speaker-0: It's almost impossible for me to read a published research study now where there isn't something like that. There is some fundamental foundational assumption that's baked into the research that everything, right? All the findings hinge on whether this baked-in assumption is defensible or not. That's usually not defensible.
speaker-1: Welcome to In-Depth Psychoanalysis in the Academy, a podcast from Academics for the Advancement of Psychodynamic Psychology, also known as A2P2. We're a group of scholars, clinicians, and educators working to promote psychodynamic research, training, and clinical practice in a field that's becoming increasingly narrow in both theory and treatment. This podcast is a space for thoughtful conversations with psychoanalytic academics. Who are actively shaping the future of psychotherapy and psychology education? If you're drawn to depth-oriented thinking, critical scholarship, and the enduring relevance of the unconscious, welcome, you're in the right place. Hi, I'm Dr. Bevan Campbell, and thank you for listening to In-Depth. No one can make an incisive critique of the terrain of psychotherapy training and research quite like Jonathan Shedler. As we planned this season of the A2P2 podcast, we knew that in addition to introducing listeners to the breadth of psychoanalytic scholarship and the variety of entry points into academia, we also wanted to paint a realistic picture of the current landscape and to help our listeners understand. What led to the divorce of psychoanalysis and mainstream clinical psychology? With his characteristic straight shooting, Dr. Shedler takes on the institutionalization of the science practice schism, how CBT became the only quote unquote evidence-based treatment, and how the psychoanalytic love of jargon has facilitated its own demise. We also discuss an idea central to the heart of A2P2's mission: that there is a real hunger in both psychology. And psychotherapy students and the public for treatments that address the whole person, not just their symptoms. Let's get into the episode. Jonathan Shedler, PhD, is known internationally as an author, clinical consultant, and master teacher. He is best known for his landmark article, The Efficacy of Psychodynamic Psychotherapy, which won worldwide acclaim for demonstrating that psychoanalytic psychotherapy is an evidence-based treatment. He is the author of over 100 scholarly articles, creator of the Shedler-Weston Assessment Procedure for Personality Diagnosis and Case Formulation, and co-author of the Psychodynamic Diagnostic Manual. Dr. Shedler lectures internationally, leads workshops for professional audiences, and provides expert use consultation to clinicians worldwide. He is clinical professor of psychiatry in the Department of Psychiatry at the University of California, San Francisco. And a training and supervising analyst at the San Francisco Center for Psychoanalysis. So I think you are very well positioned to speak to many of the systemic issues that A2P2 was created in the hopes of addressing. And one of the reasons that's true is because you occupy this somewhat unique position in our field of having to foot both in the world of research and in clinical practice. And one of the issues ⁓ that people may not know who aren't in the field is that generally there's a huge ⁓ split between research and clinical practice. And I wondered if you could just, you know, for people who are not familiar with this, can you ex explain a little bit about how this came to be, like structurally, how did this even happen?
speaker-0: Yeah. ⁓ there's really two very different traditions in psychology. It started in psychology and and then sort of broadened from there. But psychologists historically were trained as researchers. It was an academic research discipline. So the roots of psychology are actually experimental psychology. And my understanding is what really put clinical psychology on the map as a profession in in its own right. was what happened in the in the aftermath of World War Two when we had right at the time clinical treatment was provided by psychiatrists, not psychologists, and certainly not by social workers or, you know, licensed counselors or marriage and family therapists, etc. And what happened was there was an influx of returning servicemen after or after World War II in need of services that far outstripped what psychol psychiatrists could provide. And so they began training psychologists Become clinicians. And in I think in important ways, that was really the birth of psychology as a clinical discipline. But there was a tension between clinical and you know, clinical and practice from the very, very beginning. And in my day and before my day, psychologists who wanted to be the training was in PhD programs, and psychologists who wanted to be clinicians. basically had to participate in this ruse. They would, in order to get admitted, they would have to say, ⁓ yes, I'm I want to be a researcher. I want to be an academic. That's what it took to get admitted. Right. So they'd have to lie their way through the program. They'd have to do all this research, do you know, participate in research, write a research-oriented dissertation, do all this training and research, you know, meanwhile secretly preparing themselves for for a clinical career. So that was that was always true. But but then something changed. And what changed was, and and I think it was well intentioned by the people who promoted it, was the advent of the Psy D degree, P P S Y D, Doctor of Psychology. And the idea was, the well-intentioned idea was Why are we making people jump through these hoops and and and play this you know game of charades, right? This ruse that they're interested in being academic researchers when they're not. We should have a practice-oriented degree. But the idea was that the practice-oriented degree would be within ex within existing departments of psychology, right? So they would be housed within research programs and and you'd be on a different track. But it didn't create the kind of bifurcation in the field that we have now. So you know, it's kind of the law of unintended consequences. What the people who were promoting this ID degree back when didn't realize is what it was going to do was create freestanding training programs, graduate programs, completely divorced from any university, you know, divorced from university life, divorced from the culture and traditions. of academic life, right? So what we unintentionally did was institutionalize the science practice schism. And the result was that PhD programs became just research programs, including the ones that are clinical psychology PhD programs, right? They they turned into ⁓ clinical science programs. And then we have therapy oriented programs that are Absolutely divorced from any connection with you know the history and traditions of psychology as a research discipline. So, you know, basically we took something that was already a problem and made it a much worse problem. Then the range of people who are providing clinical services who are being trained as therapists. started, you know, expanding dramatically. So social work, clinical social work was a you know longstanding time honored tradition with its own disciplines. Then we got licensed professional counselors, then we got licensed marriage family therapists, then we got I I I once did a I once ⁓ did a little investigation into this. the number of different you know kinds of deg designations, you know, letters to put after your name that represent a kind of license in all of the 50 states. And I stopped counting when I got to like 60. ⁓ my gosh. 60 plus different kinds of licenses. To be, yeah. So there's all these different paths to becoming a therapist. And you know, just to speak bluntly about it, it a lot of these programs are de facto for profit programs.
speaker-1: Yeah.
speaker-0: They're cash cows for the institution. There are no meaningful admission standards or graduation standards to speak of. The qualification is that you can pay the tuition. So the field has now been, I would say, inundated with lots and lots of therapists. And the truth of the matter is the word therapist doesn't mean anything anymore. Right. There is no agreed definition of what a therapist is. There's no core common foundation of background and training. We can say anybody who's a therapist, you know, shares this foundational knowledge, you know, not true. And and there's no there's no real definition for what therapy is anymore. And that's the state of the field.
speaker-1: And you're speaking about the problematic influence on the clinical side of things, but I'm also imagining that it's a problem for research, like this disconnection, research being so disconnected from clinical realities.
speaker-0: Well, yeah, I mean, it's an enormous problem for research because ⁓ it's generally a good idea to have some actual real understanding of the subject matter you're studying before you start designing research studies. Right. So what we have are I mean, the term is now clinical scientists who are designing re not just psychology research, like experimental psychology of what psychologists used to study. But they're doing research on psychotherapy and interventions. But most of the people who are doing this work have very, very little actual clinical experience. So what we have is a situation where we were applying ⁓ rigorous, heavy-duty research methods to questions, to research questions and hypotheses that are often just clinically trivial. And and in many cases, you know, like in my opinion, demonstrably clinic ⁓ clinically false, right? Proceeding from proceeding from demonstrably false assumptions. And we could talk about, you know, how that how that plays out. So we've got more and more research going on than ever before, and more and more supposedly clinical research, much of which I think is really irrelevant to practicing clinicians. And then we've got clinicians, more and more and more clinicians, in many cases with, you know, pretty dubious training. And it's not knowing how to do research or knowing how to read race research. The the real issue for me is is knowing how to think critically and evaluate, you know, what are sound ideas and what are unsound ideas and be able to ask and answer questions like, you know, okay, here's a claim. What would it take? to provide evidence that would either support or refute that claim. I mean, before we even look at the evidence, right, is is is this is a claim that we could possibly, you know, like possibly confirm or disconfirm.
speaker-1: think what ⁓ what I was thinking is you were talking is my first job after graduate school is on a research study, which was odd because I actually have a side D, so I don't know how I ended up there, but I was responsible for interviewing people to let them into the RCT or ⁓ or, you know, see if they met the criteria. And it was I I don't think I really realized until that moment how many people will not qualify to be in a randomized controlled trial. You know, if they have ⁓ any so-called comorbid conditions, you know, if there's basically most people that you see in your clinical practice will not be making it into a trial.
speaker-0: I I think on I think on average this there's there's some literature on this. Right. Of course the range differs from study to study, but about two-thirds of the people who you know who get referred into the study don't meet the inclusion criteria. So right, you have to ask and and and but it's it's actually worse than that because the people who are the clinicians who are referring people to the study already understand. the study criteria. So you're already getting a selected sample before the people even, you know, show up for possible inclusion. And then among that selected sample, you're excluding about two-thirds of the people. Like, like who are you studying? Do these people have any, you know, do these people represent the kinds of patients that we treat clinically? And the answer is, you know, generally no. But but it's worse than that. I mean, there's this, there's a like,
speaker-1: Right.
