Talk given to Psychotherapy Department, Cambridge 16 Sept 2010

1. Exoriarealiquisnostris ex ossibusultor !” (Aeneid, IV 625). Let someone arise from my bones as an Avenger." . www.existentialacademy.com 1

2. Digby Tantam 1983 Senior Lecturer in Psychiatry, Honorary Consultant Psychiatrist, University of Manchester 1984, Member, Institute of Group Analysis, London 1990 Professor of Psychotherapy, University of Warwick (Consultant Psychiatrist, University of Warwick, Honorary Consultant Psychotherapist, Coventry) 1993-6 Chair, United Kingdom Council for Psychotherapy 1995 Clinical Professor of Psychotherapy, University of Sheffield (Consultant Psychotherapist and Psychiatrist, Sheffield Health and Social Care NHS Trust) 2007 Honorary Senior Visiting Fellow, Department of Psychiatry, University of Cambridge FRCPsych, AFBPsS, FBACP, MBABCP, FUKCP

3. Eysenck, H. (1952). The effects of psychotherapy: an evaluation. Journal of Consulting & Clinical Psychology. 16: 319-324. A kind of meta-analysis of published data Disabled or admitted to hospital often involuntarily after at least 3 months illness. ‘Severe neurosis’ unspecified. After is at least 2 years No distinction between treatment and maintenance

4. Problem of this particular study has been considered ever since: Use of appropriate controls Standardization of method (‘manualization’) Clarity about parameters e.g. length of follow up Separation of treatment and prevention (or maintenance) But first and foremost is what is the outcome of psychotherapy Early intervention Maintenance What is this? 4 www.existentialacademy.com

5. “(1) if there is no adequate study of psychoanalytic therapy showing a better improvement rate, then there is no firm evidence that the therapy is therapeutically effective. (2) A review of existing studies showed that indeed there did not exist any such adequate study. (3) Consequently, I concluded that there was no evidence of therapeutic success for psychoanalysis (or more general methods of psychotherapy, which I also analysed in a similar manner)” www.existentialacademy.com 5

6. Letter to Garfield Library, University of Pennsylvania The Psychologist, 23 (9), 736 Sept 2010 As far as I personally am concerned the outcome was that I was ostracised by the clinical fraternity, had efforts to establish alternative methods of treatment (behaviour therapy) blocked by psychiatrists, was refused research grants by embattled psychoanalysts on grantgiving bodies, and was generally treated as an outcast and a pariah...Efforts were made to terminate my appointment, and quite generally I was made to feel that one does not oppose the Zeitgeist with impunity, however correct the argument. Exoriarealiquisnostris ex ossibusultor !” “He (Hans Eysenck) developed a superb descriptive model of personality that has scarcely been bettered and contributed numerous ingenious theoretical insights. However, he took his eye off the ball by trying to exceed the fame (and citations!) of Sigmund Freud with comparably grandiose speculations. If only my father had focussed his research more onbehaviouralgenetics rather than wasting his time tilting at an endless succession of windmills!” www.existentialacademy.com 6

7. Shedler, J. (2010). "The efficacy of psychodynamic psychotherapy." American Psychologist 65(2): 98-109. As noted earlier, the goals of psychodynamic psychotherapy include, but extend beyond, alleviation of acute symptoms. Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility. Symptom-oriented outcome measures commonly used in outcome studies (e.g., the Beck Depression Inventory [Beck et al., 1961] or Hamilton Depression Rating Scale [Hamilton, 1960]) do not attempt to assess such inner capacities (Blatt & Auerbach, 2003; Kazdin, 2008). Possibly, the Dodo bird verdict reflects a failure of researchers, psychodynamic and non-psychodynamic alike, to adequately assess the range of phenomena that can change in psychotherapy. 7 www.existentialacademy.com

8. Exoriarealiquisnostris ex ossibusultor !” Aeneid, IV 625). “Let someone arise from my bones as an Avenger." Virgil Aeneid, Iv, 625 Said by Dido (Carthage) of Aeneas (Rome) Who won? Rome, not Carthage Clever though: a quote from Sigmund Freud, The Psychopathology of Everyday Life (1901) www.existentialacademy.com 8

9. www.existentialacademy.com 9 What IS a Caucus-race? said Alice; not that she wanted much to know, but the Dodo had paused as if it thought that SOMEBODY ought to speak, and no one else seemed inclined to say anything. Why, said the Dodo, the best way to explain it is to do it. (And, as you might like to try the thing yourself, some winter day, I will tell you how the Dodo managed it.) First it marked out a race-course, in a sort of circle, (the exact shape doesn't matter, it said,) and then all the party were placed along the course, here and there. There was no One, two, three, and away, but they began running when they liked, and left off when they liked, so that it was not easy to know when the race was over. However, when they had been running half an hour or so, and were quite dry again, the Dodo suddenly called out The race is over! and they all crowded round it, panting, and asking, But who has won? This question the Dodo could not answer without a great deal of thought, and it sat for a long time with one finger pressed upon its forehead (the position in which you usually see Shakespeare, in the pictures of him), while the rest waited in silence. At last the Dodo said, EVERYBODY has won, and all must have prizes. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415. Luborsky, L. and B. Singer (1975). Comparative studies of psychotherapies. Is it true that "everywone has one and all must have prizes"? Archives of General Psychiatry. 32: 995-1008.

