Research Behind Psychodynamic Therapy

Psychoanalysis is a highly specialised treatment based on the observation that people are often unaware of the many internal factors that determine their emotions and behaviour. Psychodynamic therapy and psychoanalytical psychotherapy are modern variations of psychoanalysis. There is a misconception that psychoanalysis is a treatment of the past. Psychoanalysis has a contemporary application and relevance, especially in our current times with the enormous burdens mental health disorders impose worldwide and difficulties in providing effective psychological treatments.

Overview

One of the most recent studies conducted by Leichsenring et al (2023) using the new criteria to endorse a treatment as empirically supported psychotherapeutic treatment (ESTs) examined the efficacy of psychodynamic therapy. They found there is evidence for the efficacy of psychodynamic therapy in treating depressive, anxiety, personality and somatic disorders (Leichsenring et al., 2023)

In summary, psychodynamic therapy emerges as a potent and versatile approach for addressing various mental health disorders, backed by a growing body of empirical evidence. Despite historical misconceptions, psychodynamic therapy, along with its modern variations remains relevant and effective in contemporary times. One of its core strengths lies in its emphasis on the therapeutic relationship, recognized as a key predictor of successful therapeutic outcomes across different therapeutic approaches. While psychodynamic therapy may sometimes be perceived as less known or evidence-based compared to CBT, recent research efforts have substantially contributed to affirming its efficacy and relevance in treating diverse clinical conditions. Notably, psychodynamic therapy has shown promising outcomes in the treatment of depression, personality disorders, somatic disorders, and other complex mental health issues, often yielding effects comparable to or even exceeding those of CBT and other evidence-based treatments. Moreover, its enduring effects and capacity to foster deep self-awareness and personal growth make it a valuable therapeutic option for individuals seeking comprehensive and lasting improvements in their mental well-being. Overall, the empirical evidence underscores the efficacy and importance of psychodynamic therapy as a valuable component of the therapeutic landscape, offering individuals a pathway to richer, more fulfilling lives.

Central to numerous controversies surrounding therapy lies a fundamental inquiry: Which therapy is the most effective?

One active ingredient that has been found to be the most significant predictor of successful therapeutic outcome which is shared between all approaches is the therapeutic relationship (Wampold & Brown, 2005;Flückiger et al., 2012; Duncan,  Miller, Wampold  & Hubble, 2010).

One of the major psychodynamic schools is Object Relations which focuses on relationships, and emotional bonds with significant others i.e. objects (Gomez, 1997). Relationships are interactional patterns and in therapy these dynamics are interplayed in the therapist and patient relationship which are explored and addressed to help create awareness in unconscious processes (Gomez, 1997). Object relations therapy and psychodynamic therapies share a common emphasis on the therapeutic relationship as a catalyst for meaningful change. Psychodynamic therapy stands out as one of the few therapeutic approaches that places significant emphasis on the exploration and understanding of the therapeutic relationship between therapist and client as a central component of the treatment process.

Psychodynamic therapy, while historically influential, is sometimes less known and regarded as evidence-based compared to other therapeutic approaches due to challenges in empirically validating its theoretical concepts and techniques. Its emphasis on exploring unconscious processes and childhood experiences can be complex to measure objectively, leading to difficulties in generating empirical evidence to support its efficacy (Shedler, 2010). Additionally, psychodynamic therapy’s focus on long-term treatment and the therapeutic relationship may not always align with the preference for shorter, symptom-focused interventions in contemporary healthcare settings, further contributing to its relative lack of visibility and empirical validation (Shedler, 2010).

Presently, Cognitive Behavioural Therapy (CBT) is widely recognized as the most extensively studied therapeutic modality, often regarded as the benchmark for treating psychological disorders. Nonetheless, critiques have emerged regarding certain criteria, such as the exclusive emphasis on symptom alleviation at the expense of broader psychosocial functioning, the challenge of generalizing findings from controlled research environments to real-world clinical contexts, oversight of potential design flaws and researcher biases, and the minimal requirement of just two Randomized Controlled Trials (RCTs) to establish efficacy (Charman, 2003).