speaker-0: Okay, this this literally just happened in the day before yesterday. I got an email asking me to participate in some research survey. And I'm not going to name names or institutions, but it's a serious, respected research university, right? That that has a reputation. A lot of important psych research has come out of this. And and the starting question, it was trying to figure out, you know, ⁓ I think it was really about ADHD and Whether clinicians are treating it or not treating it, or if you're qualified to treat it. But the starting question into the survey was, would you treat a patient or do you accept for treatment a patient who had a primary diagnosis of depression or anxiety or ADHD? And my first thought was, this question is meaningless to me. I don't even know how to answer it. Like, like, so think about a primary diagnosis. Is that a clinician's term? Is that a psychotherapist term? Does the term actually mean anything in the context of psychotherapy? The answer is no. Like the term primary diagnosis applies to a chart record, right? Or an insurance billing code. It has nothing. I don't know what a primary diagnosis is, right? I I see patients and typically patients meet criteria for several. DSM diagnoses. I don't know which is primary. And anyway, I'm not really that concerned about diagnoses. I'm concerned about the case formulation, what's going on psychologically that gives rise to the difficulties that end then end up with the diagnosis. So, you know, out of the starting gate, the the research was proceeding on the basis of an assumption that was false, which is that there's such a thing as a primary diagnosis in therapy, and that is somehow the determinant. Of who you're going to, you know, who you think would benefit from from therapy and who you would, you know, who you would offer therapy to, right? It it just falls. And and this I I mean, it's almost impossible for me to read a published research study now where there isn't something like that. There is some fundamental foundational assumption that's baked into the research that everything, right? All the findings hinge. on whether this baked in assumption is defensible or not, right? That's usually not defensible.
speaker-1: I mean, it's such a clear example of the problem of, you know, not communicating with clinicians to like to to ask, is this a meaningful construct? Like, is this a meaningful way to think about your the people that you're working with? Yeah. I'm I'm also thinking though about the problems that this creates in terms of communicating with the public, because if researchers and clinicians aren't speaking to each other, who's educating the public about psychological issues?
speaker-0: yeah. And sadly, unfortunately, the the answer is influencers and self promoters and various, I would say, wellness grifters, right? So now we have a bigger problem than the science practi than the science practice schism. That's a big enough problem in its own right. But now, I mean, the field has just been swamped by well well, I don't know. I let me let me rephrase that. I think there's a lot of really well-intentioned, well-meaning, serious people in the therapy professions who want to do good therapy. We don't hear from them, right? The people who make the most noise and take up the most space in public are influencers and self-promoters, and people are getting their information about psychology and psychotherapy from people who don't know anything.
speaker-1: Yeah. So there's a there's a vacuum that's had to be filled with
speaker-0: And it and it got filled. And you know, and and then it's been infused with politics and ideology. So, you know, people have a certain political or ideological worldview. And that supplants psychological understanding. And and and then if somebody comes along, a real clinician says, No, that's not how it is, and that's not how we think about it, right? The response isn't. You know, well, actually I disagree and here's why. The response is you're a bad person for thinking what you'd think. Right. So so psychology got somehow in the crossfires of the culture wars.
speaker-1: And and the way that the algorithm works, I think if someone you know, if someone's exposed to certain content and they're interested in it, they're gonna be fed more. So any misinformation, I mean, obviously this is a problem outside of psychology.
speaker-0: The language of therapy has been you know co-opted and distorted for you know self-promotion purposes, right? I mean, yeah, now everything is trauma. Nobody is ever upset, annoyed, offended, has hurt feelings, they're traumatized, right? Nobody ever deals with a difficult person or a prickly person or someone who's somewhat controlled. They're a narcissist, they're a toxic narcissist, right? So so all of this. fake therapy language has has kind of been co opted and appropriated for marketing and self promotion.
speaker-1: If we move back to academia, I wanted to ask you about ⁓ because obviously, well, I shouldn't say obviously, because if you're not in the field, you might not know this, but the the there is a dominant way of thinking and working in academic psychology, which is CBT. ⁓ and that's not always been the case. But again, this has two components of it. It's the question of how did this come to be, and then also how does this impact training, how does this impact the education of new psychologist, new psychotherapist, and I'm I'm hoping you can speak to both.
speaker-0: Well, it comes around to marketing, but not marketing by influencers and grifters, a different kind of marketing. So CBT appropriated the term evidence-based for its own use. So, you know, de facto when people speak about evidence-based therapy, and and hardly anyone outside the field knows, in fact, a lot of people inside the field don't know this. You think evidence-based means, ⁓ you know, well, there's research, right? It this applies to any psychological treatment or intervention where there's evidence of its efficacy, evidence of its of its benefits. And different therapy approaches are, you know, sort of on a level playing field. You just have to demonstrate benefits in a research program. Well That's not true. What's actually happened? Two things have happened. First of all, evidence-based has become a de facto code word for CBT. And not just CBT, but you know, for very brief manualized forms of CBT. You know, with rare exceptions. The rare exceptions being like ⁓ evidence-based treatments for borderline personality disorder, but for everything else, for the range of things that we typically treat in therapy. Depression, anxiety, trauma, panic disorder. Evidence-based means very brief, like eight to twelve, maybe sixteen at the 16 sessions, you know, at the extreme. Very brief therapies conducted with instruction manuals. And and almost always CBT or therapies related to C Bt. So so that's the first thing. It's become a it's become a code word. the second thing is you think evidence-based means the therapy works when you really dig into the primary sources and you start asking, right? This comes back to critical thinking and asking critical questions. What does work mean? What does it mean when we say this therapy works? Right. ⁓ like online, especially on on Twitter, there was a hashtag, right? Like people are treating it like like PR and the hashtag is CBT works. And you read blogs and you know, just just everywhere, online everywhere, it works. And you see this language, ⁓ scientifically proven, you know, proven benefits, evidence based, right? Science, science, science, but all about proven efficacy. And you say, what does this mean? Works like like You can't just leave it. It works. What works? What's your definition of works? Works for whom? And then you find out that for the first of all, the outcome measure is a tiny, tiny little slice of what people actually want when they go to psychotherapy. And there's research on this, right? There's it's in Lancet for God's sakes, relatively new research, right? The right the most prestigious medical journal I I think in the world. And it was a a a ⁓ meta-analysis of studies about what do people want, what do the people really want when they go to psychotherapy? And it turns out, well, yeah, symptom remission or symptom reduction is on the list, but it's way far down the list. This is this is like it's not even in the top ten of what people are looking for when they go to psychotherapy. So say what does it mean works? Works means we will throw away absolutely everything. that people think about, they think about the benefits they would like from psychotherapy, pretend they don't exist, narrow down on a symptom scale. So if it's a study of generalized anxiety disorder, you know, it's an anxiety scale. If it's a study of major depressive disorders, you know, it's a depression scale, like the Beck Depression Inventory or the PHQ nine. So we're already there's already a mismatch between Outcome as defined by researchers and outcome as clinicians and practic and and patients think about it. Now you say, well, I completely disagree, but for argument's sake, let's grant that outcome means your score on a pH q9 or your score on a back depression inventory. Let's let's just, you know, for purposes of discussion, let's accept that. That is the definition of outcome in psychotherapy. Does it work? Well, what do you mean work? Like a reasonable, you know, I think a reasonable definition of work is when if it's say treatment for depression, when you're done with treatment, you no longer meet diagnostic criteria for major depressive disorder, or for if it's PTSD when you're done. Right, you no longer meet criteria for a diagnosis of BTSD. Well, it turns out it doesn't work. So it it it turns out Instead the most commonly studied ⁓ disorder is is depression. About seventy-five percent of the people who are treated with so-called evidence-based treatment, right? Manualized eight, twelve session, you know, evidence-based therapy, seventy-five percent still have depressive diagnoses when they're over. So what what the hell does work mean? If the treatment is failing, you know, 70 to 75% of the people who get it. And that's not 75% of the population, that's 75% of a sub very, very highly selected cherry-picked subpopulation, like you were talking about. After you weed out all the people with comorbid diagnoses, with personality issues, who have suicidal ideation, after you weed out everybody you treat in the real world, we're still failing. And you go around saying, proven effective. ⁓ Scientifically proven works. You say works for whom?
speaker-1: I mean, it's it's amazing how successful the the PR though has been. I was just listening to a podcast before ⁓ I got on this call with you and Amy Polar was interviewing a celebrity. The celebrity mentioned some symptom they have. Amy Polar Googles it and says, ⁓ it says the treatment is CBT. Right. So, like there's ⁓ which I think is a very common thing. You know, I'm sure you've had patients come to you, clients come to you as I have, and they said, Well, my doctor says I need CBT. And It's it's been a successful campaign despite everything you're saying.
