to contemporary dynamic thought, see my monograph That Was Then, This is Now: Psychoanalytic Psychotherapy for the Rest of Us).
You asked about schizophrenia. Obviously, schizophrenia—or more likely, the range of conditions we call schizophrenia—has biological and genetic diatheses. No living psychoanalyst would say otherwise. So, to answer your question, of course it was a misapplication of psychoanalytic concepts. There was an a priori assumption that mental illness is caused by intrapsychic conflict and reasoning proceeded from that assumption. Again, it comes back to unexamined assumptions.
But aren’t we seeing the same kind of arrogance and reductionism in psychiatry today? How many make a priori assumptions that mental and emotional distress should be understood in terms of brain circuitry or chemistry? I cannot tell you how many depressed patients I’ve worked with in psychotherapy, successfully, or my supervisees have worked with, who had been on one medication after another for years or decades with little benefit. The idea that their difficulties could have meanings—meanings that could be understood and potentially reworked—was foreign to them. It was also, apparently, foreign to the doctors who treated their depression previously, because no one even raised it as a possibility (see my blog post This Is Talk Therapy for more discussion).
These patients often go from antidepressants to mood stabilizers to atypicals, not necessarily in that order. When they don’t improve, the answer seems to be more medication. We see polypharmacy nightmares, with patients on 5 or 6 or more psychiatric medications, and they are just as depressed as when they started. Some in psychiatry talk the talk about a biopsychosocial model but the walk is bio and nothing else. How is that less dogmatic or reductionist than the notion of a schizophrenogenic mother?
Aftab: What is your view on the relationship between clinical psychology and medicine? There is a tendency within psychiatry to conceptualize clinical psychology as falling within the purview of the medical model (under the umbrella of the biopsychosocial model). Cognitive behavioral therapists certainly appear to have made little attempt to distance themselves from the medical model. My own inclination is that clinical psychology and medicine are complementary with overlapping but different historical roots, perspectives, training skills, and target populations . . . and this constant tension of trying to fit clinical psychology within the medical framework may not be the healthiest thing for either profession.
Shedler: It’s complicated and I’ve written a little about it in a blog post. Your understanding is correct: Psychology has its own history, concepts, and methods. Wilhelm Wundt established the first experimental psychology laboratory in 1879 at the University of Leipzig, applying scientific methods to study mental life at a time when medicine still practiced bloodletting.
We would do well to build on psychological concepts and methods instead of trying to shoehorn psychology into a medical model that doesn’t necessarily fit. For example, we could study psychological processes that underlie mental and emotional suffering—not DSM categories. We could study how psychological changes can alter the trajectory of a life, not just symptom lists. The methodology exists.
My coinvestigators and I developed a personality assessment method for this purpose, called the Shedler-Westen Assessment Procedure, or SWAP. The research led to a new approach to personality diagnosis that is clinically relevant and empirically grounded.2 A research team led by Bob Spitzer conducted a “consumer preference” study comparing 5 systems for personality diagnosis that had been proposed for DSM-5, and psychiatrists and psychologists overwhelmingly preferred ours. It was more faithful to the personality syndromes seen in clinical practice and more relevant to clinical treatment. But there were too many vested interests jockeying for influence in the run up to DSM-5.
“One purpose of psychoanalytic therapy is to insert spaces for reflection where they have not previously existed and so create opportunities to know ourselves more fully, connect with others more deeply, and live life more congruently. Alleviating DSM symptoms is far down the list of what patients want from psychotherapy and what experienced psychotherapists focus on."
Aftab: One of the perpetual criticisms against psychoanalysis is that its concepts are too abstract and not amenable to scientific verification or falsification. In a Guardian article on “therapy wars,” Oliver Burkeman3 writes about a troublesome “sense that even the most sincere psychoanalyst is always engaged in a guessing-game, always prone to finding ‘proof’ of his or her hunches, whether it’s there or not . . . all this makes the whole thing unfalsifiable. Protest to your shrink that, no, you don’t really hate your father, and that just shows how desperate you must be to avoid admitting to yourself that you do.” That’s certainly reflective of a popular sentiment. Do you think this line of criticism has some validity?
Shedler: It is a popular sentiment, and a profound misunderstanding of psychoanalytic therapy. No one has privileged access to another person’s inner experience. A therapist may suggest connections or raise hypotheses for consideration, but it is a mutual process of discovery. The patient is the final arbiter of his own experience, always. When a person comes to know aspects of experience that were previously unknown, there is no doubt. They don’t need convincing. It is lived experience. They know it in their bones. A hundred other things come to mind that fit with it. Even if a therapist were able to persuade a patient of something, it wouldn’t help the person one bit. What doesn’t come from within is meaningless.