Professor Shedler’s article (2010) was one of the first to highlight the problems associated with efficacy studies and how fewer efficacy studies have been conducted into psychodynamic therapy in comparison to CBT. He also stated that psychotherapy research often yields what is termed the “dodo bird verdict,” akin to everyone being a winner, yet no clear victor emerges (Shedler, 2010). Despite efforts to discern differences, outcomes across various therapies tend to be equivalent, with positive findings often favouring the treatment advocated by the researchers (Shedler, 2010). This underscores the ongoing challenge of determining the most effective form of psychotherapy, reflecting the complexity and multifaceted nature of mental health treatment. Shedler (2010) initiated the compilation of empirical evidence affirming the efficacy of psychodynamic therapy. Today, the empirical evidence supporting the efficacy of psychodynamic therapy has grown substantially (Leichsenring et al., 2023). Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as ‘empirically supported’ and ‘evidenced based’. In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends (Leichsenring et al., 2023; Shedler, 2010).

Incorporating data from 23 randomized controlled trials involving 1,431 patients (Abbass, Hancock, Henderson, & Kisely, 2004), the research examined the outcomes of short-term psychodynamic therapy for various common mental disorders compared to controls receiving minimal treatment or “treatment as usual.” The analysis revealed a substantial overall effect size of 0.97 for general symptom improvement, which notably increased to 1.51 during long-term follow-up assessments (>9 months posttreatment). Furthermore, changes in somatic symptoms exhibited an effect size of 0.81 initially, surging to 2.21 at long-term follow-up, while anxiety ratings displayed an effect size of 1.08 initially, escalating to 1.35 post-follow-up. Similarly, depressive symptoms showed an initial effect size of 0.59, which rose to 0.98 during follow-up, indicating a consistent trend toward larger effect sizes post-treatment, suggesting that psychodynamic therapy initiates enduring psychological processes fostering ongoing change beyond the therapy period.

Depression

One systematic review and meta-analysis of individual participant data investigates the efficacy of adding short-term psychodynamic psychotherapy (STPP) to antidepressants in the treatment of depression (Driessen et al., 2023). Data was obtained from 7 RCTs. The research suggests that by combining antidepressants with STPP, patients may experience more comprehensive and long-lasting relief from depressive symptoms compared to those treated with antidepressants alone, especially for more depressed individuals (i.e. experiencing depression over 2 years). This integrated approach addresses not only the biological aspects of depression but also the underlying psychological factors contributing to the illness, making it especially suitable for individuals with complex emotional needs.

This study is consistent with previous empirical evidence finding psychodynamic therapy to be effective for treatment resistant depression i.e. chronic major depressive disorder (Fonagy et al., 2015). Another meta-analysis on 53 RCTs demonstrated the efficacy of short-term psychodynamic psychotherapy for depression and revealed promising outcomes, indicating significant reductions in depressive symptoms among treated individuals (Driessen et al., 2015). These findings underscore the effectiveness of this therapeutic approach as a viable option for addressing depression (Driessen et al., 2015).

Psychodynamic psychotherapy appears to be as effective as other treatments: effect sizes from meta-analyses suggest that it is equally, and sometimes even more effective than other psychotherapy, as effective as CBT, and often more effective than antidepressants. Second, there is established literature showing that short-term treatments tend to ameliorate demoralization and symptoms but do not lead to more established rehabilitative changes in personality and functioning (Driessen et al., 2015).

Personality Disorders

Personality Disorders are considered a major treatment challenge in and of themselves. A systematic review and meta-analysis by Leichsenring and Leibing  (2003) provided evidence of the long-term effectiveness of psychodynamic therapy for personality disorders. A more recent systematic review and meta-analysis conducted by Town (2011) further supports conclusions that psychodynamic therapy may be considered an efficacious empirically-supported treatment option for a range of personality disorders, producing significant and medium to long-term effects.

Another systematic review and meta-analysis found that in twelve RCTs that psychoanalytic psychotherapy is potentially effective in the treatment of suicidal and self-harming behaviours, and in reduction of some of the risk factors for these behaviours( Briggs, et al., 2019).

The findings regarding personality disorders are notably compelling. Another study focusing on patients with borderline personality disorder (Clarkin, Levy, Lenzenweger, & Kernberg, 2007) revealed treatment outcomes comparable to or surpassing those of another evidence-based therapy, dialectical behaviour therapy while also demonstrating alterations in underlying psychological mechanisms, specifically changes in reflective function and attachment organization believed to facilitate symptom improvement in borderline patients (Levy et al., 2006). Notably, these intrapsychic changes were observed in patients receiving psychodynamic therapy but not in those undergoing dialectical behaviour therapy, suggesting their potential role in sustaining long-term treatment benefits.