speaker-0: Well yeah. And one of the things that's different between the C B T world and the psychogenamic world is people in the C D B T world are are pretty organized and they take public relations seriously. ⁓ I mean ⁓ I mean they hire won't go into specific instances, but but there are organizations and individuals aligned with C B T who are hiring you know, professional PR firms to help get their message out. I've never once in my lifetime ever heard of a psychoanalytic or psychodynamic group doing that. And You know, it it it's even worse than that. You know, not only do we not think in terms of how we're publicly perceived and you know, public understandings of what psychoanalytic or psychodynamic means. I I think there's a long history in psychoanalysis. We've become our our own worst enemies. You know, w w we like to talk to one another in our own echo chambers and have really been kind of oblivious to how we're perceived and how we're perceived in w what people in psychoanalytic groups would call the outside world and I would call the world.
speaker-1: Yeah. How are there other ways that you think that psychoanalysis as a field has contributed to its kind of own unraveling in
speaker-0: Yeah, absolutely. So, you know, when I said oblivious, that that would be the the more charitable framing. You know, sometimes oblivious, sometimes, you know, actually disdainful of what's going on outside of you know really very close psychoanalytic circles. The other thing that we do, you so so my experience and I've been teaching and lecturing for decades. People find psychoanalytic ideas to be you know very intuitive and very compelling if you explain them in English, right? In language that people can understand with clinical examples that they can relate to. And we have this thing that, you know, this predates me, this goes back generations, but this something in psychoanalytic culture that we you know, it's like we get used to talking to other analytic people within our, you know, our own echo chambers in jargon and theoretical terminology that doesn't mean anything to anyone outside, right, outside those circles. And then analyst wanna ⁓ I say using psycho psychoanalysts broadly, psychoanalytic clinicians, psychodynamic clinicians, they they want to write or speak to the public. And the first thing they do is they trot out their impenetrable jargon in public. And they think they're helping, but what they actually do are they're they're turning people off. And and students, trainees come out of or you know, out of training programs, and a lot of them are actually hungry for psychoanalytic ideas, whether they understand that what they're looking for is psychoanalytic ideas or not. Right. And they find their way to psychoanalytic trainings or pick up a book or a workshop, and they may as well find a not welcome mat. At the door because our jargon is so inaccessible and impenetrable. And and words we just take for granted, right? Just just don't at best they don't mean anything to people outside our circles. At worst, they they have really, really negative connotations. And somehow we don't register that and we go out and use the words, and you know, and I've seen it. I've like, I've like in the relatively infrequent. Times when psychoanalytic ⁓ presenters are speaking to a general audience, you know, everyone's looking at the presenter, but if you want to do an interesting and alarming exercise, turn around and look at the audience when they're speaking, and you can see the eye rolls and the groans. And it's like some something has happened in psychoanalytic circles, right? Like, you know, in our office when we're treating patients, we're so empathically attuned, right? We we all say, we all say to each other, You know, it it's not what the therapist says. It's not the interpretations that we make that matter. It's what the patient hears, right? Every competent psychoanalytic or psychodynamic therapist understands that, but zero of that gets applied to discussing our work in public spaces. There's right, there's a hand I could count on the fingers of one hand, right? The number of people in the field who are, you know, notable exceptions to that.
speaker-1: I mean, something that you've written that I think does an amazing job of that. And I I I think I mentioned to you in a previous conversation. So your paper, ⁓ that was then, this is now, and we'll we'll link it in the show notes. But ⁓ I I assign that in a class I teach ⁓ at a graduate level as an introduction to psychoanalytic theory. And most of the students who enter into the class, because they come from an academic psychology background, are very disinclined towards psychoanalytic ideas. Yeah. But I assign your paper and I use it kind of as a basis. for core psychoanalytic concepts and discussing them and and because of the language. Yeah, that's great. Yeah. And and students will like when you talk about an idea like, yeah, you people want two different things and that creates a lot of tension. And when that happens, we tend to kind of ignore one side of the conflict. When you explain it that way, people are like, ⁓ of course, right? Like that I get that.
speaker-0: Which is exactly what I wrote it for, actually. Look at the hunger for it, right? Right. This this out of nowhere, this this thing called internal family systems. I IFS, you know, sprung up and there's no tradition behind it. It doesn't come from you know generate, it was literally made up, invented by one guy. There's zero research behind it, right? This is like one guy's promotion effort that's you know turned out to be extraordinarily successful. What's the core idea of it? It's like, ⁓ well, you know, the mind isn't unitary. Our our motives and intentions aren't unitary. We have different parts, right? That might be in dis in in the right that that might be in opposition or might have very different intentions. So they've taken this idea, turned it into sort of, I don't know, sorry, I I'm getting called, but it's like a like a like little a puppet show going on in your head. But very, very concrete. The parts have names, they have their own separate little sub-personalities. It's like a it's like a little play going on, you know, in inside your head. And but that's the closest that people get to psychoanaly, you know, the core psychoanalytic idea of the mind in conflict, right? That we're not one self, we're we're we're we're multiple selves, right? This this idea goes back a century and a quarter to Freud.
speaker-1: It's very concrete. Yeah.
speaker-0: Right. And now they've got this this whole, you know, acronym therapy that as far as I can tell, you know, breathes it doesn't breathe a word of, you know, well, you know, actually there's a tradition to these ideas before we we came to them. But people are so hungry for it, right? And they pay tens of thousands of dollars for for training in this. And, you know, meanwhile, psychodynamic practitioners who could actually offer something in you know real depth. with this. We don't respond to what non-analytically trained practitioners and students are you know are looking for. And when we attempt to, we immediately bring in all this jargon baggage that makes it inaccessible. So I think actually if you were to look at the core right not not not the periphery of what makes up psychoanalytic thought, but the the core of what makes up psychoanalytic thought. All of these things are sort of renamed and repackaged and represented in other forms of therapy. And nobody knows that they have anything to do with anything psychodynamic or psychoanalytic.
speaker-1: Right. Well ⁓ and if we go back to this idea of ⁓ you know, the homogeneity in academia of the like the the CBT perspective being the one that's taught exclusively. I I mean I want to think about that with you also from the perspective of how does that influence the therapy that the public gets and what are the limitations. I mean, one thing I always think about is, and maybe this is a failure of my imagination, but conducting therapy without a concept of transference, like how you would even do that or make sense of it. But I'm sure there are other examples of what gets lost when we just have one way of thinking.
speaker-0: Yeah, well, so so I don't think there is the CBT perspective. I think CBT I don't I I'll I'll die on this hill. I don't believe there's a human being alive today who could clearly define what CBT is anymore. Right. It it was one once upon a time there was cognitive therapy, and that was primarily Beck's cognitive therapy, and that had a definition. There was you know behaviorism that came from the it was this was this was the Right. This is the American contribution to psychology. Right. Right. American behaviorism and therapy that followed from that behaviorist tradition. And right, and that was definable. Right. Now CBT has become a an umbrella term for all kinds of different therapies that, as far as I can tell, some of them, you know, really have there's no, there's no shared conceptual basis at all. They just adopt the term CBT. And it's it, I mean, it's really used now in in a lot of quarters as a kind of a a kind of a a loose umbrella term as a substitute for the word therapy. So people want to sound in the no and they don't they don't say, ⁓ you know, you you should have therapy and talk to somebody, you know, talk to somebody who can really understand you as a person. They want to sound in the no and they say you should have therapy. CBT is proven. Right.
speaker-1: Yeah.
speaker-0: Right. Now if you really, really know the literature like I was just talking about a moment ago, no, it's not proven. It fails seventy-five percent of people for the most studied condition. But it but it's got this it's got this like like buzz around it. You know, it's got this ⁓ you know it's got this what's the word I'm looking for? It sounds like something prestigious. Yeah. ⁓ but
speaker-1: Mm. Right. Yeah.
speaker-0: And then within the CBT world, we need to distinguish between what I would call real clinicians who are treating real patients in the real world and this, you know, research study CBT, which is what your health insurance company wants you to get, you know, which is typically eight or twelve sessions of manualized treatment. Those are the treatments that fail people. And and there's a really fundamental ⁓ inconsistency at the beginning at at the very from the very get-go, which is we actually have quite a lot of research, naturalistic research, and how long does psychotherapy really take before you start to see meaningful psychological change. Obviously it differs from individual to individual, but so I'm talking about group averages that on average, like like meaningful change, not the short-term little, you know, bump where you feel a little better because someone's taking an interest in you and you feel like you're doing something, right? That that's right. But but actual an actual shift in something psychological that's causing your problems. Right, that begins around six months into treatment. And research shows and that continues, right? The changes continue for one to two years on average. Now you're talking about all the research behind CBT, most of the research. Is based on like eight session treatments, sometimes shorter than eight session treatments. So you see the therapy is actually already over in the study in the research studies before real psychological change can begin. Right. And then against that backdrop, you have people saying what you just said, ⁓ you know, well, CBT is the treatment for. Right. None of this adds up.
