L’un des souhaits fondamentaux des psychothérapies du bonheur est de vouloir conforter « l’estime de soi ». Si nous échouons dans tel ou tel domaine de notre vie, ce serait parce que nous ne nous en croyons pas capable. Cette idée nous est assénée à longueur de temps par les prosélytes de ces thérapies (la méditation pleine conscience surtout, et aussi les thérapies cognitivo-comportementales en partie). Continuer la lecture de « Les thérapies du bonheur ne vous veulent que du bien ! »
Une étude Jonathan Shedler montre que pour la dépression, l’anxiété, la panique et le stress, la psychanalyse a des effets « au moins aussi grands » que ceux des TCC (thérapies cognitivo-comportementales) ou des médicaments. Y compris neuf mois après l’arrêt de la thérapie, alors que les avantages des autres thérapies diminuent dans le temps.
Nous savions déjà que:
- les TCC sont moins efficaces et plus coûteuses que la psychanalyse: http://efleury.fr/les-tcc-sont-inefficaces-et-coteuses/
- la psychanalyse a des résultats supérieurs aux thérapies courtes http://efleury.fr/superiorite-de-la-psychanalyse-sur-les-psychotherapies-courtes/
L’article de Shedler se trouve à cette adresse : http://www.nvpp.nl/JonathanShedlerStudy20100202.pdf
Psychodynamic Psychotherapy Brings Lasting Benefits through Self-Knowledge
Patients Continue to Improve After Treatment Ends
Jonathan Shedler, PhD, January 25, 2010, Université of Colorado Denver School of Medecine, American Psychologist, vol. 65, n°2
WASHINGTON—Psychodynamic psychotherapy is effective for a wide range of mental health symptoms, including depression, anxiety, panic and stress-related physical ailments, and the benefits of the therapy grow after treatment has ended, according to new research published by the American Psychological Association.
Psychodynamic therapy focuses on the psychological roots of emotional suffering. Its hallmarks are self-reflection and self-examination, and the use of the relationship between therapist and patient as a window into problematic relationship patterns in the patient’s life. Its goal is not only to alleviate the most obvious symptoms but to help people lead healthier lives.
“The American public has been told that only newer, symptom-focused treatments like cognitive behavior therapy or medication have scientific support,” said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. “The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last.”
To reach these conclusions, Shedler reviewed eight meta-analyses comprising 160 studies of psychodynamic therapy, plus nine meta-analyses of other psychological treatments and antidepressant medications. Shedler focused on effect size, which measures the amount of change produced by each treatment. An effect size of 0.80 is considered a large effect in psychological and medical research. One major meta-analysis of psychodynamic therapy included 1,431 patients with a range of mental health problems and found an effect size of 0.97 for overall symptom improvement (the therapy was typically once per week and lasted less than a year). The effect size increased by 50 percent, to 1.51, when patients were re-evaluated nine or more months after therapy ended. The effect size for the most widely used antidepressant medications is a more modest 0.31. The findings are published in the February issue of American Psychologist, the flagship journal of the American Psychological Association.
The eight meta-analyses, representing the best available scientific evidence on psychodynamic therapy, all showed substantial treatment benefits, according to Shedler. Effect sizes were impressive even for personality disorders—deeply ingrained maladaptive traits that are notoriously difficult to treat, he said. “The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended,” Shedler said. “In contrast, the benefits of other ‘empirically supported’ therapies tend to diminish over time for the most common conditions, like depression and generalized anxiety.”
“Pharmaceutical companies and health insurance companies have a financial incentive to promote the view that mental suffering can be reduced to lists of symptoms, and that treatment means managing those symptoms and little else. For some specific psychiatric conditions, this makes sense,” he added. “But more often, emotional suffering is woven into the fabric of the person’s life and rooted in relationship patterns, inner contradictions and emotional blind spots. This is what psychodynamic therapy is designed to address.”
Shedler acknowledged that there are many more studies of other psychological treatments (other than psychodynamic), and that the developers of other therapies took the lead in recognizing the importance of rigorous scientific evaluation. “Accountability is crucial,” said Shedler. “But now that research is putting psychodynamic therapy to the test, we are not seeing evidence that the newer therapies are more effective.”
Shedler also noted that existing research does not adequately capture the benefits that psychodynamic therapy aims to achieve. “It is easy to measure change in acute symptoms, harder to measure deeper personality changes. But it can be done.”