If a therapist insists on trying to tell a patient what they “really” think or feel, the patient should run for the hills because the therapist is no good at therapy. You mentioned Oliver Burkeman’s article in The Guardian. He interviewed me and asked this very question. The interview is online and I give a fuller answer there.4
Aftab: The famous therapist Irvin Yalom said in a 2009 interview with Psychology Today5, “Someone's got to do some more research, but I would really like to know: when a CBT therapist really gets distressed, who does he go see? I just have a strong sense it's not another CBT therapist. I think he wants to go out and search for somebody who's wise and can help him explore deeper levels . . . If you come across the data let me know. I certainly see a lot of them in therapy.” Your thoughts?
Shedler: Someone already did the research and I would be surprised if Yalom didn’t know about it. Therapists are most likely to choose psychodynamic or psychoanalytic therapy for themselves.6 It would be interesting to see if that finding still holds, because there’s been so much disinformation about psychodynamic therapy in recent years.
I share Yalom’s experience and I’ve worked with plenty of cognitive behavioral therapy (CBT) therapists. They don’t come asking for CBT and they certainly don’t ask what treatment manuals I use. They don’t necessarily come asking for psychoanalysis either. They come wanting to be seen, heard, understood, and known. But that is the essence of a psychoanalytic approach. CBT therapists also come to me for clinical supervision—often in secrecy.
Aftab: The poor long-term efficacy outcomes of status quo treatments for depression, whether these are antidepressant medications or manualized therapies, are well-recognized within the profession but rarely advertised. The uncomfortable truth is that majority of patients with depression (and other disorders, such as PTSD, anxiety, etc.) do not experience sustained recovery with either medications or short-term manualized therapies. With such outcomes, one imagines there would be more willingness to look at alternatives, but instead we see a doubling-down and an insistence that we need more of the same. What does research tell us about the long-term outcomes of patients with psychodynamic psychotherapy?
Shedler: Everyone should stop and take in what you just said: Given poor outcomes, “One imagines there would be more willingness to look at alternatives, but instead we see a doubling-down and an insistence that we need more of the same.” That should get everyone’s attention. What is going on here? What is a really driving the research and the rhetoric in the profession?
People don’t always appreciate the gap between rhetoric and actual research findings. Proponents of brief, manualized CBT for depression refer to the treatments as “proven,” “evidence based,” “gold standards,” and so on. You know what the past 4 decades of research shows? It shows that 7 out of 10 patients who get these treatments do not improve or they relapse quickly. I discuss the gap between research and rhetoric in a paper, “Where is the evidence for evidence-based therapy?”7 The American Psychological Association acknowledged the same thing in its clinical practice guidelines for depression, but you would have to go through the document with a fine-tooth comb to find that.
The latest state-of-the-art network meta-analysis for antidepressants8 reported an effect size of d = .30, which has been a remarkably stable finding over time. The Guardian ran an article under the headline, “The drugs do work, antidepressants are effective.”9 I did a little arithmetic, and a .30 effect size translates into 1.7 points on the Hamilton Depression Rating Scale (HDRS)—which is obviously clinically trivial. The average patient was still clinically depressed after treatment and had a HDRS score of 24. That is high enough to get enrolled in another depression trial. There’s the gap again, between findings and rhetoric. Before people start sending hate mail, I am not anti-medication, any more than I am anti-therapy. Antidepressants work well for some depressed patients some of the time. But “research shows” they do little for the average patient with major depression in research trials, even in the short run.
You asked what research tells us about long-term outcomes in psychodynamic therapy. It suggests the benefits of psychodynamic therapy endure or even increase over time. I reviewed the research in The efficacy of psychodynamic psychotherapy10 But it is a problematic question and an even more problematic answer. For one thing, psychodynamic therapy is not a single, monolithic treatment. The psychodynamic tradition subsumes multiple theories and treatment approaches and they are quite different. I’m not even sure there is such a thing as “psychodynamic therapy,” independent of the specific clinician doing the therapy, the specific patient, and the unique rhythms and patterns of interaction that develop between them.