speaker-1: Right. Right. And you know, the other thing I I know that in your research, looking at personality has been something that you've been interested in. And I think that is an important part of this too, because I don't know that the public understands that there are some some types of therapy that are interested in whether or not you meet a certain DSM criteria and the treatment is going to be guided by whether or not you have. you know, you meet this checklist or not, versus is there more of a holistic, nuanced way of looking at who a person is that isn't just yes.
speaker-0: Well yeah. And I think people are incredibly hungry for it. They don't know what it is. They've never encountered it. They don't have a language to talk about it. Right. And then they come up with, you know, what have become now, they didn't start this way, but like they become sort of pop psychology movements. They come up with trauma. ⁓ it has something to do with, you know, what happened growing up with my parents. It's trauma. Right. And then that becomes a blanket term that that subsumes everything that we would talk about. in in psychodynamic therapy, you know, in terms of personality dynamics. Or, you know, or they say, ⁓ you know, it's attachment. Right? Like attachment is a tiny piece, an important piece, but a tiny piece of what we mean when we talk about personality patterns and personality styles, but it's all the public has ever heard about. And it's what all the you know therapy quote unquote influencers on TikTok and Instagram, it's all about your attachment and all about your trauma. They don't they've never been exposed to what I would call real psychotherapy and they don't have a a language, they don't have vocabulary to talk about the concepts that are really important. ⁓ yeah, and and and if someone's difficult, that all collapses down into one word also, then there are narcissists.
speaker-1: Right. Right. And, you know, we're we're talking about ⁓ research and we're talking about the ascendancy of CBT and how that's connected to the randomized control trial. I I did want to ask you if you could sort of speak a little bit about the current state of psychotherapy research, because I think if you looked at it, it would be very easy to conclude that the randomized control trial is the only type of research there is in psychotherapy in the world of psychotherapy and that.
speaker-0: It's a it's a very ⁓ boy, I'm gonna get myself into trouble, but it's a very scientifically naive perspective. And and people who should know better, like like you know, prominent published researchers, you know, with large and IMH grants are talking about some things like there's an idea that there's a hierarchy of evidence, there's different kinds of
speaker-1: Yeah.
speaker-0: There's different sources of information. And at the top of the hierarchy is the randomized control trial. And that's not how science works. So ⁓ There's there's a concept that I think is really crucial that that has disappeared from psychology and psychiatry research that traces back to ⁓ a philosopher of science, ⁓ Hans Reichenbach. And he talked about what he called the context of discovery and the context of justification. And the context of discovery is what are the circumstances necessary? To come up with meaningful hypotheses to study? What are those circumstances necessary to, you know, to actually develop some insight and understanding, to have an idea and say, I, you know, I think it's this. This is the explanation. This is why, right? That's the idea. That's 90% of the scientific enterprise is right, is thinking that you understand something. That's the context of discovery. The very, very, very last thing that happens is, okay, I have this idea, I have a concept, I have a hypothesis. Now what can I do to subject that to an empirical test? So right, and and that's where, and depending on the type of problem, the answer to that may or may not be an RCT. But for argument's sake, let's say it's an RCT. An RCT is. The last and final stage of a scientific process, not the first. And this brings us full circle to what we started about at the beginning about the bifurcation between science and practice, right? And clinical training taking place in PsyD programs and research training taking place in PhD programs. If you take a foolish hypothesis and you study it really, really rigorously in the context of an RCT. Right. The RC team research method doesn't magically transform a foolish hypothesis into an intelligent hypothesis. And that's the situation. We've got people applying, you know, big guns of research methods to questions that ⁓ really lack psychological understanding and insight.
speaker-1: I mean, it's so putting the cart before the horse. I remember my very brief time in the research world. It it almost felt like the starting point was not what is an interesting question for us to address. It was what will get published get published.
speaker-0: Exactly. That's it's true. And and is and just like to make this even more concrete, right? You know, you see CBT is a is treatment for depression. This comes back to critical thinking. What is depression? I mean, it it's a list of criteria in the DSM, you know, okay, but those are descriptions, not explanations. What what is depression? And you know, to me from a a a clinically sensible perspective, depression isn't one thing. Right? Depression is this the psychic equ equivalent of fever. So, you know, what what what medically, what's fever? Fever is a non-specific response to an enormous range of possible underlying conditions, from the common cold to Ebola. Right. So the idea is if there's something going on, something, you know, something biologically wrong, It's very likely to be manifest in fever. You don't treat well you you don't treat the fever. I mean you I mean you you do symptomatically, right? You know, aspirin and try to bring the fever down, but that's not the treatment. When you when you go to the doctor with a fever, the task is what's causing the fever? Right. Is it a cold? We'll send them home, drink some fluids, get some rest. Is it some, you know, is it a bacterial infection? Is it a viral infection? Is this a system? Systemic illness is right what right the task is what is it that's going on that the fever is a marker of right and then once you've sorted out the diagnosis then of course that determines the treatment and the treatments might look not might the treatments do look very very different depending on what's the underlying condition. Now we come into into psychology and psychiatry, we look at the fever. We pretend that the fever is all there is, right? Depression doesn't cause itself. What causes depression? You know, and and then the answers from that are lots and lots of different things, all of which point in a different treatment direction. So that's the clinical reality. And then we have what happens in the parallel universe of research, where the assumption is that depression is a thing. In and of itself, right? And we can measure the benefits of treatments for quote unquote depression. And pret and and then we get all these people with the the participants in the studies, right, are depressed for you know an enormous different range of reasons. We pretend that they all have the same condition, that they'll all benefit from the same treatment. You know, we get a short term basically, you know, placebo boost because the person feels better that, you know. Someone's listening, there's hope, they're taking an interest. I, you know, I think I I believe I'm getting help now that can change things, right? Somebody is listening sympathetically and with understanding. So there's pretty much always a sort of short-term boost in mood. You haven't done a thing to address the underlying conditions that are making the person vulnerable to depression. And then the study ends. And you don't do follow-up. And and then you take a victory lap and you say, Look, it's scientifically proven for depression. But if you study the same people a year out, right, the overwhelming majority of those people are seeking treatment again for the very same problem.
speaker-1: I mean, it reminds me of Deborah Lubnitz's she writes ⁓ in her book Schopenhauer's Porcupine about a patient whose depression gets worse over the course of treat or the symptoms get worse because for the first time in his life he's grieving this terrible loss and he's not defending against it in all these kind of problematic ways. And she says, you know, in writing about this, like if you just were to look at his his depression scores on a checklist, right, you would say the treatment was a failure. But he І я стоп бескарный ворот.
speaker-0: Yeah. And I absolutely completely agree. And I mean I I do a workshop on on personality, personality pathways to depression. Every personality style that we're familiar with, and and that you know, get into the DSM in in their most extreme form and get called disorders, but their personality styles, the depressive personality style, obsessive repulsive personality style, narcissistic personality style, paranoid personality style, etc. Every single personality style is its own pathway to you know what ends up coming out as depression and and needs a different treatment. I mean so we don't treat depression, we treat the underlying personality dynamics that give rise to depression. And I could close to time here, but I mean I could walk through every major personality style, you know, and tell you. why this creates a unique vulnerability to distress that looked at through a DSM lens, right, ends up getting diagnosed as depression.
speaker-1: I do want to try to end this on a hopeful note. And I feel like we could talk about these ideas just for so long, but I I guess what I wanted to ask is because you're you're someone who I see that, you know, in in in spheres like Twitter, like you've really amassed a following. And I'm wondering if you feel like that is a reflection of that hunger you were talking about for ⁓ the the kind of common sense ideas that can that psychoanalysis, that psychoanalytic thought can represent. Like, do you s do you see that?
speaker-0: I do think there I do think there's a hunger and I and I don't think that we collectively as psychodynamic you know psychodynamic practitioners are adequately responding to the hunger. ⁓ I mean, even at the level of saying things like, you know, the unconscious, it it's already un inaccessible. And it creates and it and it has negative connotations for people. Versus if you were to say, you know, because we're human beings, right? This is the human condition, none none of us fully know our own hearts and minds. There's a lot of things that we don't fully know about ourselves. If you say it that way, people are like, yeah, yeah, that makes sense. Like, tell me more about that. If you say the unconscious, there's a way you've already put out a not welcome match.
speaker-1: I feel like there's such a call to action in that for all of us who want to see, you know, more of a future for psychoanalysis and academia. ⁓ but I just want to thank you so much for being here today and for talking about these very complicated issues in a way that, as you said, is important. You know, you really broke it down in a way that I think is is comprehensible and and makes a lot of sense. And yes, I just want to say thank you. It was great.
speaker-0: Thank you. You're very welcome. I hope it's ⁓ I hope it's meaningful to listeners.