The research also suggests that when other psychotherapies are effective, it may be because they include unacknowledged psychodynamic elements. “When you look past therapy ‘brand names’ and look at what the effective therapists are actuallydoing, it turns out they are doing what psychodynamic therapists have always done—facilitating self-exploration, examining emotional blind spots, understanding relationship patterns.” Four studies of therapy for depression used actual recordings of therapy sessions to study what therapists said and did that was effective or ineffective. The more the therapists acted like psychodynamic therapists, the better the outcome, Shedler said. “This was true regardless of the kind of therapy the therapists believed they were providing.”
Article: “The Efficacy of Psychodynamic Psychotherapy,” Jonathan K. Shedler, PhD, University of Colorado Denver School of Medicine; American Psychologist, Vol. 65. No.2.
Contact Jonathan Shedler, PhD, by e-mail or by phone at (303) 715-9099 and by cell at (970) 948-4576.
The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.
L’étude de Paul Knekt et de ses collaborateurs, de l’institut national pour la santé de Helsinki en Finlande, montre l’efficacité de la psychanalyse sur un suivi de 5 ans, ainsi que sa supériorité par rapport aux psychothérapies pour des patients souffrant de dépression ou d’anxiété. Les psychothérapies « courtes » apparaissent dès lors comme des traitements « insuffisants ».
Nous savions déjà que les TCC sont inefficaces et coûteuses : http://efleury.fr/les-tcc-sont-inefficaces-et-coteuses/
L’article de Paul Knekt : http://www.ncbi.nlm.nih.gov/pubmed/21316768Continuer la lecture de « Supériorité de la psychanalyse sur les psychothérapies courtes »
L’étude de Durham montre que les TCC (Thérapies Cognitivo Comportementales) sont inefficaces, aussi bien dans le traitement de l’angoisse que celui de la psychose. De plus, son coût est plus élevé que les autres thérapies dans le traitement de l’angoisse.
L’essai clinique est réalisé par l’équipe de Durham en Ecosse, de 1985 à 2001, elle est randomisée, en aveugle et contrôlée par les échelles appropriées. Les patients souffraient de troubles anxieux généralisé, de trouble panique, du syndrome de stress post-traumatique ou de psychose. Sur les 1071 personnes entrées dans l’étude en 85, 489 ont participé à l’évaluation à la fin de l’étude (46% des entrants d’origine) en 2001.
Le traitement par la TCC n’a pas supprimé la pathologie. Quand des effets positifs ont été constaté au début, ils avaient disparus à la fin. Un traitement par la TCC plus intensif n’améliorait pas la symptomatologie durablement.
L’analyse coûts-efficacité a montré aucun avantage de la TCC par rapport aux non-TCC.
Les coûts de la TCC étaient plus élevés que les non-TCC.
La TCC n’apportait aucune différence par rapport aux traitements non-TCC.
L’analyse coût-efficacité a montré aucun avantage de la TCC par rapport aux non-TCC.
Article original ci-dessous:
Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland
RC Durham,1* JA Chambers,1,2 KG Power,2,3 DM Sharp,4 RR Macdonald,2 KA Major,5 MGT Dow2,6 and AI Gumley7
Health Technology Assessment 2005; Vol 9: number 42
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1 Psychiatry and Behavioural Sciences, Division of Pathology and Neuroscience, University of Dundee, UK
2 Department of Psychology, University of Stirling, UK
3 Department of Clinical Psychology, NHS Tayside, UK
4 Institute of Rehabilitation, University of Hull Medical School, UK
5 Health Economics, NHS Ayrshire and Arran, UK
6 Department of Clinical Psychology, NHS Fife, UK
7 Department of Psychological Medicine, University of Glasgow, UK
* Corresponding author
The aim of this study was to consider the following:
- What is the long-term outcome of participants in clinical trials of cognitive behaviour therapy (CBT) for anxiety disorders and psychosis?
- Are there significant differences in effectiveness and cost-effectiveness associated with receiving CBT in comparison with alternative treatments?
- Are there significant differences in effectiveness associated with receiving different intensities of CBT?
- How well can long-term outcome be predicted from data from the original clinical trials?
An attempt was made to contact and interview all of the participants in eight randomised, controlled, clinical trials of CBT for anxiety disorders and two randomised, controlled, clinical trials of CBT for schizophrenia conducted between 1985 and 2001. Case note reviews of healthcare resources used in the 2 years prior to entering the trials and the 2 years prior to follow-up interview were undertaken.
The clinical trials were conducted in mixed rural and urban settings in five localities in central Scotland. Anxiety disorder trials were conducted mainly in primary care and included three with generalised anxiety disorder, four with panic disorder and one with post-traumatic stress disorder (PTSD). The psychosis studies (one on relapse prevention and one with chronic disorder) were conducted in secondary care.
