A new view: ECP perspectives on psychoanalytic activities

Blind men, elephants, and psychotherapy effectiveness: Skewed views of treatment realities and how to fix them

By Katie Bruder

I recently attended a fascinating conference organized by the Consortium for Psychoanalytic Research, Inc. on treatment-resistant (TR) patients. Dr. Christopher Fowler, PhD, of the Menninger Department of Psychiatry at Baylor College presented his findings regarding TR patients and illuminated the multidimensional approach necessary to their identification and treatment.

The conference began with a glimpse of Dr. Fowler’s current research on his and his colleagues’ own measure of TR, the Global Psychiatric Severity Index (GPSI). Each of the attendees was asked to fill out a form that examined the characteristics of a “good” case and a “resistant” case from the practitioner’s point of view. The purpose of the exercise was to determine whether the expected constellation of factors comprised a resistant (or nonresistant). The exercise was fun and informative, and the data presented at the conclusion of the conference demonstrated the GPSI’s utility. 

The multidimensionality of Dr. Fowler’s assessment tool underscores his beliefs about the host of factors that must be accounted for in determining whether a patient is TR. These include genetics, relationship functioning, therapeutic alliance, and defensive structure. Dr. Fowler also emphasized that TR patients often have historical features that are not necessarily patient-specific, such as early terminations by clinicians due to external factors or revolving-door hospitalizations.

Dr. Fowler’s assessment tool is particularly helpful because it uses a nuanced clinical picture of each patient where some RCTs emphasize internal validity at the expense of real-world application. He explained the problems with these types of studies, focusing on RCTs’ often-unrepresentative patient samples. Dr. Fowler mentioned that most patients used in these studies are “gold standard” patients, or patients that have exactly one disorder. As many practitioners at the conference agreed, this sort of patient doesn’t come along very often; in fact, most patients we see have at least two comorbid diagnoses, not to mention many relevant environmental factors.  

So, how do we facilitate research that is truly representative of clinicians’ patients, and yield effective treatments? Dr. Fowler prescribes Practice Research Networks (PRNs). These are networks of professional psychologists who conduct research through their own and their colleagues’ practices by distributing paper surveys or using online surveying tools. These networks yield a representative patient population, and according to Dr. Fowler are much more likely to discover effective treatments for the types of TR patients that generally aren’t included in RCTs.

I found this conference to be exciting and informative. Dr. Fowler’s GPSI was relevant and useful, and his ideas about the TR patient were comprehensive, nuanced, and experience-near. I greatly appreciated the camaraderie of my fellow practitioners in our aspiration to give our patients treatment that works, not treatment that has been validated only in its application to the rare, “gold—standard” patient.