Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

Die DPG-Praxis-Studie

All psychotherapeutic methods must be scientifically evaluated. Empirical evaluation of evidence is a prerequisite for acceptance as scientific psychotherapy as well as for payment by health insurance. Currently the psychotherapy methods accepted within the German health system (behavioural therapy, psychodynamic psychotherapy, and analytic psychotherapy) are reviewed by a governmental evaluation committee concerning evidence, necessity and cost-effectiveness. The DPG practice study has basically two aims: 1) to conduct a large naturalistic study to investigate effectiveness, sustainability and economic aspects of psychodynamic and analytic psychotherapy and 2) to offer a framework for psychoanalytic institutes, members, candidates or groups to realize own research ideas by collecting additional data within the study. The present article describes the background, main research questions, structure and design of the DPG practice study with regard to the evaluation questions.     

Transference focused psychotherapy: overview and update

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non-analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.     

A systematic review of the effectiveness of psychoanalysis,psychoanalytic and psychodynamic psychotherapy with adults with intellectual and developmental disabilities: progress and challenges

Objectives: This systematic review aimed to critically appraise the literature on the efficacy and effectiveness of psychoanalysis, psychoanalytic and psychodynamic psychotherapy in adults with intellectual and developmental disabilities (IDD). Method: A systematic search of electronic databases was carried out. The methodological quality of the studies was assessed using a quality assessment tool and comparisons were made with a review of the quality of research on the effectiveness of cognitive behavioural therapy (CBT) for people with IDD. Results: The search yielded 13 papers which provided evidence for the effectiveness but not efficacy of psychoanalytic and psychodynamic psychotherapy; but none were found for psychoanalysis. The quality of the research was generally poor compared to the current research on the effectiveness of CBT. Conclusions: Positive outcomes have been indicated for psychoanalytic and psychodynamic psychotherapy with people with IDD. Larger scale, more controlled research is necessary to advance the evidence base.     

Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base

For many years psychoanalytic and psychodynamic therapies have been considered to lack a credible evidence-base and have consistently failed to appear in lists of ‘empirically supported treatments’. This study systematically reviews the research evaluating the efficacy and effectiveness of psychodynamic psychotherapy for children and young people. The researchers identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials. While many of the studies reported are limited by sample size and lack of control groups, the review indicates that there is increasing evidence to suggest the effectiveness of psychoanalytic psychotherapy for children and adolescents. The article aims to provide as complete a picture as possible of the existing evidence base, thereby enabling more refined questions to be asked regarding the nature of the current evidence and gaps requiring further exploration.     

The search for evidence: Psychoanalytic practice and the male imaginary

In this paper, I will attempt to discuss the future of psychoanalytic practice in the wake of the National Institute of Health and Clinical Excellence’s (NICE) embrace of ‘evidence’-based practice. In 2005, NICE, whose task is to regulate the provision of health care across the National Health Service, adopted positivistic evidence-based protocols as the sole proof of the effectiveness of psychotherapy. Despite the success over the past 40?years of psychoanalytic and humanistic therapies in primary care and psychotherapy departments of psychiatric hospitals, NICE insists on restricting therapy, to those who can claim effectiveness as a result of using the data from client questionnaires commonly described as ‘outcome measures’ and it has gone on to promoting new modalities many of which have been imported from the States. As a consequence, most of the provision of psychotherapy in the public sector currently, whether as part of the National Health Service or the voluntary sector, has embraced evidence-based practice’ and many training organisations are promoting it, which will, in time, have an effect on private practice. I use some of the threads of the work of the feminist psychoanalyst Irigaray and others to understand this turn to positivistic science and how it can be understood as an instance of the retrenchment of the ‘male imaginary’ and a re-installation of the values of detachment and mastery. I query whether there are some problems within current theory, practice and institutionalisation which interfere with the emergence of a more progressive psychoanalytic practice.     

Can research influence clinical practice?1

After briefly reviewing the unfavourable reception accorded empirical research by parts of the psychoanalytic community, as well as some of the benefits to clinical practice of analysts being involved in research activities, the author examines whether the findings of process and outcome research in psychotherapy and psychoanalysis can help identify the most appropriate forms of intervention for producing therapeutic change, given the specific condition of the patient and the relationship that the individual establishes with the analyst. He argues that research findings can influence clinical practice on various levels and in different areas, and goes on to examine a number of related issues: the specificity of therapeutic interventions versus the relevance of common curative factors; the dyadic conception of technique and ways of understanding the therapeutic action of the treatment alliance; and the strategic or heuristic conception in psychoanalytic therapy. Finally, the author presents clinical material with the aim of illustrating how the knowledge acquired through research can be applied to psychoanalytic treatment.     

