Letters to the editor

Astonishment was quickly followed by dismay as I flipped through the April edition of InPsych.

I eagerly dove into the article about the Royal Commission. It feels like a landmark time in history when we openly refuse to allow people to abuse positions of power to gratify their urges for power and sex within our institutions.

Yet as I turned to the lead article, "Sex on Campus", I was surprised that this issue was to be 'examined' since I had presumed, based on the underpinning principles of the Royal Commission, that it would be considered extremely unethical for academic staff to engage in sexual relationships with their students.

Are we not once again looking at the issue of powerful people in powerful institutions gratifying personal needs whilst clear inequalities in power, such as age, academic advancement, and often gender and race exist?

Yesterday a colleague related a disturbing story of a lasting impact on her academic record after she rejected the advances of her postgraduate supervisor. My colleague remains visibly shaken to this day. Research shows that more than half of female US graduate students are sexually harassed (Rosenthal et al., 2016) and that universities often deal with this in a very self-protective manner (Smith & Freyd, 2014).

In her InPsych piece, Dr Gullifer, agrees that there is a concerning power differential between staff and students, and that cases of sexual harassment are well documented. However, she then shifts to the blanket ban placed on staff/student relationships in many leading US universities. She notes that the prohibition of such relationships could be seen as an infringement of human rights. This is of course the very same justification put forward by so many paedophiles.

Dr Gullifer feels that this issue is "fraught with complexity". I do not agree. Who is served by sexual relationships between academic staff and students? Who will be inconvenienced by a ban of such relationships? Who has the greatest potential to be harmed by sexual relationships between students and their mentors/markers?

I find this article to be non-protective of people who are vulnerable to the misuse of power. This disappoints me when it is published by the APS, whose membership spends far more time addressing the rehabilitation of those abused in our institutions than repatriating those perpetrating the abuse.

Dr Alanda Thompson MAPS

Rosenthal, M.N., Smidt, A.M., & Freyd, J.J. (2016). Still second class: Sexual harassment of graduate students. Psychology of Women Quarterly, 40, 364-377.

Smith, C.P., & Freyd, J.J. (2014). Institutional Betrayal. American Psychologist, 69, 575-587.

We were pleased to see an article on the treatment of borderline personality disorder (BPD) in the April 2018 edition of InPsych and commend Assoc Prof Lee and his colleagues for their work in this area. We would, however, like to add to what Assoc Prof Lee and Dr Jeffery published in April and recommend something of a shift in emphasis in relation to a couple of matters.

First, we note that the bulk of the article focused on dialectical behaviour therapy (DBT) and schema therapy. This may give the misleading impression that these are the therapies for which there is the greatest evidence for effectiveness. The authors acknowledge that psychodynamic therapy also has an evidence base, but the brief discussion of this approach was confined to mentalisation based therapy (MBT). It is important that readers are aware that a recent meta-analysis, published in JAMA Psychiatry (Christea et al., 2017) reported that only psychodynamic therapy and DBT were clearly superior to control interventions. The effect size for psychodynamic therapy was greater than that of DBT, although not significantly so.

Second, we think that aside from effectiveness, psychodynamic therapy is a less complicated treatment and may be more accessible to many people. DBT is rather limited in its availability because it requires dedicated teams. This means that it can usually only be accessed through a few large public hospitals and a handful of private services, whereas there are many psychodynamic therapists who have the skills and experience to treat people presenting with BPD.

Third, some readers may have formed the impression after reading Lee and Jeffery that the effectiveness of DBT and psychodynamic therapy (or schema therapy for that matter) is a function of specific theories or techniques that inhere in that therapy. We think this is unlikely. The fact that two very different therapies can yield broadly equivalent outcomes indicates that there is something about the therapy process that is much more important than specific theories or techniques. We commend to readers the APA statement on the effectiveness of psychotherapy (APA, 2012), which concluded that there is little basis for supposing that there is any specific nexus between any disorder and a particular type of therapy.

Adjunct Prof Robert King FAPS (on behalf of the National Committee of the Psychoanalytically Oriented Psychology Interest Group of the Australian Psychological Society)

American Psychological Association (2012). Recognition of psychotherapy effectiveness. Retrieved from www.apa.org/about/policy/resolution-psychotherapy.aspx

Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of Psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319-328. doi:10.1001/jamapsychiatry.2016.4287.

We thank Professor King for his comments on our article and contribution to debate in this area. Our article was not designed to be a comprehensive review of treatments for borderline personality disorder. We mentioned MBT as there had been a recent Australian RCT on this treatment and thought it very relevant to discuss in InPsych. It is our view that DBT, schema therapy and psychodynamic approaches are all evidence-based practices for borderline personality disorder. The soonto be published APS Treatment Guidelines for BPD reviews the relevant research, and the meta-analysis cited by Professor King was indeed part of the material that was used to reach the conclusions stated in those guidelines.

We do however, respectfully disagree with the conclusion in the third paragraph. Just because two different therapies yield broadly equivalent outcomes that does not mean that identical processes are involved. Nor is the field advanced by taking this position. We recently published a study that demonstrated clear distinctions in client treatment depending on whether the therapist identified themselves as CBT, schema or psychodynamic practitioner^[1]. We do not think it is logical to conclude that if two treatments have equivalent outcome that this means that the same processes are involved. If codeine and paracetamol relieve pain to the same degree it does not mean they have the same underlying mechanisms. Indeed, as is the case with the medication example, when different mechanisms are involved it opens the possibility that if a person does not respond to one type of treatment that they may benefit from another. Differences have been found in treating BPD from a psychodynamic and a schema approach^[2]. Understanding the differences could help improve our services and makes for interesting further research.

Assoc Prof Christopher Lee MAPS and Dr Sian Jeffery

Boterhoven de Haan, K. L. & Lee C.W. (2014). Therapists Thoughts on Therapy: Clinicians' Perceptions of the Therapy Processes that Distinguish Schema, Cognitive Behavioural and Psychodynamic approaches. Psychotherapy Research, 25(5), 538-549.

Giesen-Bloo, J., et al., (2006). Outpatient Psychotherapy for Borderline Personality Disorder: Randomized Trial of Schema-Focused Therapy vs Transference-Focused Psychotherapy. Archives of General Psychiatry, 63(6), 649-658.