Does psychoanalysis have a valuable place in modern mental health services? Yes

Conflicts of interest should be reported in studies evaluating psychotherapeutic interventions

Peter Fonagy and Alessandra Lemma say that the psychoanalytical approach can provide a useful and unique contribution to modern healthcare, but Paul Salkovskis and Lewis Wolpert argue that it may have no place there at all (1 2). Not surprisingly, both groups claim to have good data for their assumption. We do not want to comment on the content of this discussion, but on a minor aspect that is inherent not only to these authors, but to most of their cited references: No one declares serious competing interests.

A serious misunderstanding that only financial relationships with for-profit companies could cause a potential for biased study reports is supposed to be one of the reasons for this neglect. While we do not want to imply that studies by authors with potential conflicts of interest are worthless, we argue that the reader of reports of clinical trials has the right to know about backgrounds that could represent a serious source of bias. We will exemplify some potential risks for biased reporting in studies about psychological interventions, and we will conclude with a proposal for how to deal with this issue.

If a scientist owns stock in or received financial support of any kind from a pharmaceutical company, the scientific community wants to know about it, especially if this scientist publishes studies of products from this company. But what about a psychotherapist who invested 50,000 pounds in psychotherapy training focused on one specific approach, and publishes results of a trial where exactly this type of intervention is evaluated? In psychotherapy research, this problem of biased reporting could be considered to be even more serious than in pharmacology research, because the training in a special approach can become a part of the personality of the scientist and might be integrated deeply in his/her belief system. Unlike in pharmacology research, the psychotherapist cannot easily switch to another product or company (e.g., from psychoanalysis to cognitive-behavioral therapies (CBT) or vice versa), if the favorite psychological intervention turns out to be less effective than others which were not the subject of the scientist’s training.

While we do not think that every attended workshop in a specific psychological technique should be declared, a specialized training in a specific approach for which the costs or cost-equivalents (e.g., invested working hours) exceed amounts of 10,000 pounds certainly represent a potential for conflict of interests. However, further conflicts of interest in psychotherapy have to be considered. If an author has published a book describing a psychotherapeutic technique, and hopes to sell thousands of copies of it, the financial interest can be comparable to that of a stockholder in a pharmaceutical company. If a psychotherapy researcher chairs a training institute providing trainings for a specific technique, the financial interest can easily exceed 100,000 pounds a year. The same fact holds true if treatment units promoting a special therapeutic approach are led by the researcher. While financial involvements do not represent the only risk for conflicts of interest, it would be a good start to overcome the neglect of these risks for research if this information is declared.

In recent years, meta-analysis has become a gold standard for rating the empirical foundation of an intervention. However, à priori assumptions, study selection criteria, variables selected for computing effect sizes, estimations of missing values, etc., offer the potential of biasing results in meta-analyses (3). Not surprisingly, nearly all meta-analyses supporting the efficacy of psychodynamic or psychoanalytic treatments cited by Fonagy and Lemma were published by proponents of this approach (4 5), which is even true for Cochrane analyses 6, while many meta-analyses on CBT are published from advocates of CBT (e.g., 7 8). Without question these articles can report correct and relevant information, yet the reader should know about the authors’ backgrounds. Moreover, it is questionable whether public decisions or guidelines of general organizations like Cochrane should be solely based on publications of proponents of the approach of interest. Obviously many recently published meta-analyses have been conducted with a clear à priori assumption to confirm the efficiency of the authors’ favorite intervention.

To conclude, we recommend that conflicts of interests be declared in studies evaluating the efficacy of psychological interventions. Substantial financial or parafinancial involvement or investment (e.g., training in a specific intervention, being head of a training center or treatment center for a specific approach) are just a few examples where researchers could develop an attitude that makes them blind for disconfirming results. The reader of articles has a right to know about these potential risks. Moreover, there is a substantial need for non-biased evaluators of psychotherapy outcome studies.

Declaration of conflict of interest: The first author declares he is trained in CBT, and chairs a postgraduate training programme and outpatient clinic for CBT. The second author declares he is trained in both CBT and psychodynamic therapies and directs psychosocial oncology and palliative care programs that rely primarily on CBT techniques.

References:

1. Fonagy P, Lemma A. Does psychoanalysis have a valuable place in modern mental health services? Yes. BMJ 2012;344.
2. Salkovskis P, Wolpert L. Does psychoanalysis have a valuable place in modern mental health services? No. BMJ 2012;344.
3. Nestoriuc Y, Kriston L, Rief W. Meta-analysis as core of evidence-based behavioral medicine: tools and pitfalls of a statistical approach. Current Opinion in Psychiatry in press;23:145-150.
4. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders. A meta-analysis. Archives of General Psychiatry 2004;61:1208-1216.
5. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy. JAMA 2008;300:1551-1565.
6. Abbass AA, Hancock JT, Henderson J, Kisely S. Short-term psychodynamic psychotherapies for common mental disorders (Review). The Cochrane Database of Systematic Review 2007(4. Art. No.: CD004687. DOI: 10.1002/14651858).
7. Ekers D, Richards D, Gilbody S. A meta-analysis of randomized trials of behavioural treatment of depression. Psychological Medicine 2008;38(05):611-623.
8. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review 2006;26:17-31.