What evidence there is about the effectiveness of psychodynamic therapy comes from?

Psychodynamic Psychotherapy

At the core of psychodynamic psychotherapy lies adynamic interaction between different dimensions of the mind. This approach is based on the belief that much of one's mental activity occurs outside one's awareness. The patient is often unaware of internal conflicts because threatening or painful emotions, impulses, and memories are repressed. Behavior is then controlled by what the patient does not know about himself or herself. Therapy objectives are to increase self-understanding, increase acceptance of feelings, and develop realistic relationships between self and others. This therapy is nondirective to allow a patient's characteristic patterns to emerge, so that self-understanding and a corrective emotional experience can then be fostered.

Psychodynamic psychotherapy has shown applicability for the treatment of anxiety and depression as well as maladaptive aspects of personality. Brief, time-limited psychodynamic psychotherapy can be appropriate for youth who are in acute situational distress. Long-term therapy can be appropriate when the biologic or social factors destabilizing the child's adaptation and development are chronic, or the psychological difficulties caused by comorbidities are complex, or if entrenched conflicts and developmental interferences are present.

Introduction

The term psychodynamic psychotherapy includes a wide range of therapeutic techniques and theoretical perspectives stemming from the early work of Sigmund Freud (1856–1939) and his colleagues. For more than a century, their psychoanalytic principles have been a major influence in the treatment of mental and behavioral problems.

When Freud introduced his theories in the late nineteenth century, the medical community was shocked by many of the concepts, primarily the role of infant sexuality in human development. Yet, by the early twentieth century, his writings had impacted not only the medical field but also much of Western culture, especially in the arts, drama, and literature. Several early concepts even became incorporated into one's everyday language (e.g., ‘Freudian slip’). The two world wars contributed to the rapid expansion of the fields of both psychiatry and psychology, bringing new insights, theories, and approaches. As a result, the early models of mental disorders and treatment techniques changed dramatically. Despite all the modifications in the field, many of those early concepts continue to have an important role in understanding psychological development and emotional disorders.

In this article of the Encyclopedia, the basic psychoanalytic theories are reviewed, their evolution over the years is examined, and their influence on the methods of psychotherapy, as well as the influence of changing life styles on the practice of psychotherapy, is considered. The research thus far that has endeavored to measure the results of psychodynamic psychotherapies, and the educational requirements for professionals entering the field, is also explored. Below, the terms ‘patient’ and ‘client’ are used interchangeably.

Psychodynamic Psychotherapy

Psychodynamic psychotherapy has the longest organized tradition of the psychotherapies. It is also known as psychoanalytic psychotherapy or expressive psychotherapy.2 This psychotherapy can be brief or time-limited, but it is usually open-ended and long-term. Sessions are generally held once or twice per week, with the patient being encouraged to talk about “whatever comes to mind.” This encouragement has been termed thefundamental rule of psychotherapy. The therapist, consequently, is usually non-directive but may encourage the patient to focus on feelings about “whatever comes to mind.” The therapist is empathic, attentive, inquiring, non-judgmental, and more passive than in other kinds of psychotherapies. The goal of psychodynamic psychotherapy is to recognize, interpret, and work through unconscious feelings that are problematic. Often unconscious feelings are first recognized in transference phenomena. Many psychodynamic psychotherapists choose to ignore positive transference phenomena, but interpret negative phenomena. For example, the patient may express the wish to be the therapist's friend. The focus would be on the patient's disappointment and frustration that a friendship cannot occur rather than a focus on the depth of the patient's longing for a friendship with the therapist. The psychotherapist deliberately avoids answering most questions directly or revealing personal information about himself or herself. This strategy, referred to as theabstinent posture, promotes the emergence of transference phenomena. The abstinent posture leaves a social void that the patient fills with his or her imagination and projections, allowing the therapist access to the patient's unconscious. The patient will get in touch with intense feelings that have been suppressed or repressed. Catharsis is the “letting go” and expression of these feelings.

At least six major theoretical systems exist under the psychodynamic model; these are summarized inBox 10-1.3–7

Psychoanalysis is an intensive form of psychodynamic psychotherapy; several of its characteristics are summarized inBox 10-2. The time and financial cost of psychoanalysis generally puts it out of range for many patients. To date, there is no persuasive evidence that psychoanalysis is more effective than psychodynamic psychotherapy. However, there is emerging evidence that psychodynamic psychotherapy is effective for a number of diagnoses.8,9