This is an unexamined assumption of psychotherapy research trials: that it is possible to isolate the specific effects of a therapy brand or model like you can isolate the biological effects of a medication from the prescriber and context of prescribing. You can pretend everything else is random error variance, but you are discarding nearly everything that matters. I would feel better if we developed research methods to fit the subject matter instead of forcing psychotherapy into the Procrustean bed of a research method designed for a different purpose, based on assumptions that don’t necessarily fit. It always comes down to the assumptions—the explicit ones and the implicit ones that are easy to overlook.
Aftab: One of the topics you have been vocal about is the issue of how long it takes for psychotherapy to be effective. You wrote a wonderful recent article with Enrico Gnaulati titled “The Tyranny of Time”11 in which you argue how data from a variety of sources converge to show that meaningful change takes time, that in most cases meaningful success in therapy requires 6 months to a year of weekly therapy, and the assumption by academic researchers that therapy is finished in 8 to 12 sessions is really just a misguided assumption. Why is there so much resistance against this idea?
Shedler: Academic researchers and clinical practitioners operate in different silos. In the academic silo, there is an incentive system disconnected from clinical realities. Academic careers advance through publications and grants. There are publication and funding cycles. It would be professionally suicidal for an academic researcher to study therapies of realistic duration while colleagues and professional rivals accumulate publications based on 8 to 10 session treatments. There’s little incentive to look beyond symptom checklists and short-term outcomes.
There are other stakeholders with vested interests. Health insurers have a financial incentive to steer patients to the briefest, cheapest therapies. Executives and administrators of health care organizations are often under financial pressure to treat more patients in less time with fewer resources. All these pressures converge to turn mental health care into an assembly line. We rarely hear the voices of patients or the clinical practitioners who work with them.
Aftab: It is a bit odd to me that clinical psychologists accepted DSM as their de facto guide to diagnosis. Why did psychology acquiesce to the adoption of a medical diagnostic framework when it could have adopted diagnostic approaches that are a more organic fit with the nature of psychotherapy?
Shedler: I want to be clear about this: “Psychology” did not acquiesce. There is a bifurcation in psychology between clinical practitioners and academic researchers who claim to speak on behalf of psychology. We rarely hear the voices of clinical practitioners in public discourse. The voices of academic researchers dominate and take up all the oxygen—and they are the voices of people with no meaningful clinical experience.
People outside psychology do not fully understand the bifurcation of science and practice in psychology. They think psychologists who are career academics and researchers know and understand what psychotherapists do. They don’t.
I think many psychologists share my view of DSM. It is one lens for looking at a patient, it’s helpful for certain purposes, and it’s a shared nomenclature for shorthand communication with colleagues about relatively overt signs and symptoms. It is not a clinical case formulation and not a substitute for one. Also, it is not a question of acquiescence: DSM was forced on us for insurance billing.
Aftab: My understanding is that only medical doctors were allowed to become trained psychoanalysts in the United States until 1988 when following a lawsuit settlement psychologists and social workers were also allowed into psychoanalytic training programs. The fact that psychologists were excluded from psychoanalysis for so long, does that have any bearing on the unfavorable manner in which psychoanalysis is viewed within academic psychology?
Shedler: It has everything to do with it. Psychoanalysis alienated generations of academic psychologists. Psychologists who sought analytic training were excluded or had to demean themselves and participate as second-class citizens. And psychoanalysis was openly dismissive of empirical research, which was central to academic psychologists’ identity.
One consequence is that few academic psychologists had an opportunity to learn about contemporary developments in psychoanalysis. What little they knew was based on distorted caricatures dating to the horse and buggy era. The caricatures made their way into psychology textbooks where they were taught as received truths about the psychoanalytic tradition, and still are. Another consequence was that the culture of academic psychology became openly hostile to anything associated with psychoanalysis. Empirical findings that supported non-psychodynamic treatments were embraced and disseminated, whereas evidence supporting psychoanalytic concepts and treatments was pointedly ignored.
This is how the term “evidence-based therapy” came to be a de facto codeword for “not psychoanalytic.” Research shows that psychodynamic therapies are at least as effective as so-called evidence-based therapies,10 but no one wanted to pay attention to the research. It was like a collective act of denial or willful blindness.
Aftab:You write in The Tyranny of Time, “This is the secret known to master clinicians: meaningful and lasting psychological change comes from focusing not on symptoms, but on the personality patterns that underlie them. This is not just clinical wisdom; it’s an empirical finding.” This is a point I raised in an earlier interview12 as well . . . does it make sense to label someone as having “treatment resistant” depression or anxiety if the concept of treatment resistance does not take into account the presence of contributing personality factors?
