Electronic Letters to:
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eLetters: Electronic letters published:
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Therapies for depression must also be flexible to deliver.
- Noel D Collins (18 November 2008)
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Bravo! Dr David Taylor
- Sue L Doyle, Patient (12 December 2008)
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Noel D Collins, SpR CNWL
Send letter to journal:
noelcollins{at}nhs.net Noel D Collins
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I enjoyed David Taylor’s spirited defence of the use of dynamic therapies in depression but feel that his clear model allegiance may have lead to the neglect of other practical considerations. The popular use of CBT in depression and other disorders is not solely due to a ‘homeopathic fantasy that short term psychological treatments are highly potent’. In comparing any NHS treatment, efficacy is only one consideration. Cost-effectiveness and flexibility in delivery are other issues to take into account. I believe CBT may be superior to dynamic therapy in these regards. The recent and compelling Layard economic argument for the cost effectiveness of CBT in adult depression has prompted the government’s Improved Access to Psychological Treatments (IAPT) initiative. It is difficult to see how psychodynamic therapies could be delivered in such a responsive way, consistent with a stepped care model. A relative advantage of CBT is that single threads of therapy at different levels of intensity can be titrated to patient need, rather than a blanket execution of the full CBT model in every case (Lovell and Richards, 2000). This is supported by Jacobson et al (1996) findings that many patients with depression improve with behavioural activation alone. What single threads of psychodynamic therapy could be similarly utilised, independent of the complex frame that dynamic therapy usually demands? Lovell and Richards (2000) argue that the traditional focus on ‘high intensity multiple-thread interventions’ to a select few, disenfranchises the remainder of people who would benefit from, but can’t access, briefer and simpler interventions. The current delivery of traditional psychodynamic therapy in traditional settings with traditionally long waiting lists is particularly vulnerable to this criticism. Whyte (1996) reports that a wider range of patients might be able to access dynamic therapy if their psychiatrists were not so deterred by long waiting lists. The coherence of CBT also lends itself more readily to training and the increased dispersion of less intensive treatments to patients directly through guided self help materials (including computerised or CCBT) or indirectly through the multi-disciplinary team through new models of brief training such as the SPIRIT (Structured Psychosocial InteRventions In Teams) course (Whitfield & Williams 2003). David Taylor makes a convincing case that dynamic therapy may be as effective as CBT in depression but he does not provide suggestions as to how dynamic therapy can be as coherent, cost effective and deliverable in busy clinical settings. His argument fuels the polarised argument of CBT verses dynamic therapy and ignores more integrative therapies such as Ryle’s Cognitive Analytical Therapy. Bateman (1997) argues that ‘a creative and constructive partnership between different psychotherapies needs to develop if psychotherapeutic psychiatry is to flourish’. He goes on to suggest the greatest threat to this ‘is the partisan approach of the psychotherapies themselves’. REFERENCES: 1.Lovell, K., & Richards, D. (2000) Multiple Access Points and Levels of Entry (MAPLE): ensuring choice, accessibility and equity for CBT services. Behavioural and Cognitive Psychotherapy, 28, 379–391 2. Jacobson, N., Dobson, K., Traux, P., et al (1996) A component analysis of cognitive behavioural treatment for depression. Journal of Consulting and Clinical Psychology,64, 295–304. 3. Whyte, C (1996) The need for dynamic therapy. Psychiatric Bulletin (1996), 20, 541-542 4. Whitfield, G. & Williams,C. (2003). The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings. Advances in Psychiatric Treatment; 9, 21–30 5. Bateman, A. (1997) Borderline Personality Disorder and Psychotherapeutic Psychiatry: An integrative Approach British Journal of Psychotherapy; 13(4),489-498 |
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Sue L Doyle, Horse-Breeder. Painter. Reearch T C D, Patient
Send letter to journal:
madmothersue1{at}hotmail.com Sue L Doyle, et al.
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As a patient receiving long-term psychoanalytic psychotherapy I can totally concur with him that this is the way forward. This is good news for Health Insurers too, as it's the kindest and most effective way to cut back on 'revolving-door' patient stays! It makes ecomomical sense to support and 'shore-up' such patients with psychoanalytic psychotherapy as out-patients, thus allowing them to 'take root' in society again. Otherwise unnecessarily frequent retreats into the artificial protection of a psychiatric hospital soon feel like the real world! |
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