In 2021 the UK government increased mental health funding by £500 million as part of their Mental Health Recovery Action Plan. They are expanding IAPT (Improved Access to Psychological Therapies), having pledged 38 million to the services to address an increased demand for psychological support (Department of Health and Social Care, 2021).
Historically much of IAPT’s funding has gone towards cognitive behavioural therapy (CBT) - it’s available in 95.6% of the mental health centres. Brief psychodynamic therapy, on the other hand, is only available at 13.2% of locations. There is a dramatic gap with respect to the ease with which people can access one type of therapy or another (Perfect et al., 2016). But does this discrepancy actually matter with respect to long-term efforts to tackle mental health problems? To know this we would have to consider if psychodynamic therapy has anything to offer that CBT cannot.
Let’s start with the basics. What is psychological therapy (psychotherapy for short)? Psychotherapy is a conversation between a therapist and a client with the aim to alleviate client distress and improve client wellbeing through the use of the therapeutic relationship and certain interventions.
CBT and psychodynamic therapy are two types of psychotherapy grounded in different theoretical schools, also known as therapeutic modalities. They have different views on what is essential and necessary for the client to improve.
Psychodynamic therapies generally agree on three core assumptions: 1) there are intrapsychic processes beyond a person’s awareness - such as feelings, thoughts, desires, and fears - or the so-called “subconscious”; 2) attachment and early life experiences are formative and crucial to explore as their present day impact is vast; 3) the therapeutic relationship can mirror real-life relationships and thus can be used to model new ways of being (Eppel, 2018).
In practice what this means is that psychodynamic therapy often involves exploring the past and how it relates to the present, internal conflicts and emotions, noticing patterns in the person’s responses, and working on interpersonal relationships including the one in the therapeutic room (Shedler, 2010). The underlying assumption is that once the client has awareness of their intrapsychic processes through exploring their feelings, attachments, formative experiences, and fantasy life, their influences will become apparent (Shedler, 2010). This newfound insight will make it easier for the client to make better decisions and distress will be alleviated as emotions and trauma have been processed. The underlying assumption here is that fostering a client’s insight and understanding of themselves will lead to better mental health.
Other therapies, like cognitive behavioural therapy, focus on what the client is struggling with in the present moment. CBT looks at what is maintaining a problem and tries to untangle it through its use of cognitive and behavioural interventions (Tolin, 2016). The reasoning behind this is that regardless of how a problem began it is often maintained by factors that are separate from its origins, often related to behavioural response patterns (Tolin, 2016).
To give an example, someone who is suffering from depression, might have begun to be depressed as a result of neglectful parenting. However, the independent factors that are maintaining their depressed state are most likely an internalised belief that they’re worthless and a range of accompanying response patterns, such as social and behavioural withdrawal that are depressing in and of themselves - nowadays they might even get along with their parents. The proposed therapeutic mechanism is that external change can lead to internal change (e.g. changing your behaviour or your environment can lead to you thinking and feeling differently about
yourself, others, and the world).
It might be tempting to try and skip the past and focus on addressing the present issue - perhaps it’s more relevant and it might be more cost-effective as well - fewer sessions are needed if we don’t examine the origins of an issue. Whilst experience is powerful in correcting faulty and biased beliefs, perceiving without a bias can be difficult (otherwise people wouldn’t need therapy!). We often use emotional reasoning and think something is true based on how we feel about it (Paredes-Mealla et al., 2022) - I feel like a failure, therefore I am; I feel like people don’t like me, therefore they don’t.
Much of the information we are presented with is perceived through the prism of our core beliefs - beliefs that often stem from past formative experiences. If we are unaware of those beliefs and how they affect us, it can be difficult to challenge our perception even in the face of contradicting information. It’s like looking at a new picture through the same one-coloured lenses - we need to change the lenses first before we can truly see the difference in the picture. Therefore, it is important that people have had the chance to process and understand some of their formative experiences and their present-day effects in order to better separate fact from subjective perception. That would be just one of the ways in which not exploring previous attachments and experiences could potentially hinder therapeutic progress or, if therapy is initially successful, can lead to relapse.