An attempt was made to follow up all 1071 entrants to the 10 studies, of whom 125 were not available to be contacted. Of the 946 who were available, 489 agreed to participate (46% of original entrants, 52% of those available to contact).
Follow-up interviews took place between 1999 and 2003, 2–14 years after the original treatment. Interviews for Trials 1–8 were conducted by a research psychologist blind to original treatment condition. Interviews for Trials 9 and 10 were conducted by community psychiatric nurses also blind to treatment condition. Case note reviews were completed following the interview.
Main outcome measures
For Trials 1–8 the main interview-based outcome measures were: Anxiety Disorders Interview Schedule – DSM-IV for diagnosis and co-morbidity, Clinical Global Severity (0–8) and the Hamilton Anxiety Rating Scale. The main patient-rated measures were: Brief Symptom Inventory, SF-36 II, Clinical Global Improvement (1–7), and the Positive and Negative Affect Scale. For Trials 9 and 10 the primary outcome measure was the interview-based Positive and Negative Syndrome Scale (PANSS).
Anxiety disorder studies (Trials 1–8)
Over half of the participants (52%) had at least one diagnosis at long-term follow-up, with significant levels of co-morbidity and health status scores comparable to the lowest 10% of the general population. Few participants had none or only mild symptoms (18%) and a significant proportion (30%) had subthreshold symptoms of at least moderate severity. Only 36% reported receiving no interim treatment for anxiety over the follow-up period with 19% receiving almost constant treatment. Patients with PTSD did particularly poorly. There was a 40% real increase in healthcare costs over the two time periods, mainly due to an increase in prescribing. A close relationship was found between poor mental and physical health for those with a chronic anxiety disorder.
Treatment with CBT was associated with a better long-term outcome than non-CBT in terms of overall symptom severity but not with regard to diagnostic status. The positive effects of CBT found in the original trials were eroded over longer time periods. No evidence was found for an association between more intensive therapy and more enduring effects of CBT. Long-term outcome was found to be most strongly predicted by the complexity and severity of presenting problems at the time of referral, by completion of treatment irrespective of modality and by the amount of interim treatment during the follow-up period. The quality of the therapeutic alliance, measured in two of the studies, was not related to long-term outcome but was related to short-term outcome.
The cost-effectiveness analysis showed no advantages of CBT over non-CBT. For the participants as a whole, CBT was associated with slightly higher costs than non-CBT and slightly higher benefits. For participants who completed CBT, versus all other participants, CBT was associated with somewhat lower costs and slightly higher benefits. The costs of providing CBT in the original trials was only a very small proportion (6.4%) of the overall costs of healthcare for this population, which are high for both physical and mental health problems.
Psychosis studies (Trials 9 and 10)
Outcome was generally poor and only 10% achieved a 25% reduction in total PANSS scores from pretreatment to long-term follow-up. Nearly all participants (93%) reported almost constant treatment over the follow-up period at a significantly higher level than for the anxiety disorder patients. Treatment with CBT was associated with more favourable scores on the three PANSS subscales. However, there were no significant differences between CBT and non-CBT groups in the proportions achieving clinically significant change and very few psychosis patients maintained a 25% reduction in PANSS scores from post-treatment to long-term follow-up regardless of treatment modality.
Cost-effectiveness analysis showed no advantages of CBT over non-CBT. Healthcare costs fell over the two time periods mainly owing to a reduction in inpatient costs.
The implications for healthcare are:
- Psychological therapy services need to recognise that anxiety disorders tend to follow a chronic course and that good outcomes with CBT over the short term are no guarantee of good outcomes over the longer term.
- Clinicians who go beyond standard treatment protocols of about 10 sessions over a 6-month period are unlikely to bring about greater improvement.
- Poor outcomes over the long term are related to greater complexity and severity of presenting problems at the time of referral, failure to complete treatment irrespective of modality and the amount of interim treatment during the follow-up period.
- The relative gains of CBT are greater in anxiety disorders than in psychosis.
Recommendations for future research
Longitudinal research designs over extended periods of time (2–5 years), with large numbers of participants (500+), are required to investigate the relative importance of patient characteristics, therapeutic alliance and therapist expertise in determining the cost-effectiveness of CBT in the longer term.
A better understanding of the mechanisms by which poor treatment responders become increasingly disabled by multiple physical and mental disorders will require close collaboration between researchers in the clinical, biological and social sciences.
Durham RC, Chambers JA, Power KG, Sharp DM, Macdonald RR, Major KA, et al. Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland. Health Technol Assess 2005;9(42).
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