Psychodynamic psychotherapy is often the overlooked stepchild in modern psychotherapeutic circles. While still regularly taught and practiced, it’s a therapeutic style that’s largely fallen out of favor in the U.S. with the rise of shorter-term therapies, such as cognitive behavioral therapy (CBT), which typically have a stronger research base.
New research published yesterday in JAMA (the Journal of the American Medical Association) suggests that, in a large-scale meta-analysis of 23 previously published studies on the efficacy of psychodynamic therapy, it can be a very effective therapeutic technique, especially in complex cases (such as those involving a personality disorder).
What is psychodynamic psychotherapy and what are its defining characteristics? As the accompanying JAMA editorial notes, psychodynamic therapy is:
“A therapy that involves careful attention to the therapist-patient interaction, with carefully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the therapist’s contribution to the two-person field.” Identification and interpretation of transference and resistance are distinctive features of psychoanalytic psychotherapies that are commonly misunderstood.
Transference is defined as, “those perceptions of, and responses to, a person in the here and now that more appropriately reflect past feelings about, or responses to, important people earlier in one’s life, especially parents and siblings.” Transference occurs regularly in everyday life outside a psychotherapy setting. A strong reaction to a person or situation in which the intensity of the emotion is more than what would be attributable to the current situation may be a clue to the presence of transference.
Resistance is the “patient’s attempt to protect herself or himself by avoiding the anticipated emotional discomfort that accompanies the emergence of conflictual; dangerous; or painful experiences, feelings, thoughts, memories, needs, and desires.
Of course, as regular readers of World of Psychology know, a meta-analysis can be a powerful tool to combine the data from many different studies to look at larger, general effects of a specific treatment. But it also has a significant drawback (as all metanalyses do), in that it is only as good as the selection criteria chosen for what studies to include in the analysis. And then the actual studies analyzed.
Reviewing the studies in this analysis gives one a little pause in feeling the cards were stacked for a positive outcome. One third of the studies included medication being prescribed at the same time as the psychodynamic therapy. Over half didn’t use a control or comparison group, or used one that included a different type of psychodynamic therapy (which isn’t a true “comparison” group to determine the efficacy of psychodynamic therapy versus something else). Some studies included group therapy, while others were focused solely on individual (two very different types, with two very different type of dynamics). One of the largest studies included featured government-subsidized long-term therapy (could free therapy ever produce a negative outcome?).
Although I didn’t go through all 23 studies, in my random sample of the studies used, I found additional concerns in a few (e.g., comparison of two groups who weren’t homogeneous at the onset of the study). And although done in other meta-analyses, I question the wisdom of including studies without regard to geographic region (e.g., comparing psychodynamic therapy and diagnosis done in Nordic countries with that done in Israel with that done in New York, as though all cultures and training were the same). Not all studies analyzed even included a psychiatric or psychological outcome measure.
Utilizing flawed studies can produce flawed results. One can argue that the data don’t lie, despite the flaws. I’d agree, up to a point. This meta-analysis shows that, contrary to many clinicians’ opinions, psychodynamic psychotherapy can be an effective modality, especially in cases of chronic depression or anxiety, or personality disorders such as borderline personality disorder. It cannot say whether it’s better than other long-term psychotherapies (virtually all psychotherapy techniques and approaches can be used for years, although many are focused on short-term symptom relief and change). And the analysis says nothing to the placebo effect of just being with another human being for a year or more.
Read the news story: Long-term Psychotherapy Indicated for Complex Disorders
Read the JAMA editorial on the study (subscription required): Psychodynamic Psychotherapy and Research Evidence: Bambi Survives Godzilla?
Reference:
Leichsenring, F. & Rabung, S. (2008). Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis. JAMA, 300(13), 1551-1565.
12 comments
John – does Psychodynamic Psychotherapy have any relationship or resemblance to Neuro Linguistic Programming? Do you have an opinion on NLP?
Thanks!