10. www.existentialacademy.com 10 Psychotherapy works to remoralize through its placebo effect. Theory is what commends it to clients, not an explanation of its actions

11. 11 Causes or reasons1 BEHAVIOUR Tantam, D. (2002). "Reasons and psychological explanation." International Journal Of Psychotherapy7(2): 165-173. ACTION ACTION Justifications or Reasons 2 www.existentialacademy.com

12. Issue is not main effect, but persistence with treatment What are the factors that determine persistence/compliance? Focus on preoccupying concern Congruence of values Emotional flavour Tantam, D. (2003). "The flavour of emotions.” Psychology and Psychotherapy, 76, 23-45 www.existentialacademy.com 12

13. Preoccupying concern Tantam, D. and Kumar, B. Existential supervision and the NHS. In Existential Perspectives on Supervision in Counselling and Psychotherapy eds. E. van Deurzen and S. Young, 2009, Palgrave Press www.existentialacademy.com 13

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15. There is no clear evidence of advantages in terms of symptom control or likelihood of discontinuation (due to intolerable side effects and/or lack of treatment efficacy) MeReC (Rapid review) National Prescribing Centre Crossley N et al. Efficacy of atypical v. typical antipsychotics in the treatment of early psychosis: meta-analysis. B J Psych 2010;196:434-9 www.existentialacademy.com 15

16. The influence of special interests in selectively targetting drugs. Selective publication www.existentialacademy.com 16

17. www.existentialacademy.com 17 IAPT stands for ‘Increasing Access to Psychological Therapies’. It is a national Department of Health programme aimed to improve and increase access to evidenced based psychological therapies such as CBT. Clinical evidence has shown that better access to therapies such as Cognitive Behavioural Therapy (CBT) can help treat depression and anxiety and reduce both time off work due to ill-health, and the claiming of Incapacity Benefits. Patients also prefer to receive talking therapies rather than medication alone Lord Layard’s review of the economic and emotional costs of mental ill health demonstrated the financial benefits to providing psychological therapies to people suffering from depression and anxiety.

18. Kirsch, I., B. J. Deacon, et al. (2008). "Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration." PLoS Medicine 5(2): e45. www.existentialacademy.com 18

19. www.existentialacademy.com 19 Cuijpers, P., F. Smit, et al. (2010). "Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias." The British Journal of Psychiatry196(3): 173-178

21. Doncaster service 1/6/06 – 6/5/09 Clients = 10792 473 had >1 referral, status unclear 10319 735 Awaiting 1st contact 9584 Discharged - No contacts recorded (Total=2819): Episode completed = 1129 Declined treatment = 548 Not suitable = 385 Dropped out = 752 Deceased = 5 >=1 contact = 6765 897 Still in treatment Discharged 5868

23. Newham service: 23/6/06 – 23/3/09 6 month periods July 2006 to Dec 2008 Referrals 3287 (255>1 referral) 361 429 559 680 838 560 still in treatment Discharged 2727 1570 (57.6%) No intervention session No contact established = 468 (30%) Flexible engagement session only = 165 (10%) Assessed = 60% Intervention 1157 (42.4%)

24. Patient Satisfaction: Research Cohort CSQ-8

25. Speed of access & chronicity The mean (sd) time since the first onset of depression, anxiety or stress was 10.3 (11.3) years for comparator sites and 8.3 (9.9) years for IAPT sites. The mean (sd) duration of current episode, prior to referral, was 1.7 (3.7) years for comparator sites and 1.8 (4.4) years for demonstration sites. For Doncaster and Newham: The time since ‘first onset’ was 8.1 (9.7) years for Doncaster and 9.3 (10.7) years for Newham The duration of most recent episode was 1.3 (3.4) years for Doncaster and 3.1 (6.8) years for Newham.

26. Drugs replace directions for patients as well as doctors www.existentialacademy.com 26

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30. Persistence in therapy is a sine qua non

31. Tantam, D. and Klerman, G. 'Patient transfer from one clinician to another and dropping-out of out-patient treatment'. Social Psychiatry 14, 107-113, 1979.

32. 1/3rd of clients drop-out with each change of clinicianwww.existentialacademy.com 29

33. “a better improvement rate” i.e. outcome measures that capture what makes psychotherapy different esp. longer-term psychotherapy Schedler suggests well-being Other possibilities include social relationships (tried, but did not work), ‘defences’ (too theory driven)… www.existentialacademy.com 30

34. Continuing education in psychotherapy project: Sheffield, Leuven, Bordeaux Universities and Dilemma Consultancy www.existentialacademy.com 31

35. Freedom Not freedom from inner conflicts, but Freedom to take life as it comes Imagination www.existentialacademy.com 32

36. Thank you! Slides at slideshare.net (see link on our website) www.existentialacademy.com 33

37. Hogarty, G. E., S. J. Kornblith, et al. (1997). "Three-year trials of personal therapy among schizophrenic patients living with or independent of family, I: Description of study and effects on relapse rates." American Journal Of Psychiatry154(11): 1504-1513. www.existentialacademy.com 34