Sweden opens up CBT monopoly, gives nod to psychodynamic therapies

Psychodynamic therapists of the world, rejoice! After years of complaining that CBT sucks up all the public funding, it seems that psychodynamic therapists may be about to get a break - in Sweden at least.

For the last four years or so, Sweden's government has put substantial funds (around £200 million according to one source) into CBT provision and CBT training. Now, it looks like the government's National Board of Health and Welfare, Socialstyrelsen, has accepted that psychodynamic therapies are as effective as CBT at treating depression - which experts say is likely to lead to the introduction of government support for psychodynamic therapies.

This is significant for UK mental health policy, as our government has also put substantial funds into CBT, and is facing a similar dispute from psychodynamic therapists who claim that practice-based research shows that all therapies work equally well in the field - therefore they should all get funding, not just CBT.

The shift in Swedish policy is in part due to the work of Rolf Holmqvist, professor of clinical psychology at Linköping University, whose research suggests that just about every form of talking therapy is equally effective when used in the field. He's written an article in the new issue of Socionomen, the journal for social workers in Sweden, in which he presents his latest research. Rolf agreed to be interviewed to explain his findings and their implications. I should say at the beginning that I'm a big supporter of CBT and the UK government's funding for it, but don't want to be blindly defending my own preferences.

JE: Sweden’s government is a big supporter of CBT, isn’t it?

RH: Yes, it’s a pretty similar situation to the UK. In Sweden, the government has put a lot of money into training therapists to do CBT.

JE: I read it has spent 2 billion kronor (£200 million) on it in the last four years or so.

RH: I’m not sure of the exact figures, but it’s a lot of money. Several hundred therapists and social workers have been trained in CBT. Unfortunately, at some places therapists do not really do CBT, they just call it that to get public money. The government sponsors CBT treatments for depression and anxiety, up to around £1,000 per person.

JE: So therapists must ‘convert’ to CBT?

RH: They’re not obliged to. But if they want government funding, they must either provide CBT or Interpersonal Psychotherapy (IPT)

JE: So tell me about the new issue of Socionomen, and how Swedish mental health policy is changing.

RH: In our study we used the CORE-OM system for rating therapy outcomes [as opposed to the Beck Depression Index, designed by Aaron Beck, who's also the founder of Cognitive Behavioural Therapy]. We started by examining outcomes in primary care centres. In Sweden, there is perhaps one such centre for every 10,000 people. And at every centre, there is one or two people providing psychological treatment. We asked therapists to ask their patients to rate their state on the CORE-OM outcome measure, so we could follow the progress of their treatment, which was typically rather short – on the average six sessions. We compared a number of things, particularly how different treatment orientations succeeded – particularly CBT and psychodynamic,. We found exactly the same results, for both depression and anxiety. They all got good results, with about half of patients recovering. Even supportive therapy, which is the Cinderella of therapies because it seems too simple, got quite good results.

Effect Size for All Treatments

	CORE-OM	Function	Symptoms	N
Supportive	.68	.56	.68	108
Dynamic	1.04	.82	1.0	84
CBT	1.05	.85	1.09	99
Cognitive	1.72	1.43	1.67	41
Crisis intervention	1.18	.85	1.34	49
Behavioral	.91	.73	.81	21
Relational	1.25	.95	1.57	12
Client-centered	.48	.35	.27	10
Systemic	.64	.48	.66	17
Counselling	1.0	.53	.85	10
Directive	1.16	.97	1.14	173
Reflective	1.07	.85	1.06	99

JE: Can you briefly describe the difference between CBT and psychodynamic therapies?

RH: CBT is directive. It’s educational, and it helps people to train themselves to get better. Psychodynamic therapy is reflective. It helps people reflect on their feelings.

JE: So does the research show the famous Dodo effect - all talking therapies seem to have the same impact.

RH: Yes, on many psychiatric states. And we also found that, in practice, therapists don’t always follow only one therapeutic approach. In practice, therapists and patients together tend to negotiate and find a treatment that works for the patient. By the way, there was a parallel study in the UK recently that found exactly the same results: Stiles at al (2008) [for a response from David M. Clark, the chief champion of the government's support for CBT, to Stiles at al, see this paper].

JE: So your study found that all these different therapies showed some beneficial results? Because I saw a write-up of the Socionomen report which suggested it says the government’s CBT programme has had no impact whatsoever, or even a negative impact.

RH: That was another report by professors in health economy from the Karolinska Institute. They were looking at whether CBT was helping people to get off benefits and go back to work. In that respect, they couldn’t see any effect of CBT treatment. But I wouldn’t say there was no effect - we were able to show a good effect.

JE: So is it true the Swedish government is changing its approach and broadening the range of therapies that it might support?

RH: It’s true that the National Board of Health and Welfare, Socialstyrelsen, said a few months ago that it feels as if psychodynamic therapies are as good as CBT for depression. It still insists CBT is the best for anxiety, although our practice-based findings suggest psychodynamic therapies are also just as good for anxiety.

JE: Is that likely to mean a broadening of financial support for training in and provision of other therapies?

RH: Yes, it’s likely.

JE: What are the other implications of your research?

RH: I think the main implication is to recognise that there are two types of valid research paradigms: firstly, randomised controlled trials (RCTs), where you compare clearly defined treatments. Secondly, practice-based studies, where you don’t compare narrowly-defined treatments for selected patients, but instead look at how therapies are provided within real settings. The problem with RCTs is they are not as clean as they claim to be - a lot of noise gets in to them, through researchers’ allegiance and therapists’ expectations and so on. When governments in Sweden and the UK looked at which therapies to support, they decided there must be accountability. So they looked at the field of therapies, and they found lots of RCT studies for CBT, and few for psychodynamic therapies. But practice-based studies better show the successful outcomes for psychodynamic therapies. Practice-based studies are becoming more accepted now. For example, in the new edition of the Handbook of Psychotherapy and Behavioural Change, there will be a new chapter on practice-based studies.

JE: What I don’t understand about the Dodo effect is that these different therapies often have very different and conflicting conceptual underpinnings. Different theories about what emotions are and how to change them, for example. So they can’t all be right, can they? I mean, either emotions are connected to beliefs, and you can change them by changing your beliefs, or they’re not.

RH: Well, what you often find is what therapists say is the mechanism of change is usually not. So in cognitive therapy, for example, Aaron Beck thought that cognitive restructuring of beliefs is the way to change people’s mood. In fact, some research suggests that the depression changes first, then the thinking. [It also seems that, with anxiety disorders, the behavioural component of CBT is as important or more important in recovery than cognitive restructuring - see Clark et al (2008)]

We’ve lived now for some decades with this big debate between psychodynamic therapy and CBT. And in 15 years, there will be other kinds of division between them. Even now, people use lots of combinations of the two.But, in general, it seems that talking therapies, when they work, enhance the possibility to stand and accept strong emotions. They help people explore affects and try to stand them.

I can think of critiques to Rolf's findings - if, by his own admission, therapists in the field are using a jumble of all kinds of different therapies (while often calling it CBT), then how can he compare the outcomes for CBT to psychodynamic therapies? The Dodo effect also has worrying implications for government support for mental health policy. If all therapies work the same (and I'm not sure they do, for specific conditions like social anxiety for example), then should government finance everything from maracas-shaking shamans to aromatherapists?  There is also, clearly, a difference between passing episodes of stress, which might naturally clear up on their own no matter what therapy a person receives, and more chronic conditions - a point made in Clark's rebuttal to Stiles et al, which is linked to above. I will discuss these issues, and the problem of the Dodo effect, further in my newsletter tomorrow. In the meantime, feel free to leave comments below.