speaker-1: Thank you. Thank you for listening to in-depth. Academics for the Advancement of Psychodynamic Psychology is a community-driven organization working to shape the future of psychoanalytic education, from undergraduate study through postdoctoral training. We have ongoing projects devoted to improving mentorship and educational resources, supporting psychoanalytic research, and changing the public discourse around psychoanalytic and psychodynamic training. Join one of our existing projects or suggest one of your own. We're actively looking for volunteers and we especially encourage students to get involved. If this work resonates with you, visit a2p2group.org or reach out to us at a squaredp squared at group.org and take part in shaping what comes next.
speaker-1: Welcome to In-Depth Psychoanalysis in the Academy, a podcast from Academics for the Advancement of Psychodynamic Psychology, also known as A2P2. We're a group of scholars, clinicians, and educators working to promote psychodynamic research, training, and clinical practice in a field that's becoming increasingly narrow in both theory and treatment. This podcast is a space for thoughtful conversations with psychoanalytic academics. Who are actively shaping the future of psychotherapy and psychology education? If you're drawn to depth-oriented thinking, critical scholarship, and the enduring relevance of the unconscious, welcome, you're in the right place. Hi, I'm Dr. Bevan Campbell, and thank you for listening to In-Depth. No one can make an incisive critique of the terrain of psychotherapy training and research quite like Jonathan Shedler. As we planned this season of the A2P2 podcast, we knew that in addition to introducing listeners to the breadth of psychoanalytic scholarship and the variety of entry points into academia, we also wanted to paint a realistic picture of the current landscape and to help our listeners understand. What led to the divorce of psychoanalysis and mainstream clinical psychology? With his characteristic straight shooting, Dr. Shedler takes on the institutionalization of the science practice schism, how CBT became the only quote unquote evidence-based treatment, and how the psychoanalytic love of jargon has facilitated its own demise. We also discuss an idea central to the heart of A2P2's mission: that there is a real hunger in both psychology. And psychotherapy students and the public for treatments that address the whole person, not just their symptoms. Let's get into the episode. Jonathan Shedler, PhD, is known internationally as an author, clinical consultant, and master teacher. He is best known for his landmark article, The Efficacy of Psychodynamic Psychotherapy, which won worldwide acclaim for demonstrating that psychoanalytic psychotherapy is an evidence-based treatment. He is the author of over 100 scholarly articles, creator of the Shedler-Weston Assessment Procedure for Personality Diagnosis and Case Formulation, and co-author of the Psychodynamic Diagnostic Manual. Dr. Shedler lectures internationally, leads workshops for professional audiences, and provides expert use consultation to clinicians worldwide. He is clinical professor of psychiatry in the Department of Psychiatry at the University of California, San Francisco. And a training and supervising analyst at the San Francisco Center for Psychoanalysis. So I think you are very well positioned to speak to many of the systemic issues that A2P2 was created in the hopes of addressing. And one of the reasons that's true is because you occupy this somewhat unique position in our field of having to foot both in the world of research and in clinical practice. And one of the issues ⁓ that people may not know who aren't in the field is that generally there's a huge ⁓ split between research and clinical practice. And I wondered if you could just, you know, for people who are not familiar with this, can you ex explain a little bit about how this came to be, like structurally, how did this even happen?
speaker-0: Yeah. ⁓ there's really two very different traditions in psychology. It started in psychology and and then sort of broadened from there. But psychologists historically were trained as researchers. It was an academic research discipline. So the roots of psychology are actually experimental psychology. And my understanding is what really put clinical psychology on the map as a profession in in its own right. was what happened in the in the aftermath of World War Two when we had right at the time clinical treatment was provided by psychiatrists, not psychologists, and certainly not by social workers or, you know, licensed counselors or marriage and family therapists, etc. And what happened was there was an influx of returning servicemen after or after World War II in need of services that far outstripped what psychol psychiatrists could provide. And so they began training psychologists Become clinicians. And in I think in important ways, that was really the birth of psychology as a clinical discipline. But there was a tension between clinical and you know, clinical and practice from the very, very beginning. And in my day and before my day, psychologists who wanted to be the training was in PhD programs, and psychologists who wanted to be clinicians. basically had to participate in this ruse. They would, in order to get admitted, they would have to say, ⁓ yes, I'm I want to be a researcher. I want to be an academic. That's what it took to get admitted. Right. So they'd have to lie their way through the program. They'd have to do all this research, do you know, participate in research, write a research-oriented dissertation, do all this training and research, you know, meanwhile secretly preparing themselves for for a clinical career. So that was that was always true. But but then something changed. And what changed was, and and I think it was well intentioned by the people who promoted it, was the advent of the Psy D degree, P P S Y D, Doctor of Psychology. And the idea was, the well-intentioned idea was Why are we making people jump through these hoops and and and play this you know game of charades, right? This ruse that they're interested in being academic researchers when they're not. We should have a practice-oriented degree. But the idea was that the practice-oriented degree would be within ex within existing departments of psychology, right? So they would be housed within research programs and and you'd be on a different track. But it didn't create the kind of bifurcation in the field that we have now. So you know, it's kind of the law of unintended consequences. What the people who were promoting this ID degree back when didn't realize is what it was going to do was create freestanding training programs, graduate programs, completely divorced from any university, you know, divorced from university life, divorced from the culture and traditions. of academic life, right? So what we unintentionally did was institutionalize the science practice schism. And the result was that PhD programs became just research programs, including the ones that are clinical psychology PhD programs, right? They they turned into ⁓ clinical science programs. And then we have therapy oriented programs that are Absolutely divorced from any connection with you know the history and traditions of psychology as a research discipline. So, you know, basically we took something that was already a problem and made it a much worse problem. Then the range of people who are providing clinical services who are being trained as therapists. started, you know, expanding dramatically. So social work, clinical social work was a you know longstanding time honored tradition with its own disciplines. Then we got licensed professional counselors, then we got licensed marriage family therapists, then we got I I I once did a I once ⁓ did a little investigation into this. the number of different you know kinds of deg designations, you know, letters to put after your name that represent a kind of license in all of the 50 states. And I stopped counting when I got to like 60. ⁓ my gosh. 60 plus different kinds of licenses. To be, yeah. So there's all these different paths to becoming a therapist. And you know, just to speak bluntly about it, it a lot of these programs are de facto for profit programs.
speaker-1: Yeah.
speaker-0: They're cash cows for the institution. There are no meaningful admission standards or graduation standards to speak of. The qualification is that you can pay the tuition. So the field has now been, I would say, inundated with lots and lots of therapists. And the truth of the matter is the word therapist doesn't mean anything anymore. Right. There is no agreed definition of what a therapist is. There's no core common foundation of background and training. We can say anybody who's a therapist, you know, shares this foundational knowledge, you know, not true. And and there's no there's no real definition for what therapy is anymore. And that's the state of the field.
speaker-1: And you're speaking about the problematic influence on the clinical side of things, but I'm also imagining that it's a problem for research, like this disconnection, research being so disconnected from clinical realities.
speaker-0: Well, yeah, I mean, it's an enormous problem for research because ⁓ it's generally a good idea to have some actual real understanding of the subject matter you're studying before you start designing research studies. Right. So what we have are I mean, the term is now clinical scientists who are designing re not just psychology research, like experimental psychology of what psychologists used to study. But they're doing research on psychotherapy and interventions. But most of the people who are doing this work have very, very little actual clinical experience. So what we have is a situation where we were applying ⁓ rigorous, heavy-duty research methods to questions, to research questions and hypotheses that are often just clinically trivial. And and in many cases, you know, like in my opinion, demonstrably clinic ⁓ clinically false, right? Proceeding from proceeding from demonstrably false assumptions. And we could talk about, you know, how that how that plays out. So we've got more and more research going on than ever before, and more and more supposedly clinical research, much of which I think is really irrelevant to practicing clinicians. And then we've got clinicians, more and more and more clinicians, in many cases with, you know, pretty dubious training. And it's not knowing how to do research or knowing how to read race research. The the real issue for me is is knowing how to think critically and evaluate, you know, what are sound ideas and what are unsound ideas and be able to ask and answer questions like, you know, okay, here's a claim. What would it take? to provide evidence that would either support or refute that claim. I mean, before we even look at the evidence, right, is is is this is a claim that we could possibly, you know, like possibly confirm or disconfirm.
speaker-1: think what ⁓ what I was thinking is you were talking is my first job after graduate school is on a research study, which was odd because I actually have a side D, so I don't know how I ended up there, but I was responsible for interviewing people to let them into the RCT or ⁓ or, you know, see if they met the criteria. And it was I I don't think I really realized until that moment how many people will not qualify to be in a randomized controlled trial. You know, if they have ⁓ any so-called comorbid conditions, you know, if there's basically most people that you see in your clinical practice will not be making it into a trial.
