Accumulating Evidence for the Effectiveness of Psychodynamic Therapy

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In an era where Cognitive-Behavioral Therapy (CBT) often dominates therapeutic discourse, a recent comprehensive review lends robust support to the effectiveness of psychodynamic psychotherapies (PDTs). This endorsement comes from a detailed assessment of Randomized Controlled Trials (RCTs) involving PDTs—a gold standard in the evaluation of psychosocial interventions.

The study was spearheaded by Peter Lilliengren, an Assistant Professor at Stockholm University with specialized knowledge in Intensive Short-Term Dynamic Psychotherapy (ISTDP).

Published in Psychoanalytic Psychotherapy, Lilliengren’s research suggests that PDTs often surpass the effects of no treatment at all and demonstrate comparable outcomes to other active treatments, such as CBT.

“Categorization of outcomes suggests that PDTs typically outperforms inactive controls, while comparisons with active treatments, including Cognitive-Behavior Therapy (CBT), typically indicate no statistical difference,” Lilliengren writes. “While the evidence base for PDTs is growing, there are still major limitations and many research questions yet to be addressed. There is a pressing need for disseminating the existing research on PDTs to policymakers and the general public, as well as integrating findings in psychodynamic training curriculums.”

The goal of the current research was to create a descriptive “birds-eye” view of the current psychoanalytic landscape. In order to accomplish this goal, the author reviewed all available randomized control trials involving PDTs and created an overview of the field.

The author located 298 studies published between 1967 and 2022 involving randomized control trials of PDTs. A large portion of these studies (123 or 41.2%) were published in the last ten years. In order to be included in the current review, studies had to use a randomized design and include at least one treatment based on psychodynamic theory. This includes short-term psychotherapy, long-term psychotherapy, psychoanalysis, and other forms of PDT. No restrictions were placed on how these therapies were administered or the targeted population.

The studies were categorized into four groups by the author. The first group, called “comparative” studies, tested PDT against other interventions, including treatment as usual and no treatment. The second group, “additive” studies, involved adding PDT to the treatment that participants were already receiving, such as medication. The third group, “parametric” studies, compared different circumstances of PDT, such as individual PDT versus group PDT. The fourth and final group, “dismantling” studies, examined the effects of “full package” PDT compared to PDT where some elements were removed.

There were eight primary conditions identified: mood disorders, anxiety disorders, personality disorders, psychosomatic disorders, eating disorders, substance abuse disorders, trauma/stress-related disorders, and psychotic disorders.

The author identified treatment characteristics in each study as well, such as treatment format (group, individual, couple, or parent-infant), treatment type (short-term PDT, long-term PDT, integrative, etc.), and treatment setting (outpatient versus inpatient).

Most of the included studies came from Europe (55.7%), North America (25.8%), and Asia (14.4%). Just seven studies of 298 included came from South America. No research from Africa was included. The countries most accounted for in the current research were the United States (19.8% of all included studies), the United Kingdom (14.1%) and Germany (11.4%).

Mood disorders were the most common diagnostic category targeted by PDTs in the current research (22.5%). Anxiety disorders (11.7%) and personality disorders (12.8%) were also common areas of focus. Individual PDT was overwhelmingly the most common format (72.2%), with couples PDT being extremely rare (0.1%). Short-term PDT of 40 sessions or less was the most common treatment type (70%), and the vast majority of PDT in the current research was delivered on an outpatient basis 93.6%).

In studies comparing PDT to no treatment, 90.1% found that PDT had better outcomes. When compared to cognitive behavior therapy, 69.6% of studies showed no significant difference in outcome, while 24.4% favored cognitive behavior therapy. Additionally, 75% of studies showed no difference in outcome between PDT and medication alone. However, when PDT was added to medication, 72.7% of studies showed improved outcomes. On the other hand, when medication was added to PDT, 83.3% of studies found no significant difference in outcome.

The author acknowledges several limitations to the current work. The study design excluded unpublished studies those not published in English. All coding was done by a single researcher, which increased the chances of bias. The quality of the included studies was not assessed, and the individual authors’ theoretical “allegiance”  was not coded.

As most randomized control trials involving PDT are done by authors with allegiances to psychodynamic theory, some level of bias is to be expected. As the author set out to do a descriptive analysis, effect sizes were not calculated.

The author concludes:

“This review suggests that there is a growing body of controlled outcome research in PDTs that generally indicates that these are effective treatments. However, there are still significant limitations and areas that need to be investigated further. Thus, the debate over the efficacy of PDTs is not likely to settle any time soon, and there is a risk of further marginalization of PDTs unless the evidence base continues to be expanded and disseminated to policymakers and the general public.”

Research has found that PDTs are effective for depressive, anxiety, personality, and somatic symptom disorders. Similar research found short-term PDT to be effective in treating depression, bipolar disorder, and treatment-resistant affective disorders.