Somatoform Disorders

A systematic review and meta-analysis conducted by Abbass, Kisely, and Kroenke in 2009 examining 23 clinical trials suggest that short-term psychodynamic psychotherapy is an effective intervention for somatic disorders, showing significant improvements in symptom reduction and overall patient well-being. This research highlights the potential of psychodynamic approaches in addressing a wide range of somatic conditions (e.g., dermatological, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal,

genitourinary, immunological) and underscores the importance of considering psychological factors in the treatment of such disorders. Another finding of this study was that 77.8% of patients reported reductions in health care utilisation if they were engaged in psychodynamic therapy—a finding with potentially enormous implications for health care reform.

Another meta-analysis conducted by Town and Driesssen (2013) found a comprehensive body of studies investigating the effectiveness of short-term psychodynamic therapy with personality disorders and somatic disorders, contributing to an emerging body of evidence supporting its efficacy in these clinical domains.

Children and Young People

One study found that psychodynamic treatment to be significantly effective for younger children who may experience anxiety disorders, self-harm and eating disorders, and has comparable outcomes to other psychological treatments such as CBT or systemic family therapy (Midgley et al., 2021).

Enduring Effects

Knekt (2011) conducted a study comparing the effectiveness of short-term and long-term therapies with psychoanalysis and found that psychoanalytic psychotherapy was more effective in the long run, particularly evident at the 5-year follow-up assessment. Although short-term therapies provided quicker benefits initially, psychoanalysis demonstrated superior efficacy in reducing psychiatric symptoms and improving work ability and functional capacity over time. These findings suggest that psychoanalytic psychotherapy may offer enduring benefits for patients with mood and anxiety disorders, highlighting its potential as a preferred treatment option for long-term symptom management.

Especially noteworthy is the recurring finding that the benefits of psychodynamic therapy not only endure but increase with time, a finding that has now emerged from at least five independent meta-analyses (Abbass et al., 2006; Anderson & Lambert, 1995; de Maat et al., 2009; Leichsenring & Rabung, 2008). These meta-analyses represent the most recent and methodologically rigorous evaluations of psychodynamic therapy.

Comparisons with other Approaches

A couple recent systematic reviews and meta-analyses compared psychodynamic therapy to the ‘gold standard of treatment’ CBT. Their results are consistent with previous meta-analysis which found no differences in outcome between psychodynamic therapy and other treatments (Driessen et al.,2015; Keefe et al., 2014) adding more robust data to support the notion of equivalence between treatments.

While all therapy styles are beneficial, psychodynamic therapy offers clients a unique experience. By allowing clients to lead discussions based on their individual concerns, providing a safe environment to express genuine emotions, and encouraging reflection on the significance of feelings and experiences, psychodynamic therapy cultivates essential self-awareness and understanding (Charman, 2003). As Dr. Shedler puts it, “For many individuals, psychodynamic therapy may cultivate internal resources and abilities that lead to more enriched, liberated, and satisfying lives.”

Michiel Gonzales

Registered Psychologist

WRITERS COMMENTS

In summary, back to the phenomena requires theory drivenprocess research. Psychodynamic psychotherapy has a longtradition of understanding and working with complex anddifficult patients, the type of patients more characteristic oftoday’s clinical patients. (Charman, 2003).

What was particularly telling in these studies is that over time, the clients who received psychodynamic treatment continued feeling better even after treatment had ended. Conversely, clients who had received other types of therapy saw a gradual decline in symptom relief—in short, they stopped feeling better. Dr. Shedler suggests that even the positive results shown in other modalities may have come from psychodynamic influences, such as attention to the therapist/client relationship, as well as promoted awareness of implicit feelings and meanings (aka, the unconscious!). He also proposes that past research studies did not consider enduring positive changes, but merely the results yielded during treatment. This would skew the measurable benefits of other therapy styles compared with psychodynamic therapy because the enduring benefits of psychodynamic therapy were previously unacknowledged.  (Charman, 2003).

References

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