speaker-0: I I think on I think on average this there's there's some literature on this. Right. Of course the range differs from study to study, but about two-thirds of the people who you know who get referred into the study don't meet the inclusion criteria. So right, you have to ask and and and but it's it's actually worse than that because the people who are the clinicians who are referring people to the study already understand. the study criteria. So you're already getting a selected sample before the people even, you know, show up for possible inclusion. And then among that selected sample, you're excluding about two-thirds of the people. Like, like who are you studying? Do these people have any, you know, do these people represent the kinds of patients that we treat clinically? And the answer is, you know, generally no. But but it's worse than that. I mean, there's this, there's a like,
speaker-1: Right.
speaker-0: Okay, this this literally just happened in the day before yesterday. I got an email asking me to participate in some research survey. And I'm not going to name names or institutions, but it's a serious, respected research university, right? That that has a reputation. A lot of important psych research has come out of this. And and the starting question, it was trying to figure out, you know, ⁓ I think it was really about ADHD and Whether clinicians are treating it or not treating it, or if you're qualified to treat it. But the starting question into the survey was, would you treat a patient or do you accept for treatment a patient who had a primary diagnosis of depression or anxiety or ADHD? And my first thought was, this question is meaningless to me. I don't even know how to answer it. Like, like, so think about a primary diagnosis. Is that a clinician's term? Is that a psychotherapist term? Does the term actually mean anything in the context of psychotherapy? The answer is no. Like the term primary diagnosis applies to a chart record, right? Or an insurance billing code. It has nothing. I don't know what a primary diagnosis is, right? I I see patients and typically patients meet criteria for several. DSM diagnoses. I don't know which is primary. And anyway, I'm not really that concerned about diagnoses. I'm concerned about the case formulation, what's going on psychologically that gives rise to the difficulties that end then end up with the diagnosis. So, you know, out of the starting gate, the the research was proceeding on the basis of an assumption that was false, which is that there's such a thing as a primary diagnosis in therapy, and that is somehow the determinant. Of who you're going to, you know, who you think would benefit from from therapy and who you would, you know, who you would offer therapy to, right? It it just falls. And and this I I mean, it's almost impossible for me to read a published research study now where there isn't something like that. There is some fundamental foundational assumption that's baked into the research that everything, right? All the findings hinge. on whether this baked in assumption is defensible or not, right? That's usually not defensible.
speaker-1: I mean, it's such a clear example of the problem of, you know, not communicating with clinicians to like to to ask, is this a meaningful construct? Like, is this a meaningful way to think about your the people that you're working with? Yeah. I'm I'm also thinking though about the problems that this creates in terms of communicating with the public, because if researchers and clinicians aren't speaking to each other, who's educating the public about psychological issues?
speaker-0: yeah. And sadly, unfortunately, the the answer is influencers and self promoters and various, I would say, wellness grifters, right? So now we have a bigger problem than the science practi than the science practice schism. That's a big enough problem in its own right. But now, I mean, the field has just been swamped by well well, I don't know. I let me let me rephrase that. I think there's a lot of really well-intentioned, well-meaning, serious people in the therapy professions who want to do good therapy. We don't hear from them, right? The people who make the most noise and take up the most space in public are influencers and self-promoters, and people are getting their information about psychology and psychotherapy from people who don't know anything.
speaker-1: Yeah. So there's a there's a vacuum that's had to be filled with
speaker-0: And it and it got filled. And you know, and and then it's been infused with politics and ideology. So, you know, people have a certain political or ideological worldview. And that supplants psychological understanding. And and and then if somebody comes along, a real clinician says, No, that's not how it is, and that's not how we think about it, right? The response isn't. You know, well, actually I disagree and here's why. The response is you're a bad person for thinking what you'd think. Right. So so psychology got somehow in the crossfires of the culture wars.
speaker-1: And and the way that the algorithm works, I think if someone you know, if someone's exposed to certain content and they're interested in it, they're gonna be fed more. So any misinformation, I mean, obviously this is a problem outside of psychology.
speaker-0: The language of therapy has been you know co-opted and distorted for you know self-promotion purposes, right? I mean, yeah, now everything is trauma. Nobody is ever upset, annoyed, offended, has hurt feelings, they're traumatized, right? Nobody ever deals with a difficult person or a prickly person or someone who's somewhat controlled. They're a narcissist, they're a toxic narcissist, right? So so all of this. fake therapy language has has kind of been co opted and appropriated for marketing and self promotion.
speaker-1: If we move back to academia, I wanted to ask you about ⁓ because obviously, well, I shouldn't say obviously, because if you're not in the field, you might not know this, but the the there is a dominant way of thinking and working in academic psychology, which is CBT. ⁓ and that's not always been the case. But again, this has two components of it. It's the question of how did this come to be, and then also how does this impact training, how does this impact the education of new psychologist, new psychotherapist, and I'm I'm hoping you can speak to both.
speaker-0: Well, it comes around to marketing, but not marketing by influencers and grifters, a different kind of marketing. So CBT appropriated the term evidence-based for its own use. So, you know, de facto when people speak about evidence-based therapy, and and hardly anyone outside the field knows, in fact, a lot of people inside the field don't know this. You think evidence-based means, ⁓ you know, well, there's research, right? It this applies to any psychological treatment or intervention where there's evidence of its efficacy, evidence of its of its benefits. And different therapy approaches are, you know, sort of on a level playing field. You just have to demonstrate benefits in a research program. Well That's not true. What's actually happened? Two things have happened. First of all, evidence-based has become a de facto code word for CBT. And not just CBT, but you know, for very brief manualized forms of CBT. You know, with rare exceptions. The rare exceptions being like ⁓ evidence-based treatments for borderline personality disorder, but for everything else, for the range of things that we typically treat in therapy. Depression, anxiety, trauma, panic disorder. Evidence-based means very brief, like eight to twelve, maybe sixteen at the 16 sessions, you know, at the extreme. Very brief therapies conducted with instruction manuals. And and almost always CBT or therapies related to C Bt. So so that's the first thing. It's become a it's become a code word. the second thing is you think evidence-based means the therapy works when you really dig into the primary sources and you start asking, right? This comes back to critical thinking and asking critical questions. What does work mean? What does it mean when we say this therapy works? Right. ⁓ like online, especially on on Twitter, there was a hashtag, right? Like people are treating it like like PR and the hashtag is CBT works. And you read blogs and you know, just just everywhere, online everywhere, it works. And you see this language, ⁓ scientifically proven, you know, proven benefits, evidence based, right? Science, science, science, but all about proven efficacy. And you say, what does this mean? Works like like You can't just leave it. It works. What works? What's your definition of works? Works for whom? And then you find out that for the first of all, the outcome measure is a tiny, tiny little slice of what people actually want when they go to psychotherapy. And there's research on this, right? There's it's in Lancet for God's sakes, relatively new research, right? The right the most prestigious medical journal I I think in the world. And it was a a a ⁓ meta-analysis of studies about what do people want, what do the people really want when they go to psychotherapy? And it turns out, well, yeah, symptom remission or symptom reduction is on the list, but it's way far down the list. This is this is like it's not even in the top ten of what people are looking for when they go to psychotherapy. So say what does it mean works? Works means we will throw away absolutely everything. that people think about, they think about the benefits they would like from psychotherapy, pretend they don't exist, narrow down on a symptom scale. So if it's a study of generalized anxiety disorder, you know, it's an anxiety scale. If it's a study of major depressive disorders, you know, it's a depression scale, like the Beck Depression Inventory or the PHQ nine. So we're already there's already a mismatch between Outcome as defined by researchers and outcome as clinicians and practic and and patients think about it. Now you say, well, I completely disagree, but for argument's sake, let's grant that outcome means your score on a pH q9 or your score on a back depression inventory. Let's let's just, you know, for purposes of discussion, let's accept that. That is the definition of outcome in psychotherapy. Does it work? Well, what do you mean work? Like a reasonable, you know, I think a reasonable definition of work is when if it's say treatment for depression, when you're done with treatment, you no longer meet diagnostic criteria for major depressive disorder, or for if it's PTSD when you're done. Right, you no longer meet criteria for a diagnosis of BTSD. Well, it turns out it doesn't work. So it it it turns out Instead the most commonly studied ⁓ disorder is is depression. About seventy-five percent of the people who are treated with so-called evidence-based treatment, right? Manualized eight, twelve session, you know, evidence-based therapy, seventy-five percent still have depressive diagnoses when they're over. So what what the hell does work mean? If the treatment is failing, you know, 70 to 75% of the people who get it. And that's not 75% of the population, that's 75% of a sub very, very highly selected cherry-picked subpopulation, like you were talking about. After you weed out all the people with comorbid diagnoses, with personality issues, who have suicidal ideation, after you weed out everybody you treat in the real world, we're still failing. And you go around saying, proven effective. ⁓ Scientifically proven works. You say works for whom?
speaker-1: I mean, it's it's amazing how successful the the PR though has been. I was just listening to a podcast before ⁓ I got on this call with you and Amy Polar was interviewing a celebrity. The celebrity mentioned some symptom they have. Amy Polar Googles it and says, ⁓ it says the treatment is CBT. Right. So, like there's ⁓ which I think is a very common thing. You know, I'm sure you've had patients come to you, clients come to you as I have, and they said, Well, my doctor says I need CBT. And It's it's been a successful campaign despite everything you're saying.
