Episode 10: "The Problem with Clinical Trials" with Jonathan Shedler, PhD

Jonathan Shedler, Phd is a clinical professor of psychiatry at the University of California, San Francisco (UCSF) and faculty member at the San Francisco Center for Psychoanalysis. He is author of numerous scientific and scholarly articles, and his article The Efficacy of Psychodynamic Psychotherapy won worldwide acclaim for firmly establishing psychoanalytic therapy as an evidence-based treatment. He has more than 25 years’ experience teaching and supervising psychologists, psychiatrists, and psychoanalysts.
In this episode Jonathan and Bruce talk about what constitutes meaningful psychological change and whether or not randomized clinical trials of eight to sixteen sessions are actually relevant to real-world psychotherapy. Jonathan also discusses some of the evidence for psychodynamic therapy as an effective long term psychological intervention.
Find out more about Jonathan and his work at jonathanshedler.com/
References:
Ormel J, Hollon SD, Kessler RC, Cuijpers P, Monroe SM. More treatment but no less depression: The treatment-prevalence paradox. Clin Psychol Rev. 2022 Feb;91:102111. doi: 10.1016/j.cpr.2021.102111. Epub 2021 Dec 11. PMID: 34959153. pubmed.ncbi.nlm.nih.gov/34959...
Beutel, M., Rasting, M., Stuhr, U., Ruger, B., & LeuzingerBohleber, M. (2004). Assessing the impact of psychoanalyses and long-term psychoanalytic psychotherapies on health care
utilization and cost. Psychotherapy Research, 14, 146-160.
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The intro and outro music is the Borromeo String Quartet performing Beethoven's "String Quartet No. 3 in D Major"
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[@carmelvickers]

Thank you Dr Shedler for a very articulate description of Psychotherapeutic treatment and trials. You brought the discussion back to point every time, before it got too complicated. Getting to the source with a patient is life changing for them. But takes time.

[@samwich852]

As a clinician, thank you for this

[@LSreggae]

100% agree with Shedler on this.

[@martabonn3400]

Excellent interview. Thank you dr Shedler

[@pdxyadayada]

Brilliant piece! I’ve said, for ages, that the clinical studies of therapy outcomes rarely take into account differences in outcomes for specific diagnostic groups, as well as effectiveness of therapy over the long term. Rarely are functional outcomes measured in these studies, needless to say long term functional changes. Also, I’m not sure if other factors affecting outcomes (health factors, medication, socio-economic factors) are included in the meta-analyses being studied.

[@iwasjustintrance]

The conversation we needed! Part 2 anyone?

[@SylviabombsmithUjhy75bd34]

yes please

[@samwich852]

Yes! Part 2 and with fewer interruptions from Shedler. I love his passion but we gotta set some ground rules for the next chat 😅

[@marvinsmith9039]

Very good discussion/argument surrounding different perspectives in particular clinical modalities.

[@ronalbucher]

I very much enjoyed the interview too. I respect both of your work and very much appreciate the contributions you have made to our field.
Over the last 10 years, I have been studying a form of shorter term psychodynamic psychotherapy (intensive short term, dynamic psychotherapy) I think this model has significant advantages to the traditional psychodynamic approach that I was taught, and that Dr. Schedler discussed, including doing away with the technique of free association which often feeds into intellectual defenses and prolongs treatment. ISTDP is very good at identifying, unconscious anxiety, as well as syntonic defense mechanisms, and repressed affect. Like psychoanalysis it does seek to promote character change. I am curious if either of you are familiar with it and it’s research literature?

[@waldezurbe]

excellent interview. ty both.

[@emerward1064]

Excellent interview really value Jonathan Shedlers view as a psychodynamic Psychotherapist but also used Bruce Wampold great writings in my Assignments.

[@kennethgarcia25]

Talking about change, but is there an objective measure regarding the degree of change. Most individuals with personality disorders require a breakthrough in perspective that would require a level of de novo reconsolidation/integration that would require months if not years of trusting reliance on a competent therapist. Dr. Feelgood Wampold does not recognize the degree that the superficial phenomena "flight into health" or placebo arises when individuals have entered into therapy after a period of profound hopelessness. Just allowing themselves to be vulnerable in therapy briefly provides a tremendous sense of relief while allowing them to avoid anything significantly confrontational to their egos which would be so difficult for them to tolerate. So many "escape" with their transitory experience of relief from their isolation and experiencing a hope when they were previously hopeless, yet not having actually learned what is necessary for meaningful change.