6.05.4.1 Outcome Research

At the time of this writing, there have been a total of at least 278 randomized trials of psychodynamic psychotherapy (Lilliengren, 2021). Likely the first of these was published in 1967 by Gelder, Marks, & Wolff. These researchers compared psychodynamic psychotherapy—combining individual and group formats—to systematic desensitization for the treatment of various phobic states. Since that time, psychodynamic therapy has been tested in controlled trial settings for common psychiatric conditions such as mood disorders (esp. depression), anxiety disorders (e.g., panic disorder, social phobia), eating disorders (e.g., bulimia nervosa), post-traumatic stress disorder, schizophrenia, and personality disorders (e.g., borderline personality disorder, Cluster C personality disorders). Psychodynamic therapy has also been applied to medical conditions such as idiopathic headaches, Chron's disease, medically-unexplained pain, rheumatic disease, irritable bowel syndrome, and others. As was the case with other orientations, many outcome studies conducted prior to the 1980s were conducted with neither specific psychotherapy manuals nor checks of therapist adherence and competence (see Sharpless and Barber, 2009). As such, it is difficult to ascertain certain methodological elements of these studies. Modern trials of psychodynamic therapy, however, appear to have been implemented with levels of methodological rigor roughly equivalent to cognitive behavioral and other approaches (e.g., see Gerber et al., 2011; Thoma et al., 2012).

Enough psychodynamic trials have been completed to allow for meta-analysis. Indeed, a number of meta-analyses have been conducted over the past two decades which focused on short (e.g., Driessen et al., 2015; Leichsenring et al., 2004), medium (e.g., Keefe et al., 2020; Leichsenring and Leibing, 2003), and even long-term dynamic therapy approaches (e.g., Leichsenring and Rabung, 2008; Woll and Schönbrodt, 2020). We first focus on the results from a wide-ranging meta-analysis (Barber et al., 2021) published in the latest edition of Bergin & Garfields Handbook of Psychotherapy and Behavior Change (Barkham et al., 2021). Hedge's g effect sizes are reported for all comparisons.

By way of brief summary, available evidence indicates that psychodynamic therapy is no less effective than other approaches (Barber et al., 2021). Therefore, with some limited exceptions to be detailed below, the “dodo bird verdict” remains largely intact. Of note, there have been sufficient trials of psychodynamic therapy to enable meta-analysis of certain individual disorders as well as classes of disorders.

Considering major depressive disorder, available evidence indicates that psychodynamic therapy is clearly more efficacious than waitlist-control (g = −1.14) and treatment as usual (g = −0.48). When compared to more active and formalized treatments (e.g., cognitive behavior therapy; interpersonal psychotherapy; psychopharmacology), psychodynamic therapy did not significantly differ at either post-therapy (g = −0.01) or follow-up assessment (g = −0.01) periods (see also Driessen et al., 2010; Leichsenring, 2001).

Though typically associated with cognitive and behavioral therapies, there is also evidence for the efficacy of psychodynamic therapy for many anxiety disorders (e.g., panic disorder, social anxiety disorder). Psychodynamic therapy was superior to control conditions (g = −0.94) including minimum treatment (viz., that include psychoeducation and instructions for patient self exposure). It was also found to not significantly differ in outcome from alternate treatments at post-treatment (g = −0.01), short-term follow-up (g = 0.08), or long-term follow-up (g = 0.21) assessments (see also Keefe et al., 2014).

However, there was some evidence that psychodynamic therapy for generalized anxiety disorder may be significantly less effective than alternate treatments at follow-up. It should be noted that a recent pilot study of Intensive Short-Term Dynamic Therapy for generalized anxiety disorder (Lilliengren et al., 2017) was associated with significant symptom reductions as well as reductions in overall healthcare costs at 4 years post-treatment. Therefore, more research on generalized anxiety disorder appears warranted. Further, another possible exception would be specific phobia. Though we are not aware of recent trials comparing psychodynamic therapy to cognitive behavior therapy for specific phobias, effective and very efficient forms of the latter exist (i.e., Davis et al., 2012).

Barber et al. (2021) were also able to conduct meta-analyses on the efficacy of psychodynamic therapy for personality disorders (i.e., borderline personality disorder and Cluster C personality disorders). Similar to the above, psychodynamic therapy was significantly more efficacious than control conditions (g = −0.63), but not significantly different from alternate treatments at post-therapy (g = 0.05) or follow up (g = 0.00) periods. It is noteworthy that they have as yet been no trials—psychodynamic or otherwise—for narcissistic and other common personality disorders.