speaker-0: Well yeah. And one of the things that's different between the C B T world and the psychogenamic world is people in the C D B T world are are pretty organized and they take public relations seriously. ⁓ I mean ⁓ I mean they hire won't go into specific instances, but but there are organizations and individuals aligned with C B T who are hiring you know, professional PR firms to help get their message out. I've never once in my lifetime ever heard of a psychoanalytic or psychodynamic group doing that. And You know, it it it's even worse than that. You know, not only do we not think in terms of how we're publicly perceived and you know, public understandings of what psychoanalytic or psychodynamic means. I I think there's a long history in psychoanalysis. We've become our our own worst enemies. You know, w w we like to talk to one another in our own echo chambers and have really been kind of oblivious to how we're perceived and how we're perceived in w what people in psychoanalytic groups would call the outside world and I would call the world.
speaker-1: Yeah. How are there other ways that you think that psychoanalysis as a field has contributed to its kind of own unraveling in
speaker-0: Yeah, absolutely. So, you know, when I said oblivious, that that would be the the more charitable framing. You know, sometimes oblivious, sometimes, you know, actually disdainful of what's going on outside of you know really very close psychoanalytic circles. The other thing that we do, you so so my experience and I've been teaching and lecturing for decades. People find psychoanalytic ideas to be you know very intuitive and very compelling if you explain them in English, right? In language that people can understand with clinical examples that they can relate to. And we have this thing that, you know, this predates me, this goes back generations, but this something in psychoanalytic culture that we you know, it's like we get used to talking to other analytic people within our, you know, our own echo chambers in jargon and theoretical terminology that doesn't mean anything to anyone outside, right, outside those circles. And then analyst wanna ⁓ I say using psycho psychoanalysts broadly, psychoanalytic clinicians, psychodynamic clinicians, they they want to write or speak to the public. And the first thing they do is they trot out their impenetrable jargon in public. And they think they're helping, but what they actually do are they're they're turning people off. And and students, trainees come out of or you know, out of training programs, and a lot of them are actually hungry for psychoanalytic ideas, whether they understand that what they're looking for is psychoanalytic ideas or not. Right. And they find their way to psychoanalytic trainings or pick up a book or a workshop, and they may as well find a not welcome mat. At the door because our jargon is so inaccessible and impenetrable. And and words we just take for granted, right? Just just don't at best they don't mean anything to people outside our circles. At worst, they they have really, really negative connotations. And somehow we don't register that and we go out and use the words, and you know, and I've seen it. I've like, I've like in the relatively infrequent. Times when psychoanalytic ⁓ presenters are speaking to a general audience, you know, everyone's looking at the presenter, but if you want to do an interesting and alarming exercise, turn around and look at the audience when they're speaking, and you can see the eye rolls and the groans. And it's like some something has happened in psychoanalytic circles, right? Like, you know, in our office when we're treating patients, we're so empathically attuned, right? We we all say, we all say to each other, You know, it it's not what the therapist says. It's not the interpretations that we make that matter. It's what the patient hears, right? Every competent psychoanalytic or psychodynamic therapist understands that, but zero of that gets applied to discussing our work in public spaces. There's right, there's a hand I could count on the fingers of one hand, right? The number of people in the field who are, you know, notable exceptions to that.
speaker-1: I mean, something that you've written that I think does an amazing job of that. And I I I think I mentioned to you in a previous conversation. So your paper, ⁓ that was then, this is now, and we'll we'll link it in the show notes. But ⁓ I I assign that in a class I teach ⁓ at a graduate level as an introduction to psychoanalytic theory. And most of the students who enter into the class, because they come from an academic psychology background, are very disinclined towards psychoanalytic ideas. Yeah. But I assign your paper and I use it kind of as a basis. for core psychoanalytic concepts and discussing them and and because of the language. Yeah, that's great. Yeah. And and students will like when you talk about an idea like, yeah, you people want two different things and that creates a lot of tension. And when that happens, we tend to kind of ignore one side of the conflict. When you explain it that way, people are like, ⁓ of course, right? Like that I get that.
speaker-0: Which is exactly what I wrote it for, actually. Look at the hunger for it, right? Right. This this out of nowhere, this this thing called internal family systems. I IFS, you know, sprung up and there's no tradition behind it. It doesn't come from you know generate, it was literally made up, invented by one guy. There's zero research behind it, right? This is like one guy's promotion effort that's you know turned out to be extraordinarily successful. What's the core idea of it? It's like, ⁓ well, you know, the mind isn't unitary. Our our motives and intentions aren't unitary. We have different parts, right? That might be in dis in in the right that that might be in opposition or might have very different intentions. So they've taken this idea, turned it into sort of, I don't know, sorry, I I'm getting called, but it's like a like a like little a puppet show going on in your head. But very, very concrete. The parts have names, they have their own separate little sub-personalities. It's like a it's like a little play going on, you know, in inside your head. And but that's the closest that people get to psychoanaly, you know, the core psychoanalytic idea of the mind in conflict, right? That we're not one self, we're we're we're we're multiple selves, right? This this idea goes back a century and a quarter to Freud.
speaker-1: It's very concrete. Yeah.
speaker-0: Right. And now they've got this this whole, you know, acronym therapy that as far as I can tell, you know, breathes it doesn't breathe a word of, you know, well, you know, actually there's a tradition to these ideas before we we came to them. But people are so hungry for it, right? And they pay tens of thousands of dollars for for training in this. And, you know, meanwhile, psychodynamic practitioners who could actually offer something in you know real depth. with this. We don't respond to what non-analytically trained practitioners and students are you know are looking for. And when we attempt to, we immediately bring in all this jargon baggage that makes it inaccessible. So I think actually if you were to look at the core right not not not the periphery of what makes up psychoanalytic thought, but the the core of what makes up psychoanalytic thought. All of these things are sort of renamed and repackaged and represented in other forms of therapy. And nobody knows that they have anything to do with anything psychodynamic or psychoanalytic.
speaker-1: Right. Well ⁓ and if we go back to this idea of ⁓ you know, the homogeneity in academia of the like the the CBT perspective being the one that's taught exclusively. I I mean I want to think about that with you also from the perspective of how does that influence the therapy that the public gets and what are the limitations. I mean, one thing I always think about is, and maybe this is a failure of my imagination, but conducting therapy without a concept of transference, like how you would even do that or make sense of it. But I'm sure there are other examples of what gets lost when we just have one way of thinking.
speaker-0: Yeah, well, so so I don't think there is the CBT perspective. I think CBT I don't I I'll I'll die on this hill. I don't believe there's a human being alive today who could clearly define what CBT is anymore. Right. It it was one once upon a time there was cognitive therapy, and that was primarily Beck's cognitive therapy, and that had a definition. There was you know behaviorism that came from the it was this was this was the Right. This is the American contribution to psychology. Right. Right. American behaviorism and therapy that followed from that behaviorist tradition. And right, and that was definable. Right. Now CBT has become a an umbrella term for all kinds of different therapies that, as far as I can tell, some of them, you know, really have there's no, there's no shared conceptual basis at all. They just adopt the term CBT. And it's it, I mean, it's really used now in in a lot of quarters as a kind of a a kind of a a loose umbrella term as a substitute for the word therapy. So people want to sound in the no and they don't they don't say, ⁓ you know, you you should have therapy and talk to somebody, you know, talk to somebody who can really understand you as a person. They want to sound in the no and they say you should have therapy. CBT is proven. Right.
speaker-1: Yeah.
speaker-0: Right. Now if you really, really know the literature like I was just talking about a moment ago, no, it's not proven. It fails seventy-five percent of people for the most studied condition. But it but it's got this it's got this like like buzz around it. You know, it's got this ⁓ you know it's got this what's the word I'm looking for? It sounds like something prestigious. Yeah. ⁓ but
speaker-1: Mm. Right. Yeah.
speaker-0: And then within the CBT world, we need to distinguish between what I would call real clinicians who are treating real patients in the real world and this, you know, research study CBT, which is what your health insurance company wants you to get, you know, which is typically eight or twelve sessions of manualized treatment. Those are the treatments that fail people. And and there's a really fundamental ⁓ inconsistency at the beginning at at the very from the very get-go, which is we actually have quite a lot of research, naturalistic research, and how long does psychotherapy really take before you start to see meaningful psychological change. Obviously it differs from individual to individual, but so I'm talking about group averages that on average, like like meaningful change, not the short-term little, you know, bump where you feel a little better because someone's taking an interest in you and you feel like you're doing something, right? That that's right. But but actual an actual shift in something psychological that's causing your problems. Right, that begins around six months into treatment. And research shows and that continues, right? The changes continue for one to two years on average. Now you're talking about all the research behind CBT, most of the research. Is based on like eight session treatments, sometimes shorter than eight session treatments. So you see the therapy is actually already over in the study in the research studies before real psychological change can begin. Right. And then against that backdrop, you have people saying what you just said, ⁓ you know, well, CBT is the treatment for. Right. None of this adds up.
