That Dodo is No Dodo

During a recent workshop on science and psychoanalysis chaired by Leonard Horowitz at the 2002 spring meetings of the ApsaA, roughly 40 psychoanalysts heard Lester Luborsky, a foremost authority on psychotherapy research, summarize a perplexing but consistent finding derived from statistical analyses of over one hundred treatment outcome studies: when patients are professionally treated, they get better, but symptomatic improvement is not related to the type of therapy they receive.

The good news from Luborsky's report about the state of comparative psychotherapy research is that it confirms what practioners believe: psychotherapy definitively helps to reduce patient distress. The mixed news is that the improvement is about the same whether patients receive psychodynamic psychotherapy, cognitive therapy, behavioral therapy or pharmacotherapy. I say ‘mixed’ because these findings suggest that our belief in the superiority of psychoanalytic psychotherapy is not supported by empirical evidence; nevertheless, some of us will find solace in the idea that we are at least as good as the others. While many of us would immediately argue that these findings do not address the more complex question of personality reorganization that is central to psychoanalysis, this “treatment outcome equivalence” phenomenon nevertheless suggests that, all other things being equal, offering a phobic, anxious or depressed patient psychoanalytic psychotherapy is empirically and ethically sound since no other treatment has been reliably shown to be better.

It is safe to say that patients are motivated to improve when they can expect a reasonable and competent professional with a coherent treatment ideology to guide them. At the same time, results like those Luborsky presented have been used to challenge the superiority contention of the so-called “empirically validated” (or empirically supported) treatments. While there are some exceptions to the overall comparative outcome findings, the most frequent scientific conclusion about therapeutic effects based on methodologically divergent treatments supports the claim that the various therapies have more in common than the theories that give rise to them would acknowledge. On the comparative treatment outcome front, there is no one winner.

Sixty-six years ago, without benefit of the information that hundreds of subsequent empirical studies have produced, research psychologist Saul Rosenzweig (known to many analysts for his research on experimentally- induced repression whose theoretical significance Freud was to minimize), wrote “Some Implicit Common Factors in Diverse Methods of Psychotherapy” for the American Journal of Orthopsychiatry. In this article, Rosenzweig granted the therapeutic success proclaimed by each of the three competing psychological treatment methods (Christian Science, something called ‘persuasion’ and, of course, psychoanalysis) for supremacy in the therapeutic marketplace. He then presciently argued that the value of their unique features would be diminished by the weight of their similarities and concluded that the race for therapeutic superiority would probably end in a three-way tie. Rosenzweig identified catharsis, the good therapist's personality, the coherence of the therapeutic ideology, and the therapist's ability to provide the patient with a different way of thinking about herself as factors common to any successful treatment whose presence would “reduce the effectual importance of … differences between one form of psychotherapy and another.”

Saul Rosenzweig's legacy to psychotherapy efficacy research is emblematized in the remark he took from Lewis Carol's dodo bird character in the third chapter of Alice in Wonderland to introduce his ideas about the therapeutic processes and characteristics shared by different psychotherapeutic methods. The Dodo, an extinct, awkward, fifty-pound, universally vilified, flightless pigeon and symbol of immobility and stupidity, after initiating a drying-off race for Alice and several other drenched wonderland creatures, is then asked to announce the winner. The Dodo's uncharacteristically brilliant reply, representing Rosenzweig's insight, rediscovered, revived and memorialized in 1975 by Lester Luborsky and colleagues and still recognized as an apt summary of the status of contemporary comparative therapeutic efficacy research, was simply: “Everybody has won and all must have prizes”.

Surely, that dodo was no birdbrain.