Now, based on the national health service's (NHS) spending one would assume that CBT much outperforms psychodynamic therapy with respect to client outcomes. I myself have a soft spot for CBT as a practitioner, but I think it’s important to look at the available evidence, when deciding what therapies to offer to the public - especially ones that are tax-funded.
Two of the most robust and well-known therapeutic mechanisms are the therapeutic relationship and improving the client’s awareness and insight (Eubanks & Goldfried, 2019), which arguably psychodynamic therapy focuses a lot more on. Corrective experiences are also on that list, but it is generally understood that corrective experiences and insight are equally important in the therapeutic process. Furthermore,
psychodynamic therapy seems to be as effective as CBT (Shedler 2010) when comparing client outcomes in treating patients struggling with depression (Leichsenring, 2001), personality disorders (Leichsenring & Leibing, 2003), social anxiety (Bögels et al., 2014), and in alleviating target symptoms (Steinert et al., 2017)
Why is it important to have access to more than one type of therapy? Currently no therapy is 100% effective - that will depend on the target population, presenting problems, specific circumstances of the client and their preferences. A recent review of CBT found that it only had a mean response rate of 49.5%, which is comparable to its response rate for depression (Loerinc et al., 2015). Thus, even the best therapies cannot help every single person, and a wider range of therapeutic modalities might offer an advantage and fill in the gaps.
The most important point is that by offering a therapy service where clients can utilise a wider range of evidence-based therapeutic mechanisms - instead of a limited number - we can increase the likelihood of patients responding to therapy and going into remission. To make this cost-effective for the NHS, it could be offered as an integrative therapeutic modality - for example where psychodynamic therapy incorporates corrective experiences within the sessions, or CBT offers some attachment work. We may very well be missing out on an improved service by not being offered these options. Nonetheless, it’s important to acknowledge that the government’s increased funding will contribute to expanded services and better mental health outcomes.
References:
Bögels, S. M., Wijts, P., Oort, F. J., & Sallaerts, S. J. (2014). Psychodynamic psychotherapy versus cognitive behavior therapy for Social Anxiety Disorder: An efficacy and partial effectiveness trial. Depression and Anxiety, 31(5), 363–373. https://doi.org/10.1002/da.22246
Department of Health and Social Care (2021) Mental health recovery plan backed by £500 million. Available at: https://www.gov.uk/government/news/mental-health-recovery-plan-backed-by-500-million.
Eppel, A. (2018). Short-term psychodynamic psychotherapy. Springer International Publishing.
Eubanks, C. F., & Goldfried, M. R. (2019). A principle-based approach to psychotherapy integration. Handbook of Psychotherapy Integration, 88–104. https://doi.org/10.1093/med-psych/9780190690465.003.0004
Leichsenring, F. (2001). Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in Depression. Clinical Psychology Review, 21(3), 401–419. https://doi.org/10.1016/s0272-7358(99)00057-4
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry, 160(7), 1223–1232. https://doi.org/10.1176/appi.ajp.160.7.1223
Loerinc, A. G., Meuret, A. E., Twohig, M. P., Rosenfield, D., Bluett, E. J., & Craske, M. G. (2015). Response rates for CBT for anxiety disorders: Need for standardized criteria. Clinical Psychology Review, 42, 72–82. https://doi.org/10.1016/j.cpr.2015.08.004
Paredes-Mealla, M., Martínez-Borba, V., Miragall, M., García-Palacios, A., Baños, R. M., & Suso-Ribera, C. (2022). Is there evidence that emotional reasoning processing underlies emotional disorders in adults? A systematic review. Current Psychology. https://doi.org/10.1007/s12144-022-03884-4
Perfect, D., Jackson, C., Pybis, J., & Hill, A. (2016). (rep.). Choice of therapies in IAPT: an overview of the availability and client profile of step 3 therapies. Lutterworth, Leicestershire: British Association for Counselling and Psychotherapy.
Press release. (2021, March 27). Mental health recovery plan backed by £500 million. GOV.UK. Retrieved November 21, 2022, from https://www.gov.uk/government/news/mental-health-recovery-plan-backed-by-500-million
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378
Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943–953. https://doi.org/10.1176/appi.ajp.2017.17010057
Tolin, D. (2016). Doing CBT: A Comprehensive Guide to Working with Behaviours, Thoughts, and Emotions (1st ed.). Guildford Press.