[@chachi958-rg8ju]

Jonathan keeps receipts and instead of being praised for it he is shunned by the accepted consensus (i.e. something is better than nothing, in the short term, but we will tell you its the best). Tells you all you need to know about the current system of mental health care.

[@SylviabombsmithUjhy75bd34]

well said

[@EmbraceTerror]

I'm having trouble finding the industry's empurical evidence of disorders. Any suggestions?

[@poor_jafar]

36:56

[@Bboydomaz555]

Psychoanalysis/psychodynamic is great but it’s not assessable to therapists 3 years of school and tens of thousands of dollars (after grad school).

[@canondigemini1106]

1😊

[@josephwehbeparis]

Very interesting, but it's unfortunate that Dr. Shedler repeatedly interrupts Dr. Wampold, not giving him time to finish asking his question. Maybe nuances in the questions are being missed.

[@maxwellcooper2]

I was extremely interested in what Jonathan had to say- but to me this became unwatchable before the end of the hour with him constantly cutting off Wampold, not letting him finish a single question, comment, or response. Please, Jonathan, could you please give the man a chance to finish speaking - as others have pointed out here, a certain amount of nuance can be lost, if you cut a person off *every time* before they're finished, just assuming/anticipating you understand the question. The interview is 97% one person talking (which is fine, since it's an interview), but please, show some courtesy and restraint and let the interviewer finish! I would have enjoyed this a great deal more if not for that aspect.
ALSO- would be very fascinated by a deeper discussion (even debate, as they referred to at one point), between Jonathan and (either Wampold, or, perhaps more interestingly, a CBT advocate of some kind). Would love to see someone put that together- could be fascinating. (Please have a moderator present though!;)

[@DigitalPsyche]

Viewing this like a session, Bruce seems to avoid something that makes him uncomfortable.

[@williamjames3995]

Viewing this like a session, Shedler is going full „Overcontroller“ by interrupting Bruce a lot.

[@LisaFladager]

@@williamjames3995 indeed! My one criticism of Jonathan is that I wish he didn't interrupt so much. Let the man finish his sentences!

[@EmbraceTerror]

I hope you two get out of your ivory towers sometime.

[@EmbraceTerror]

This was kind of funny. Shedler saying he's upset by researchers conducting studies and telling clinicians how they should adopt their latest treatment, yet doesn't give equal weight to people with lived experience also having an equal voice. It was scary how much Wampold dismissed Shedler -- OUCH!!
I saw a video of an alleged debate between Wampold and Fonagy, where Fonagy said there are 2,400 treatments. Today, Shedler said that all treatments are equally effective. Hmmm.
In the same debate video, Wampold stated that he wants research to find out what it is with some therapists that makes them effective. Hmmmm. No mention of that today. Just a presumption that therapies (and presumably, therapists) "work". Hmmm.

[@smp4533]

Cutting off Walpold the entire hour. Appreciate Shedler’s passion but there should be more give and take in a discussion to actually call it a discussion. Also, too much vocal fry (likely some tension in vocal cords) can be irritating to listeners.

[@LisaFladager]

Agree. This is my one criticism of Shedler in many interviews - although I agree with many if not all of his points, he is usually chomping at the bit and cuts people off. Take a breath, Jonathan!

[@EmbraceTerror]

This was kind of funny. Shedler saying he's upset by researchers conducting studies and telling clinicians how they should adopt their latest treatment, yet doesn't give equal weight to people with lived experience also having an equal voice. It was scary how much Wampold dismissed Shedler -- OUCH!!
I saw a video of an alleged debate between Wampold and Fonagy, where Fonagy said there are 2,400 treatments. Today, Shedler said that all treatments are equally effective. Hmmm.
In the same debate video, Wampold stated that he wants research to find out what it is with some therapists that makes them effective. Hmmmm. No mention of that today. Just a presumption that therapies (and presumably, therapists) "work". Hmmm.