The complex business of change

I usually struggle to engage with academic papers but I enjoyed Jonathan Shedler’s article, The Efficacy of Pyschodynamic Pyschotherapy (pdf).

For outsiders, it may be heavy going but it’s clearly got industry insiders excited (the President of the American Psychoanalytic Assocation calls it an intellectual feast and I agree).

It’s been written in the context of some long-standing turf wars between competing models for psychotherapy – in this case the focus seems to be on comparing psychodynamic methods with cognitive behaviour therapy (CBT).

There are several reasons I found it fascinating. This is just a hasty summation and I’m conscious that I’m trying to simplify a fairly complex topic.

First, Shedler identifies a lot of painstaking research that has been done over the years to establish whether psychotherapy works, and what it is that works when it does. I think a lot of people dismiss therapy as hocus pocus and don’t realise that there’s reasonable evidence to the contrary.

Second, Shedler’s work conveys to me that it’s a very complex business measuring effectiveness in psychotherapy and it’s very easy to misinterpret the evidence – for instance, when he looked at the apparent success of CBT. Researchers found that people practising apparently different therapeutic approaches often, probably unconsciously, actually practised stuff from other schools. He suggests that a lot of the apparent success of CBT comes when its practioners deviate from the CBT rule book and implement what he argues are actual practices from the psychodynamic model.

He also points to interesting work showing how research into these areas is usually biassed by the researchers’ personal preferences for treatment techniques.

We hear a lot about the importance of “evidence-based” approaches and I think it’s important to see here just how easy it is to interpret or misinterpret the evidence.

Third, notwithstanding those caveats, I like seeing CBT put in it’s place, even if I should be wary of turf wars. Shedler identifies what separates psychodynamic approaches:

The psychodynamic prototype emphasized unstructured, open-ended dialogue (e.g., discussion of fantasies and dreams); identifying recurring themes in the patient’s experience; linking the patient’s feelings and perceptions to past experiences; drawing attention to feelings regarded by the patient as unacceptable (e.g., anger, envy, excitement); pointing out defensive maneuvers; interpreting warded-off or unconscious wishes, feelings, or ideas; focusing on the therapy relationship as a topic of discussion; and drawing connections between the therapy relationship and other relationships.

from CBT:

The CBT prototype emphasized dialogue with a more specific focus, with the therapist structuring the interaction and introducing topics; the therapist functioning in a more didactic or teacher-like manner; the therapist offering explicit guidance or advice; discussion of the patient’s treatment goals; explanation of the rationale behind the treatment and techniques; focusing on the patient’s current life situation; focusing on cognitive themes such as thoughts and belief systems; and discussion of tasks or activities (“homework”) for the patient to attempt outside of therapy sessions.

OK that’s two big cans of worms but for me CBT sounds so much like the vast majority of approaches to change in organsations, a mixture of hyper-rationality, lots of fixation with goals and a teacher-pupil vibe. So I’m cheering when Shedler identifies its failings.

(And I may have a further post about the whole business of exploring fantasy for what it is, versus the taken-for-granted future fixation of CBT and related models.)

Fourth, we’re talking here about therapy, where one person tries to change one other person, or help one person change, usually where the changee has volunteered, to some degree or another to participate. It turns out that it’s not a simple process.

You might think, then that changing whole organisations – where there’s rather less voluntary participation – might be regarded as a bigger challenge. Yet it seems to me a lot of business writers and thinkers present it as just a matter of following a few basic steps.

I’m rather conscious of the challenges of evaluating complex things at the moment as I’m looking forward to being at this event in Melbourne in early May: Show me the Change.

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