Dynamic therapy as 'Alternative medicine'

“Complementary and alternative medicine” (CAM) is a category that includes all the methods of physical or mental healing that do not fall under the umbrella of western medicine. Examples include comprehensive healing traditions from other cultures, such as Chinese or Ayurvedic (Indian) medicine; herbal remedies; and a wide variety of mind-body treatments, such as meditation and yoga. CAM treatments are popular everywhere, including here in the U.S. But they are considered unproven by western medicine, usually because they haven’t shown statistically significant treatment effects, as compared to placebo, in randomized controlled trials (RCTs).

Advocates of CAM argue that RCTs are the wrong tool to assess such treatments. Western medicine is founded on diagnosing a disease, then applying one or more treatments known to fight that disease. Individual differences among patients who share a given disease are considered error variance that can’t be accounted for. These differences are averaged out in subject groups, which is why large subject groups lend more statistical power to RCTs than do small subject groups. Thus, antidepressant drugs and cognitive behavioral therapy (CBT) are accepted as legitimate in western medicine because research subjects with diagnosed major depressive disorder improve — on average — with these treatments to a greater degree than similar patients in control groups. Differences between responders and non-responders in a given group are usually unstudied and unknown, and in any case irrelevant to the finding that the treatment is “effective.”

A common feature of CAM is that individual differences are highlighted, not thrown away as noise. Chinese and Ayurvedic medicine describe subtle balances of tendencies or energies within the individual, and seek to restore health by correcting imbalances. Similar principles are purportedly at work in chiropractic, western herbalism, tai chi, and so forth. It remains an empirical — but often hard to test — question whether these CAM practices actually have a healing effect.

Psychodynamic psychotherapy (and for purposes of this discussion, psychoanalysis) is not considered CAM because it does not fall outside the umbrella of western medicine. Dynamic principles are taught to psychiatry residents (i.e., physicians), health insurers pay for treatment, and non-psychiatric physicians have few qualms about referring their patients for such therapy.

However, this is changing. The term “evidence based treatment” is increasingly used to differentiate psychiatric interventions that fit the standard RCT paradigm. These include FDA-approved medications and other somatic treatments such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). They also include CBT in its various forms. Notably, dynamic therapy and psychoanalysis are not included, despite a sizable literature showing efficacy. “Evidence based treatment” is thus a misleading term, a kind of sales pitch for certain types of treatment. But it’s an effective sales pitch. It is becoming “common knowledge” that some psychotherapy is “evidence based” and some is not. There are only small, fledgling efforts thus far to counter this misperception.

Dynamic therapy is thus veering from mainstream legitimacy to something approaching CAM. It’s no coincidence that it also shares important commonalities with CAM: a focus on individual differences, subtle energies (unconscious impulses and feelings in this case), a “balancing” paradigm within the individual, and a rejection of one-size-fits-all treatment.

On the one hand, it is small comfort that psychodynamics now joins company with implausible healing arts such as reiki and homeopathy. It feels unfair to discount our careful theories, myriad case reports, our documented successes. We’re not some crackpot cult positing invisible entities and forces, like chakras, kundalini, and chi. Except that, in the eyes of many these days, we are. It can all be a bit depressing.

On the other hand, sometimes CAM eventually gains legitimacy even in the eyes of western medicine. Acupuncture and probiotics are arguably two such examples. Perhaps the pendulum will swing back when more sophisticated research methods show unique advantages for dynamic treatments. Or more simply, when “evidence based” isn’t accepted blindly.

In the meantime, given the unfortunate delegitimization of dynamic treatment, practitioners may be well served to embrace its undeniable and laudable kinship with CAM. “Precision medicine,” a buzzword these days, rightly applies not only to genetic testing and personalized pharmacology, but also to individualized psychological treatment. Focusing on the person and not the disease need not be the sole province of eastern healing philosophies. Attention to subtlety and nuance need not be relegated to mystical, esoteric practices. In all these areas, the dynamic tradition has been there and done that.

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