It’s about time! I myself prefer to work with short-term modalities (including single session which current research is showing to have long-term gains) but, this is very exciting news for my colleagues who work longer term with clients.
Your critique brought to mind a comment made by one of my grad research professors — “if you torture the numbers long enough, they’ll tell you whatever you want them to say.” I’m not sure how valid this is but, my guess is it could be applied to many things.
My experience has been, if you look hard enough, you can find a flaw with pretty much any study — some more glaring than others. In addition, many studies that support a null hypothesis don’t get published even though this might add to our pool of knowledge. Even the “best practice” literature is currently being questioned and critiqued. Ultimately, without critique there can be no progress in knowing what works — mistakes bring about the possibility of doing things in a new way.
I have been discouraged by what I call the “therapy wars” — therapists arguing about which modality is better than another. I appreciate you stating clearly the finding that one therapy has not been shown to be better than others. The common factors research has been fascinating in this sense.
I was also impressed with your statement regarding cultural differences. The literature has had a long history of not speaking to this reality (for a number of valid reasons) — one which can no longer be ignored in the face of globalization.
Your brief article covered a number of pertinent points. I thank you for being thorough with the issues.
@Carey – No, NLP and psychodynamic therapy have little in common. To learn more about NLP. Type in “NLP” into Google to learn more about it.
@Jaya – Thanks for your insightful comments. I think this study is an important milestone for psychodynamic psychotherapy, and puts a stake in the ground for future research to aspire to. Long term therapies such as psychodynamic therapy definitely have their place in this world, and this study shows that such treatments can likely be effective for people who stick with them, especially for difficult mental health problems.
quote :And the analysis says nothing to the placebo effect of just being with another human being for a year or more. :endquote
I am loathe to call human companionship for the mentally ill a ‘placebo effect.’ It is a release valve. It is therapy, although it is not particularly psychodynamic.
It’s a placebo effect in that one would not necessarily be doing any type of therapy, and such time could readily be provided by a friend or family member (rather than a professional).
All psychotherapies suffer from this generalized effect — paying someone to sit and listen to your problems is likely therapeutic in and of itself (assuming the professional does indeed listen and is generally nonjudgmental).
Useful critique.
It is hard to operationalize `psychodynamic therapy’ into something so that you can ensure that people who are being given `psychodynamic therapy’ are fairly much getting the same thing. So very much easier to operationalize `cognitive behavior therapy’ into the little handout worksheets and particular strategies (e.g., activity scheduling, relaxation, systematic desensitization, behavior analyses) so that you can ensure that everyone being given `cognitive behavior therapy’ is being given fairly much the same thing.
As such, experimental psychology (of which clinical psychology is a part) has focused fairly much on cognitive behavior therapy. Because:
– It is teachable. You can teach training therapists particular techniques (such as those mentioned above).
– It is suitable for control trials. It can be operationalized into the above techniques so that different therapists are delivering the relevantly same thing.
– It is newer than Freud (hence we have made scientific progress)
– It (is seen to) tie into the experimental psychology literature rather well (even though behaviorism heyday was in the 60’s and the `cognitive’ in `CBT’ really has nothing to do with the experimental cognitive psychology movement.
It is important to note that the absence of evidence (e.g., the relative lack of evidence for the efficacy of psychodynamic therapy) really isn’t evidence for inefficacy. There are a number of problems with experimentally investigating the efficacy of psychodynamic therapy (some of them noted above). Some of those come down to political considerations and arbitrary field divisions rather than anything inherently unscientific…
If I were my dx then I’d give a shit about the most effective treatment for my dx. Fortunately… I am not my dx so I really don’t give a shit about efficacy studies. I think… That I can tell whether something is helpful for me or not. And I can assure you that I’d well and truly done my time with CBT. I can teach myself how to cognitively restructure or activity schedule from a book. I can’t teach myself how to deal with interpersonal relationships and the physical presence of a therapist from a book, however. Or not in a way that translates into my way of interacting with the world, at any rate.
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