Restoring humanity to life

Stacking the Deck

12/26/2016        In the News 0 Comments

teenager-422197_960_720by Matt Stevenson


Psychology Today reports the results of a study, For Depressed Teens, Therapy Shows No Edge Over Routine Care, concluding that psychotherapy doesn’t work with adolescents. But, this is an example of how the researchers stacked the deck by looking only at short term types of therapy. Such a model of research treats psychotherapy as if it were just another medical intervention that can be “applied”, rather than the interactive, relationship-dependent, and individualistic process that it is.

When people are depressed, there is a reason – usually it relates in large part to depressing events or difficult relationships in that person's life, which have often taken years to develop!

In this particular study, adolescents were only given a small handful of therapy sessions; to quote the article: “The median number of treatment sessions differed significantly between patients in the brief psychosocial intervention group (n=6 [IQR 4–11]), CBT group (n=9 [5–14]), and short-term psychoanalytical therapy group (n=11 [5–23]; p<0·0001), but there was no difference between groups in the average duration of treatment (27·5 [SD 21·5], 24·9 [17·7], 27·9 [16·8] weeks, respectively; Kruskal–Wallis p=0·238).”

Seeing someone 6, 8, or 10 times is likely to be modestly supportive during the limited timeframe the intervention is given, but it's nowhere near long enough to examine in depth the complex life experiences that may have led a person to feel depressed.

Forming a positive therapeutic alliance for a person in a difficult emotional state often takes 6-10 sessions or more on its own, before contributors to the feelings of depression are explored, which might in turn allow a person to gain insights and change their behavior in ways that really allow them to feel better. Thus, we should not be surprised that significant differences did not turn up in this particular study, since the intervention was likely not lengthy or intensive enough to allow significant differences to emerge.

An interesting contrast to this study lies in the meta-analyses of long-term psychotherapy (for 1 year or more) performed by Falk Leichsenring, Paul Knekt, and Barry Duncan:

For example, in Leichsenring's meta-analysis comparing long-term psychotherapies with shorter-term approaches, 96% of patients getting longer-term therapy felt and functioned better than patients in the shorter-term group. See specifics here:

http://jamanetwork.com/journals/jama/article-abstract/1028649

http://www.carlapulliam.com/web_documents/bjp_long-term.pdf

So in other words, more human help does tend to make a difference, regardless of the approach.

And in Barry Duncan's analysis of various kinds of therapy, about 80% of clients were better off with therapy than without, and this effect usually increased over longer periods of time. Interestingly, most therapy approaches did similarly well, suggesting that it's the quality of the relationship as perceived by the client that matters most. Supportive human relationships also provides benefits that can last without adverse side effects, so common in drug treatment:

https://www.amazon.com/Heart-Soul-Change-Delivering-Therapy/dp/1433807092/

So giving someone a handful of sessions of “general support”, “CBT”, or “psychoanalytic therapy” (the latter may be a misnomer for a short-term approach) may be about equally supportive over a few months, but it doesn't say much about the value of forming a longer-term helping relationship with an understanding professional or peer. Building a trusting relationship and making significant life changes that lead one to feel less depressed take time, as common sense should tell us.

Lastly, here is another study demonstrating that long-term intensive psychoanalytic therapy (over about 18 months) can make a dramatic difference for very disturbed depressed individuals:

http://www.riksforeningenpsykoterapicentrum.se/psykoterapi/forskning/Fonagy_et_al_2015_Tavistock_Adult_Depression_RCT.pdf

Maybe this type of approach should be tried with adolescents also?

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