A different meta-analysis conducted by Steinert et al. (2017) tested whether there was equivalence of outcome for short-term psychodynamic therapy when compared to two other established treatment conditions (i.e., cognitive behavior therapy and pharmacotherapy). Steinert and colleagues used adversarial collaboration (Kahneman and Klein, 2009) to control for any potential allegiance effects associated with the two therapy conditions. This has been a frequent criticism of the broader literature for quite some time. More specifically, the authors of this meta-analysis included representatives of both psychodynamic and cognitive-behavioral modalities who participated in important aspects of the study design (e.g., selection of studies to include and analysis). Results indicated that psychodynamic therapy was indeed equivalent to these other, more established treatments at termination (g = −0.15) and follow-up (g = −0.05).

Whereas there have been numerous trials of short-term psychodynamic therapy, there are far fewer trials of long-term approaches. This is unfortunate, as certain complex and/or chronic patients may be less appropriate for short-term treatments. Interestingly, there may be some indirect evidence for this point coming from non-psychodynamic modalities. Specifically, Hollon and Ponniah (2010) found that treatments with additional continuation and maintenance had lower risks of relapse. However, a review of the available meta-analyses of long-term psychodynamic therapy revealed mixed results. For example, Leichsenring et al. (2013) found that longer forms of therapy were superior in some ways whereas the Smit et al. (2012) meta-analysis was less clear. Interestingly, at least one study found that higher weekly session frequencies were better than lower (Blomerg et al., 2001).

Most recently, Woll and Schönbrodt (2020) updated Leichsenring et al. (2013b) meta-analysis of long-term psychodynamic therapy as compared to other forms of psychotherapy. They found small, yet statistically-significant advantages in terms of psychiatric symptoms (g = 0.24), social functioning (g = 0.35), and overall effectiveness (g = 0.28). The authors tentatively concluded that long-term psychodynamic psychotherapy may be superior to other forms of therapy for patients with complex mental disorders.

The efficacy of internet-delivered psychodynamic psychotherapies has also been assessed via meta-analysis. These approaches all utilized some form of computer software to implement therapeutic interventions (e.g., text, videos) and foster some amount of interaction between the patient and an actual therapist. Based upon a meta-analysis of seven studies, Lindegaard et al. (2020) found internet-delivered psychodynamic therapy to be superior to control conditions in terms of main outcomes (g = 0.44), depression (g = 0.46), anxiety (g = 0.20), and quality of life (g = 0.40).

In closing this section, it is important to note that the evidentiary base of any form of psychotherapy need not be limited to randomized controlled trials. Their appeal is intuitive, of course, especially when considering public interest in outcomes of direct head-to-head comparisons with well-established treatments. However, given the presence of certain macro-level headwinds (e.g., decreased funding for clinical trials, declining representation of psychodynamic faculty in doctoral research programs, and the increased medicalization of mental health disorders), a more flexible research basis may soon become necessary for the continued growth of the psychodynamic field (e.g., see Barber and Sharpless, 2015). Therefore, many contemporary psychotherapy researchers would argue for a need to supplement clinical trials with alternative approaches such as effectiveness studies, single case design research (Fishman, 2000), and the use of large practice-research networks (e.g., see Borkovec, 2002; Castonguay et al., 2015). From a broader economic standpoint, additional documentation of the cost-effectiveness of psychodynamic therapy would be beneficial. The existing studies (e.g., Abbass et al., 2015; Lilliengren et al., 2017) appear promising, especially in terms of reducing long-term healthcare costs.

Psychodynamic psychotherapy

Psychodynamic psychotherapy is derived from psychoanalysis and is based on several key analytical concepts. These include Freud’s ideas about psychosexual development, defence mechanisms, free association as the method of recall, and the therapeutic techniques of interpretation, including that of transference, defences and dreams. Such therapy usually involves once-weekly sessions, the length of treatment varying between 3 months and 2 years. The long-term aim is symptom relief and personality change. Psychodynamic psychotherapy is classically indicated in the treatment of unresolved conflicts in early life, as might be found in non-psychotic and personality disorders. There is no convincing evidence concerning its superiority over alternative forms of treatment.

Summary

Psychodynamic psychotherapy is a time-honored mode of in-depth exploration of the patient's internal world and the derivatives of that internal world in the patient's world and daily life. There are a variety of theoretical models that are typically used by psychodynamic therapists, and these models are tailored to the specific characteristics of the patient with the notion that no one conceptual framework explains all the psychopathology. A critical aspect of psychodynamic psychotherapy is to use what transpires within the therapeutic relationship as primary data to understand what happens in relationships outside the therapy. Psychodynamic psychotherapy has now accumulated sufficient empirical evidence through randomized controlled trials to support it as an efficacious treatment modality. Both STPP and LTPP have been shown to be useful in a range of psychiatric disorders.

