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 --- from list marxism-psych-AT-lists.village.virginia.edu ---
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