speaker-1: Right. Right. And you know, the other thing I I know that in your research, looking at personality has been something that you've been interested in. And I think that is an important part of this too, because I don't know that the public understands that there are some some types of therapy that are interested in whether or not you meet a certain DSM criteria and the treatment is going to be guided by whether or not you have. you know, you meet this checklist or not, versus is there more of a holistic, nuanced way of looking at who a person is that isn't just yes.
speaker-0: Well yeah. And I think people are incredibly hungry for it. They don't know what it is. They've never encountered it. They don't have a language to talk about it. Right. And then they come up with, you know, what have become now, they didn't start this way, but like they become sort of pop psychology movements. They come up with trauma. ⁓ it has something to do with, you know, what happened growing up with my parents. It's trauma. Right. And then that becomes a blanket term that that subsumes everything that we would talk about. in in psychodynamic therapy, you know, in terms of personality dynamics. Or, you know, or they say, ⁓ you know, it's attachment. Right? Like attachment is a tiny piece, an important piece, but a tiny piece of what we mean when we talk about personality patterns and personality styles, but it's all the public has ever heard about. And it's what all the you know therapy quote unquote influencers on TikTok and Instagram, it's all about your attachment and all about your trauma. They don't they've never been exposed to what I would call real psychotherapy and they don't have a a language, they don't have vocabulary to talk about the concepts that are really important. ⁓ yeah, and and and if someone's difficult, that all collapses down into one word also, then there are narcissists.
speaker-1: Right. Right. And, you know, we're we're talking about ⁓ research and we're talking about the ascendancy of CBT and how that's connected to the randomized control trial. I I did want to ask you if you could sort of speak a little bit about the current state of psychotherapy research, because I think if you looked at it, it would be very easy to conclude that the randomized control trial is the only type of research there is in psychotherapy in the world of psychotherapy and that.
speaker-0: It's a it's a very ⁓ boy, I'm gonna get myself into trouble, but it's a very scientifically naive perspective. And and people who should know better, like like you know, prominent published researchers, you know, with large and IMH grants are talking about some things like there's an idea that there's a hierarchy of evidence, there's different kinds of
speaker-1: Yeah.
speaker-0: There's different sources of information. And at the top of the hierarchy is the randomized control trial. And that's not how science works. So ⁓ There's there's a concept that I think is really crucial that that has disappeared from psychology and psychiatry research that traces back to ⁓ a philosopher of science, ⁓ Hans Reichenbach. And he talked about what he called the context of discovery and the context of justification. And the context of discovery is what are the circumstances necessary? To come up with meaningful hypotheses to study? What are those circumstances necessary to, you know, to actually develop some insight and understanding, to have an idea and say, I, you know, I think it's this. This is the explanation. This is why, right? That's the idea. That's 90% of the scientific enterprise is right, is thinking that you understand something. That's the context of discovery. The very, very, very last thing that happens is, okay, I have this idea, I have a concept, I have a hypothesis. Now what can I do to subject that to an empirical test? So right, and and that's where, and depending on the type of problem, the answer to that may or may not be an RCT. But for argument's sake, let's say it's an RCT. An RCT is. The last and final stage of a scientific process, not the first. And this brings us full circle to what we started about at the beginning about the bifurcation between science and practice, right? And clinical training taking place in PsyD programs and research training taking place in PhD programs. If you take a foolish hypothesis and you study it really, really rigorously in the context of an RCT. Right. The RC team research method doesn't magically transform a foolish hypothesis into an intelligent hypothesis. And that's the situation. We've got people applying, you know, big guns of research methods to questions that ⁓ really lack psychological understanding and insight.
speaker-1: I mean, it's so putting the cart before the horse. I remember my very brief time in the research world. It it almost felt like the starting point was not what is an interesting question for us to address. It was what will get published get published.
speaker-0: Exactly. That's it's true. And and is and just like to make this even more concrete, right? You know, you see CBT is a is treatment for depression. This comes back to critical thinking. What is depression? I mean, it it's a list of criteria in the DSM, you know, okay, but those are descriptions, not explanations. What what is depression? And you know, to me from a a a clinically sensible perspective, depression isn't one thing. Right? Depression is this the psychic equ equivalent of fever. So, you know, what what what medically, what's fever? Fever is a non-specific response to an enormous range of possible underlying conditions, from the common cold to Ebola. Right. So the idea is if there's something going on, something, you know, something biologically wrong, It's very likely to be manifest in fever. You don't treat well you you don't treat the fever. I mean you I mean you you do symptomatically, right? You know, aspirin and try to bring the fever down, but that's not the treatment. When you when you go to the doctor with a fever, the task is what's causing the fever? Right. Is it a cold? We'll send them home, drink some fluids, get some rest. Is it some, you know, is it a bacterial infection? Is it a viral infection? Is this a system? Systemic illness is right what right the task is what is it that's going on that the fever is a marker of right and then once you've sorted out the diagnosis then of course that determines the treatment and the treatments might look not might the treatments do look very very different depending on what's the underlying condition. Now we come into into psychology and psychiatry, we look at the fever. We pretend that the fever is all there is, right? Depression doesn't cause itself. What causes depression? You know, and and then the answers from that are lots and lots of different things, all of which point in a different treatment direction. So that's the clinical reality. And then we have what happens in the parallel universe of research, where the assumption is that depression is a thing. In and of itself, right? And we can measure the benefits of treatments for quote unquote depression. And pret and and then we get all these people with the the participants in the studies, right, are depressed for you know an enormous different range of reasons. We pretend that they all have the same condition, that they'll all benefit from the same treatment. You know, we get a short term basically, you know, placebo boost because the person feels better that, you know. Someone's listening, there's hope, they're taking an interest. I, you know, I think I I believe I'm getting help now that can change things, right? Somebody is listening sympathetically and with understanding. So there's pretty much always a sort of short-term boost in mood. You haven't done a thing to address the underlying conditions that are making the person vulnerable to depression. And then the study ends. And you don't do follow-up. And and then you take a victory lap and you say, Look, it's scientifically proven for depression. But if you study the same people a year out, right, the overwhelming majority of those people are seeking treatment again for the very same problem.
speaker-1: I mean, it reminds me of Deborah Lubnitz's she writes ⁓ in her book Schopenhauer's Porcupine about a patient whose depression gets worse over the course of treat or the symptoms get worse because for the first time in his life he's grieving this terrible loss and he's not defending against it in all these kind of problematic ways. And she says, you know, in writing about this, like if you just were to look at his his depression scores on a checklist, right, you would say the treatment was a failure. But he І я стоп бескарный ворот.
speaker-0: Yeah. And I absolutely completely agree. And I mean I I do a workshop on on personality, personality pathways to depression. Every personality style that we're familiar with, and and that you know, get into the DSM in in their most extreme form and get called disorders, but their personality styles, the depressive personality style, obsessive repulsive personality style, narcissistic personality style, paranoid personality style, etc. Every single personality style is its own pathway to you know what ends up coming out as depression and and needs a different treatment. I mean so we don't treat depression, we treat the underlying personality dynamics that give rise to depression. And I could close to time here, but I mean I could walk through every major personality style, you know, and tell you. why this creates a unique vulnerability to distress that looked at through a DSM lens, right, ends up getting diagnosed as depression.
speaker-1: I do want to try to end this on a hopeful note. And I feel like we could talk about these ideas just for so long, but I I guess what I wanted to ask is because you're you're someone who I see that, you know, in in in spheres like Twitter, like you've really amassed a following. And I'm wondering if you feel like that is a reflection of that hunger you were talking about for ⁓ the the kind of common sense ideas that can that psychoanalysis, that psychoanalytic thought can represent. Like, do you s do you see that?
speaker-0: I do think there I do think there's a hunger and I and I don't think that we collectively as psychodynamic you know psychodynamic practitioners are adequately responding to the hunger. ⁓ I mean, even at the level of saying things like, you know, the unconscious, it it's already un inaccessible. And it creates and it and it has negative connotations for people. Versus if you were to say, you know, because we're human beings, right? This is the human condition, none none of us fully know our own hearts and minds. There's a lot of things that we don't fully know about ourselves. If you say it that way, people are like, yeah, yeah, that makes sense. Like, tell me more about that. If you say the unconscious, there's a way you've already put out a not welcome match.
speaker-1: I feel like there's such a call to action in that for all of us who want to see, you know, more of a future for psychoanalysis and academia. ⁓ but I just want to thank you so much for being here today and for talking about these very complicated issues in a way that, as you said, is important. You know, you really broke it down in a way that I think is is comprehensible and and makes a lot of sense. And yes, I just want to say thank you. It was great.
speaker-0: Thank you. You're very welcome. I hope it's ⁓ I hope it's meaningful to listeners.
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