Another recent meta-analysis found that psychodynamic therapies worked as well as cognitive behavioral therapies. Some research has suggested short-term PDT may be more effective in treating depression than cognitive behavioral therapy. Combining PDT with cognitive behavioral approaches may improve outcomes for the treatment of anxiety.

 

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Peter Lilliengren (2023) A comprehensive overview of randomized controlled trials of psychodynamic psychotherapies, Psychoanalytic Psychotherapy, 37:2, 117-140, DOI: 10.1080/02668734.2023.2197617 (Link)

 

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Richard Sears
Richard Sears teaches psychology at West Georgia Technical College and is studying to receive a PhD in consciousness and society from the University of West Georgia. He has previously worked in crisis stabilization units as an intake assessor and crisis line operator. His current research interests include the delineation between institutions and the individuals that make them up, dehumanization and its relationship to exaltation, and natural substitutes for potentially harmful psychopharmacological interventions.

10 COMMENTS

  1. I still don’t get MIAs love of psychodynamic psychotherapy, and its uncritical reporting of research into it really undercuts its incisive and critical approach to psychiatric drug research.

    Literally any intentional intervention outperforms inert conditions in random trials for depression. Doing anything in service to your wellbeing with someone’s else’s support is better than doing nothing. It tells us nothing about psychodynamic therapy that this is shown to be marginally helpful except that it is a time consuming, expensive, and limitedly accessible way to produce such marginal outcomes, and the outcome indicators in these studies are all over the place. What exactly exactly does it help with? Each study answers this differently.

    As noted in the study limitations, unpublished data biases, allegiance biases, small sample size equivalence, published in an analytic journal, and single coder biases are all present here, all for a review that shows equalivelence or less to CBT, which is framed as an underserving psychotherapy standard. So great job, review! You showed PTD is sometimes equivalent and sometimes worse than the therapy that it critiques as not actually effective. This is supposed to show evidence of effectiveness?

    Please stop uncritically trying to build a case for psychodynamic therapy as the alternative to drug treatment. Psychotherapy deserves as much critique as the other primary tool of psychiatric care as drug treatment.

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    • Are you saying anything is better than telling someone they have an incurable brain disease and there’s nothing they can do about it except hope that the doctors have a magic pill that never seems to develop?

      A sensitive 8 year old can do better than a standard psychiatric intervention. On the average, listening to someone is going to help, but who needs to be a therapist to listen? And what guarantee is there that a therapist can and will listen anyway?

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  2. Psychoanalytic therapy in its many variations is not a way forward. The anti-psychiatry movement in the 1960s represented by Cooper, Laing, Deleuze, Guattari and many others reacted against it for that reason. The assumption that a suffering person needs an expert on the analysis of the unconscious to explain to them the mystery of their suffering is authoritarian, patronising and ripe for all sorts of abuses. For what it counts, my own “lived experience” of psychoanalytic treatment was catastrophic, and decades later I’m still trying to come to grips with the utter terror of it. The power differential inherent in the analyst-analysand dynamic is far more problematic than in any other form of therapy, because, as a specialist in interpreting the unconscious, the therapist, at a certain level, is assumed to understand the patient better than he or she understands themselves. We owe the emergence of biological psychiatry largely to the failure of psychoanalytic treatment.

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  3. To truly understand therapy, read clinical vignettes used to demonstrate “negative reactions in therapy.” Then, do your best to comprehend what the therapist is saying or doing (since they often write about the client and sometimes unconsciously include their feelings toward the client – often hostility or disdain).
    You will be shocked by how much they are not saying though through implication, including the fact that “they did not like the client in the first place.” So, what happens when you are treating a person you do not believe in or care about? Well, as in any normal human interaction, that person, because they are human just like you, will sense your disdain and not react as you would like them to like allowing you the therapist to influence them.

    Unfortunately, this basic human understanding is lacking in most therapies. This is also another influence from the field of psychiatry, which implies that merely having interaction with psychiatry already makes a person suspicious to societal norms.

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  4. ‘The author acknowledges several limitations to the current work. The study design excluded unpublished studies those not published in English. All coding was done by a single researcher, which increased the chances of bias. The quality of the included studies was not assessed, and the individual authors’ theoretical “allegiance” was not coded.

    As most randomized control trials involving PDT are done by authors with allegiances to psychodynamic theory, some level of bias is to be expected. As the author set out to do a descriptive analysis, effect sizes were not calculated’

    These two paragraphs alone ought to invalidate this entirely and these glaring issues inevitably lead to a raft of other invalidating elements. Garbage in garbage out.

    Try reading William M Epstein
    The illusion of psychotherapy
    Psychotherapy as religion
    Psychotherapy and the social clinic in the United States, soothing fictions.

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