Treatment manuals and the advancement of psychoanalytic knowledge: The Treatment Manual of the Tavistock Adult Depression Study

This paper has two aims: first, it seeks to understand the absence of treatment manuals in psychoanalysis. Secondly, it summarizes the treatment manual of the Tavistock Adult Depression Study, which describes the form of psychoanalytic psychotherapy whose effectiveness has been evaluated both in the Tavistock Adult Depression Study (TADS); and in the German Die Langzeittherapie bei chronischen Depressionen (LAC) Studie. Throughout the history of psychoanalysis, opinions about treatment manuals, empirical research and their antecedents have been deeply divided. After tracing the often polarized unfolding of these matters, the paper proposes that emotional and cognitive difficulties as well as scientific ones underpin their persistence. It is suggested that greater familiarity with them may lead to better combinations of outcome research and psychoanalysis: for example, the Tavistock manual seeks to match one account of the objects, aims, values, spirit and methods of psychoanalysis (as well as of connected forms of psychoanalytic psychotherapy); and also to meet what is required of treatment manuals by random allocation controlled trials. It has been a crucial element in the above studies of the outcome of long‐term psychoanalytic psychotherapies with chronically depressed patients. After describing the Tavistock Manual, the paper concludes suggesting that, if appropriately constructed, treatment manuals can make a contribution to the advancement of specifically psychoanalytic knowledge.     

The emerging dialogue between psychoanalysis and neuroscience: neuroimaging perspectives

Current progress in the cognitive neurosciences is highly relevant to the development of psychoanalytic theory and practice. Neuroscience is today becoming mature enough to provide empirical biological approaches for the investigation of psychoanalytic models and observations. The current state of functional neuroimaging techniques is reviewed, selected paradigms and findings relevant to psychotherapy research are presented, and ways to pursue the dialogue between psychoanalysts and neuroscientists are discussed, as are some related obstacles and pitfalls. The emerging dialogue between psychoanalysts and neuroscientists may help not only to reestablish a solid position of psychodynamic theory and treatment in contemporary medicine, but also to bridge the division between "psychological" and "somatic" treatments, and gain important insights into the mind-brain relationship.     

Antidepressants,Psychotherapy or their Combination: Weighing Options for Depression Treatments

Psychotherapy and antidepressant medications are the two preeminent treatment choices for depression. This article puts each of these treatments into perspective by presenting an overview of what is currently known about their effectiveness either singly or in combination. Discussion of placebos, common factors among therapies, relapse rates, depression severity, patient treatment preferences and exaggerations in pharmaceutical advertising provide guidance for clinicians in deciding on the best course of treatment. Overall, research reveals the importance of psychosocial factors, no matter what the mode of treatment, and the need for fostering a collaborative bond between clinicians and their patients. We argue that empirical evidence points to making psychotherapy the initial treatment choice for most cases of depression.     

Integration of Cognitive-Behavioral and Interpersonal Therapies for Latinos: An Argument for Technical Eclecticism

The integration of psychotherapeutic techniques is a common practice among today's clinicians. However, most discussions on psychotherapy integration have focused on general theoretical issues without attention to special populations. Latinos now represent the largest ethnic minority population in the United States and the mental health needs of this population are increasing. Although there are few controlled outcome studies that focus on Latinos, basic research suggests that integrating components of interpersonal therapy (IPT) into cognitive-behavioral therapy (CBT) may be particularly effective with this population. Specific suggestions for integrating CBT and IPT techniques are presented, and ways in which this integration can be adapted in a culturally sensitive manner are reviewed. An ethical and culturally sensitive CBT-IPT integration for Latinos requires empirical verification. Future studies on CBT-IPT synthesis should demonstrate the effectiveness of such integration relative to CBT or IPT alone.     

Is there room for criticism of studies of psychodynamic psychotherapy?

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler declared unequivocally that "empirical evidence supports the efficacy of psychodynamic therapy" (p. 98). He did not mention any specific criticisms that have been made of evidence on psychodynamic psychotherapies or address possible distinctions between evidence for short-term versus long-term psychodynamic psychotherapies. Instead, he attributed dissenting views to biases in evidence dissemination and review, which he suggested are rooted in a "lingering distaste in the mental health professions professions for past psychoanalytic arrogance and authority" related to a "hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research" (Shedler, 2010, p. 98). Shedler (2010) justified his blanket dismissal of criticisms of evidence supporting psychodynamic psychotherapy on the basis of several published meta-analyses. The validity of conclusions from metaanalyses depends on the quality of the evidence synthesized, the nature of the studies included, and the rigor of the statistical analyses employed. Many meta-analyses, however, are not performed rigorously, which can result in treatment efficacy estimates that obscure important intertrial differences and that are unlikely to be replicated in clinical practice.     

