File spoon-archives/marxism-psych.archive/marxism-psych_1997/97-04-21.221, message 6


Date: Sun, 23 Mar 1997 14:24:53 GMT
From: Chris Burford <cburford-AT-gn.apc.org>
Subject: M-PSY: Efficacy and cost of therapy


(was "A New Intiative")

Ilan:
-----

My opinion is that for the common applicant for psychological services,
the so called "dynamic psychotherapies" are both a great waste of
resources and hampering the development of self-reliance.

<>

I think that few basic methods of maintenance of mind and body of the
individual are relatively independent of era and society and some times
are solved by the individual in private.  


Russell:
--------

Surely the point with _all_ pschotherapies is that it is the 'therapeutic
relationship', ie, the internalisation of the relationship with the
therapist that matters. Empirical studies of the effectiveness of different
therapies all seem to hinge on this point. It might even be possible to
conceive of a totally 'fraudulent' or placebo therapy that 'cured' the
patient- perhaps much like the way that studies of industrial workers
improve productivity simply because someone is takes an interest in them.



Chris:
------

Perhaps we need to be clearer about the different frames of 
reference against which we are judging psychological treatments.

Earlier on this list there were some exchanges about cost.
A key question is who is paying. It seems to me that psycho-
therapy is powerfully divided into whether we are talking about

a) state funded treatment for those who cannot pay (often
because their disability is so incapacitating

b) those who want to pay privately.

The state-funded sector has always been on the cheap.
Even in 1945 when the National Health Service was set up
in Britain at a time when it was believed in principle that
all health needs could be met, psychotherapy was not in 
practice available for all, as it is very labour intensive.
Only a small proportion of 
working class people got psychotherapy. 
(The inspiration for group therapy that came out of 
collective work with soldiers at the end of the war being
rather an exception).

Attempts were made to clarify prioritisation criteria for the
very small proportion of people who did get psychotherapy on 
the NHS. It was acknowledged that the selection criteria were
rather similar to those receiving psychotherapy privately.

One ironical attempt to classify them threw up the acronym
YAVIS: young, attractive, verbal, intelligent, single.
The class basis of this always seemed to me to be implicit.

Nowadays the pressure is on us once again to use treatments
that are said to be evidence-based. ie of demonstrable 
effectiveness and efficiency.


b) Paradoxically as the market forces intensify, the pressures
seem to be on for an expansion of the private market, with more
and more people becoming aware of talking therapies. Even the 
police are now publically known to receive counselling after 
mass traumas, and there is less stigma in Britain about having 
therapy, though still more so than the United States.

This market operates on the principle increasingly that the 
customer is always right. Whereas the psychodynamic therapies
in Britain went through a period of increasing specialisation
and defence of professional standards, now the move is towards 
a register of reputable therapists. I am unfamiliar with the 
latest stage of this controversy. 

This is likely to intensify pressure not towards treatments 
that are effective, but treatment approaches that give the 
customer some sense of relief, and I would guess will be 
shorter in duration (as indeed there is pressure in the state
sector for psychotherapy treatments to be shorter in duration.)

Russell's comments I read as consistent with the psychodynamic 
school as soon as Freud analysed the problem of the infatuations
his patients developed towards him while he practised hypnosis,
holding his fingers on their forehead, and turned it into
the therapeutic tool of transference.

The argument for this treatment approach is that you need to 
explore experientially your transference tendencies in a 
sustained relationship with a highly professional therapist
who presents an opaque surface to you against which your transference
can be projected.

While this has some face validity, I think it is vulnerable to 
arguments about efficiency, as Ilan states, and political
or aesthetic arguments against dependency. I would prefer to 
explore my transference tendencies in the more democratic 
context of group therapy.

Quite a lot of research has been done about efficacy of 
psychodynamic psychotherapy. I am unfamiliar with the latest
overview of this (can anyone help?). I recall Malan did a 
lot of work on brief focal psychotherapy and found that success 
was correlated with the identification of one focal complex,
and with the patient accepting the therapist's interpretation of 
the existence of this complex.

Ilan's model of therapy comes over to me as a highly 
operationalised one in which the relationship with the therapist
is meant to be quite open, and the patient is taught 
a method to monitor his or her visceral emotions. 
Despite the fact that I guess Ilan can put up a fairly 
cogent case for this, and could probably also draw on 
evolutionary psychology, a lot will depend on what market it is
for. 

If for the state sector we would need very tight evidence 
of its efficiency and its applicability to psychosis. In addition
there would be a substantial problem of training. In reality
it would probably take several decades to penetrate into 
mainstream practice (par for the course?)

If it is used privately then its reputation has to spread in the 
market of customers, and would-be therapists. 

I do not think there is anyway of getting round the tendency that 
in capitalist society our services are effectively commodities
whether the customer is the mass of private individuals looking 
for relief from the strains of bourgeois society, or the customer
is the state sector, unable to withdraw its minimal obligations 
>from the more serious casualties.

All therapies delivered to individuals, whoever is paying, 
seem to me to have the disadvantage of at best helping them
to tailor their response to the external environment, even 
when we recognise as marxists that social factors are very 
important. I therefore prefer ideally a problem solving family 
therapy, although again, delivering this labour intensive service 
in an efficient way is a challenge, which has not yet been 
reliably solved.


Chris Burford


 


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