VI.A Psychodynamic Psychotherapy

Psychodynamic psychotherapies evolved from psychoanalytic therapies, and as such they were originally designed to assist patients in the modification of their personality. This task occurs via the uncovering and bringing to awareness of unconscious conflicts that interfere with functioning. Recent adaptations of psychodynamic psychotherapies that have focused on depression emphasize more active approaches while continuing to uncover unconscious conflicts. Psychodynamic psychotherapies tend to emphasize the development of a therapeutic alliance that can increase patients’ self-efficacy with respect to problem solving. Once the therapeutic alliance is developed, patients are then better able to gain insight into their problems by learning more about their relationship patterns, which then leads to increased potential for change. Some of this insight is developed via an exploration of the therapist–patient relationship and an examination of the ways in which this relationship mirrors the patients’ real-world relationships.

When compared with other forms of psychotherapy for adults, psychodynamic psychotherapy tends to perform equivalently. Unfortunately, few studies have successfully compared psychodynamic psychotherapy with placebo conditions; therefore, the extent to which psychodynamic psychotherapy offers benefits that are particular to the psychoanalytic orientation remains in dispute.

Brief psychodynamic psychotherapy (BPP) comprises a group of psychotherapeutic interventions characterized by their short-term adaptations of psychoanalytically inspired psychotherapy. The following criteria represent the constituents of a prototypic definition of BPP: the theory of psychopathology explaining the disorder and treatment techniques employed are psychoanalytic in origin (clarification, interpretation and confrontations), patients are selected for their ability to withstand intensive psychotherapy, treatment is time-limited with brevity maintained by maintaining treatment focused on a specific issue or conflict, and the intent of treatment is to provide limited personality or character change. Historically, there has always been a subgroup of psychoanalysts who have attempted to keep psychoanalysis brief, and their efforts have led to the development of BPP. In contrast to psychoanalysts and long-term dynamic therapists, therapists who conduct BPP see patients once or twice a week, sitting up, for a limited number of sessions. Recent proponents of BPP have developed treatment manuals detailing their specific therapeutic techniques. In addition to aiding clinicians, many of these manuals have been implemented in efficacy studies of BPP to ensure that therapists followed treatment guidelines. Although a meta-analytic review of several studies indicates that BPP is an effective treatment, well conducted research for specific psychological problems remains scarce.

Who Can Benefit?

Psychodynamic psychotherapy, whether performed by a psychiatrist, psychologist, social worker, or other mental health clinician, can be a powerful adjunctive treatment for patients. Referrals need not come only from psychiatrists; neurologists, internists, family physicians, and others can take advantage of resources in their communities. Psychodynamic psychotherapy is generally indicated for individuals stuck in irrational behaviors, unsatisfying relationships, or unfulfilling jobs and for individuals with depressive or anxiety disorders. Psychodynamic therapy can also benefit more severely disturbed individuals with personality or thought pathologies, although care should be taken to refer these patients to therapists experienced in caring for them.

PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy has the longest organized tradition of the psychotherapies. It is also known as psychoanalytic psychotherapy or expressive psychotherapy.7 This psychotherapy can be brief or time-limited, but it is usually open-ended and long-term. Sessions are generally held once or twice per week, with the patient being encouraged to talk about “whatever comes to mind.” This encouragement has been termed the fundamental rule of psychotherapy. The therapist, consequently, is usually nondirective but may encourage the patient to focus on feelings about “whatever comes to mind.” The therapist is empathic, attentive, inquiring, nonjudgmental, and more passive than in other kinds of psychotherapies. The goal of psychodynamic psychotherapy is to recognize, interpret, and work through unconscious feelings that are problematic. Often unconscious feelings are first recognized in transference phenomena. Many psychodynamic psychotherapists choose to ignore positive transference phenomena, but interpret negative phenomena. For example, the patient may express the wish to be the therapist's friend. The focus would be on the patient's disappointment and frustration that a friendship cannot occur rather than a focus on the depth of the patient's longing for a friendship with the therapist. The psychotherapist deliberately avoids answering most questions directly or revealing personal information about himself or herself. This strategy, referred to as the abstinent posture, promotes the emergence of transference phenomena. The abstinent posture leaves a social void that the patient fills with his or her imagination and projections, allowing the therapist access to the patient's unconscious. The patient will get in touch with intense feelings that have been suppressed or repressed. Catharsis is the “letting go” and expression of these feelings.

At least six major theoretical systems exist under the psychodynamic model; these are summarized in Table 10-1.

Psychoanalysis is an intensive form of psychodynamic psychotherapy; several of its characteristics are summarized in Table 10-2. The time and financial cost of psychoanalysis generally puts it out of range for many patients. To date, there is no persuasive evidence that psychoanalysis is more effective than psychodynamic psychotherapy. However, there is emerging evidence that psychodynamic psychotherapy is effective for a number of diagnoses.13,14