The scientific status of psychoanalytic clinical evidence (I)

The main source of evidence for psychoanalytic theory comes from the clinical situation. Yet recent empirical studies in verbal conditioning and the social psychology of persuasion indicate that psychoanalysts and therapists of other schools are speciously validating their own theories by unwittingly influencing their patients’ behavior. In the light of this evidence it is small wonder that psychoanalysts consistently ‘validate’ psychoanalytic theory in their clinical practice while therapists of other schools ‘validate’ their own theories in their clinical practice. Although Freud was not unaware of the problems of ‘suggestion’ and the conflicting evidence of rival schools of psychotherapy, he never met these problems successfully. Contemporary psychoanalysts have added little to Freud's original position. One recent attempt, by Fritz Schmidl, to formulate new criteria for the correctness of psychoanalytic clinical interpretations, does not completely escape the problem of suggestion and has new problems of its own.     

An Overview of Directions in Psychotherapy Integration Research

In general, empirical research in psychotherapy integration has lagged behind the growing theoretical and clinical interest in the field. Even though many of the theoretically integrative treatment models currently available are based on empirical findings and clinical observations, the models themselves remain, for the most part, untested. Rigorous examination of integrative psychological theories and therapeutic programs is a necessary and useful way to increase our understanding of the process of psychotherapy and establish the efficacy and effectiveness of integrative therapies. The present article explores five different research areas in the field of psychotherapy integration, discussing several published studies in each area. The utility of this research for practicing clinicians is also discussed. Additional investigations in these areas and others are encouraged, with the goals of greater understanding of psychotherapy, as well as the further development and acceptance of integrative approaches.     

On the nature and standing of psychoanalytic psychotherapy

In this paper, I offer some reflections on the standing of psychoanalytic psychotherapy in the National Health Service (NHS), with special reference to contemporary forms of evidence-based thinking. I consider what may follow when a narrow view of science or psychotherapeutic practice becomes conventional wisdom and assumes dominance. I place stress on the potential loss to NHS psychology and psychiatry if psychoanalytic psychotherapy becomes increasingly marginalized on the one hand, or overly standardized on the other.     

Minding the gap between positivism and hermeneutics in psychoanalytic research

Two quite different cultures are to be found within psychoanalysis, one more clinical in orientation, more focused on meaning and interpretation, and relying primarily on the traditional case study method, the other more research-oriented, focused on cause-and-effect relationships, and relying primarily on methods borrowed from the natural and social sciences. The history of this divide is reviewed and arguments, pro and con, about the potential contributions of specific types of empirical investigation are discussed. Increasingly, it seems, criticisms concerning the scientific status of psychoanalysis are being responded to by empirical research. This has contributed to a growing recognition within the scientific community of the credibility of aspects of psychoanalytic theories and of the effectiveness of psychodynamic treatment. However, some segments of the psychoanalytic community are concerned that this increase in the quantity and quality of empirical research on psychoanalytic concepts risks creating an empirical one-sidedness, while other segments are concerned that not engaging in systematic empirical research can lead to intellectual isolation, fragmentation, stagnation, and orthodoxy. To counter this polarizing tendency, a recommendation is made for methodological pluralism. Adopting this stance could contribute to an enriched understanding of the clinical process and to the development of new research methodologies to investigate complex psychodynamic hypotheses, thus bridging the gap between the two psychoanalytic cultures, as well as the gap between research and clinical practice.     

The promise of EMDR in family and systemic psychotherapy: a clinical complement to Field and Cottrell

Annalisa Field and David Cottrell's careful and balanced summary of the current state of evidence of the effectiveness of eye movement desensitization and reprocessing (EMDR) with children and adolescents is to be welcomed. They conclude that there is, despite an overall lack of good quality studies, some encouraging emerging evidence. They set out a future scenario for development in which these hopeful indications may be sufficient to convince clinicians to train and consider using EMDR in practice. That may in turn lead to more people publishing the results of their nascent practice, and greater availability of therapists would enable larger scale randomized controlled studies to be designed and carried out. In this clinical addendum I seek to complement Field and Cottrell's sense of promise by setting out ways in which EMDR has become incorporated in my systemic psychotherapy practice during the last 3 years.     

On the Dissemination of Clinical Experiences in Using Empirically Supported Treatments

This article addresses the long-standing gap that has existed between psychotherapy research and practice and the efforts that have been made to bridge it. It also introduces one such effort, which has consisted of 3 clinical surveys on the experiences of practitioners in using empirically supported treatments for panic disorder, social anxiety, and OCD. In contrast to attempts to close the gap by disseminating research findings to the clinician, the clinical surveys are intended to allow for practitioners to disseminate their clinical experiences to the researcher—and also to other clinicians. What we view as a “two-way bridge” initiative is a collaboration between the Society of Clinical Psychology, Division 12 of the APA, and the Psychotherapy Division of the APA—Division 29. The mechanism that has been established provides a way for clinicians to be a part of the research process, which we hope will provide evidence that can help to enhance our clinical effectiveness.