Shedler: It makes no sense to me at all. There are almost always contributing personality factors. In fact, they are not just “contributing,” they are the factors. I don’t just mean personality disorders. Everyone has a personality. This is a radically different way of thinking about depression. It is less about what we have and more about who we are. Our difficulties are woven into the fabric of our lives and rooted in enduring patterns of thinking, feeling, motivation, attachment, coping, defending, and relating to others—that’s what we mean by personality. From this perspective, depression is an effect, not a cause. It cannot be treated in a vacuum, separate from the person experiencing it.
I’ll give some simple examples to illustrate what I mean using familiar personality constructs. One thing we have learned through our research on personality is that almost every personality style represents its own unique pathway to depression and requires a different focus in psychotherapy.
Consider someone with a narcissistic personality style. There is a chronic, painful gap between the person’s grandiose expectations of the world versus what the world actually affords. No matter what successes or satisfactions come their way, they fall short of inner expectations, get devalued, and therefore are not experienced as successes or satisfactions. Instead of joy or fulfillment, the person experiences repeated disappointment and resentment. This is a pathway to what then gets diagnosed as “depression.” Behind major depressive disorder, we often find a deflated narcissist.
Paranoid personality style is another pathway. People with paranoid styles are filled with hostility and anger but they defend against it by projecting it onto others. That is an empirical finding. They see their own hostility everywhere they look, and the result is their world feels cold, comfortless, and dangerous. This is a pathway to depression.
Consider a person with an avoidant personality style. Life entails a certain amount of stress and conflict. That’s the human condition. But people with avoidant styles defend against perceived threats, internal and external, by shrinking away. These avoidant responses become bars in a psychological prison, limiting freedom of choice and action until there is nowhere to go. It cuts them off from sources of satisfaction and fulfillment and meaning. This is a pathway to depression.
Perhaps you can see why I reacted to the term “contributing personality factors,” which implies that depression is separable from the personality dynamics that fuel it. I long ago lost count of the number of patients I have seen with “treatment-resistant” depression (TRD) who were helped by psychotherapy. Show me a patient with a diagnosis of TRD, and the likelihood is that I will show you someone whose underlying personality dynamics were never understood or addressed in psychotherapy. And it can’t be done in 8 to 12 sessions, because ingrained psychological patterns that develop over a lifetime do not change in a matter of weeks.
Aftab: What are your hopes for the future of our professions?
Shedler: I just read a paper by Nancy McWilliams13 where she distinguishes 3 meanings of the term psychoanalytic, referring to a type of treatment, a body of knowledge, and a certain sensibility or ethos. The psychoanalytic ethos includes the values of “self-understanding, authenticity, empathy and compassion, egalitarianism, adaptation to unchangeable realities, growth in agency and personal responsibility, acceptance of normal dependency, and respect for others as subjects rather than as objects” (emphasis added). I hope future generations of psychiatrists and psychologists will be able to recognize themselves in those descriptions.
Aftab: Thank you!
The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.
Dr Aftab is a psychiatrist in Cleveland, OH, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times Advisory Board. He can be reached at firstname.lastname@example.org or on Twitter @awaisaftab. Dr Aftab and Dr Shedler have no relevant financial disclosures or conflicts of interest.
Previously in Conversations in Critical Psychiatry
Relentless Warrior for Mental Health: Allen Frances, MD
The Structure of Psychiatric Revolutions: Anne Harrington, DPhil
Skepticism of the Gentle Variety: Derek Bolton, PhD
Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD
Chaos Theory with a Human Face: Niall McLaren, MBBS, FRANZCP
The Rise and Fall of Pragmatism in Psychiatry: S. Nassir Ghaemi, MD, MPH
Integrating Academic Inquiry and Reformist Activism in Psychiatry: Sandra Steingard, MD, and G. Scott Waterman, MD
Social Constructionism Meets Aging and Dementia: Peter Whitehouse, MD, PhD
50 Shades of Misdiagnosis: Susannah Cahalan
Institutional Corruption and Social Justice in Psychiatry: Lisa Cosgrove, PhD
The Impoverishment of Psychiatric Knowledge: Giovanni Fava, MD
Psychiatry and the Human Condition: Joanna Moncrieff, MD
Psychiatric Disorders as Imperfect Community: Peter Zachar, PhD
Weaving Conceptual and Empirical Work in Psychiatry: Kenneth S. Kendler, MD
The Battle for the Soul of Psychiatry: Ronald W. Pies, MD
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