Response to Carswell et. al.

Psychodynamic therapy can be adapted to and implemented in non-western cultures   – a comment on the WHO treatment guideline for mental disorders

a  Prof. Dr. Falk Leichsenring, University of Giessen, Department of Psychosomatics and

Psychotherapy, Giessen, Germany and University of Rostock, Department of

Psychosomatics and Psychotherapy, Germany

b  Prof. Dr. Allan Abbass, Dalhousie University, Halifax, Canada

c  Prof. Dr. Peter Fonagy, Research Department of Clinical, Educational and Health

Psychology, University College London, London, United Kingdom

d  Prof. Dr. Kenneth N. Levy,  Pennsylvania  State University, College of the Liberal Arts,

USA

e  Prof. Dr. Peter Lilliengren, Department of Psychology, University of Stockholm, Sweden

f  Prof. Dr. Patrick Luyten, Faculty of Psychology and Educational Sciences, University of

Leuven, Leuven, Belgium  and Research Department of Clinical, Educational and Health

Psychology, University College London, London, United Kingdom

g  Prof. Dr. Nick Midgley, Research Department of Clinical, Educational and Health

Psychology, University College London, London, UK

h   Prof. Barbara Milrod, Albert Einstein College of Medicine,  New York, USA

We thank Kenneth Carswell and colleagues for their response to our comment on the WHO guideline for psychotherapy.1,2 Carswell et al. agree that CBT is not the only evidence-based psychotherapeutic approach and indicate that embracing a broader array of empirically-supported psychotherapies will be considered during future guideline updates. However, several statements by the authors are debatable.

Carswell et al. emphasize that lower-intensity psychotherapeutic interventions are urgently needed in low and middle income countries (LMICs), including interventions that are brief and can be delivered by non-specialists or through guided self-help.1 We agree, but as we stated2,  such interventions are available for non-CBT approaches such as psychodynamic therapy (PDT).

The authors emphasize the rigorous WHO guideline methodology they applied. In spite of this, the WHO expert group missed substantial evidence for non-CBT approaches such as PDT.2,3 Furthermore, this expert group did not encompass proponents of other approaches such as PDT or interpersonal therapy to ensure a balanced review.

The authors suggest that LMIC psychotherapy research has predominantly focused on CBT due to the relative ease with which non-specialists can be trained in CBT.1 However, there is no evidence that non-specialists can be trained more easily in CBT than in other approaches. Evidence shows that PDT, for example, is adaptable and can be effectively taught to new practitioners from diverse theoretical and professional backgrounds.4,5 There are more than 50 RCTs of PDT from LMICs including Iran, Brazil, Mexico, Chile, Cambodia, Indonesia and China addressing a broad range of mental disorders and conditions, demonstrating that PDT can be adapted to and implemented in non-Western cultures.3 Study quality needs to be assessed for CBT as well.

Carswell et al. further argue that the prominence of CBT recommendations in the WHO guideline is due to the fact that more evidence is available for CBT than for other approaches. However, more studies do not necessarily imply higher efficacy of a treatment or certainty of evidence. CBT has not been proven to be more efficacious or to show better study quality than other approaches.2  As we noted, the response rates of CBT range between 24% and 42%.2 Thus, the majority of patients did not respond to CBT. These patients may benefit from other approaches.

More high-quality psychotherapy research in LMICs is required, focusing not only on narrow symptoms but transdiagnostically on general psychopathology and psychosocial functioning, areas preferably addressed by PDT.