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.     

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: an updated narrative review of the evidence base

While the evidence base for psychodynamic therapy with adults is now quite substantial, there is still a lack of research evaluating the effectiveness of psychodynamic therapies with children and young people. Those studies that have been carried out are also not widely known in the field. To help address the second point, in 2011, we carried out a review of the evidence base for psychodynamic psychotherapy for children and adolescents, which identified 35 studies which together provided some preliminary evidence for this treatment for a range of childhood disorders. The present study is an updated review, focusing on research published between March 2011 and November 2016. During this period, 23 additional studies were published, of which 5 were reports on randomised controlled trials, 3 were quasi-experimental controlled studies and 15 were observational studies. Although most studies covered children with mixed diagnoses, there were a number of studies examining specific diagnostic groups, including children with depression, anxiety and disruptive disorders. whilst the quality of studies was mixed, some were well-designed and reported, and overall indicated promising findings. Nevertheless, further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy across a range of different disorders, and to ensure that services can provide a range of evidence-based treatments for children and young people.     

Dynamic interpersonal therapy in an NHS tertiary level specialist psychotherapy service

We describe the introduction of dynamic interpersonal psychotherapy (DIT) into an National Health Service (NHS) tertiary psychoanalytic specialist psychotherapy service. Training in DIT began as our contribution to Improving Access to Psychological Therapies and primary care services, supporting the training and supervision of their DIT practitioners. We then discovered DIT could be a valuable treatment within our own tertiary NHS service for patients with complex presentations. Currently fighting for survival, like many NHS psychoanalytic psychotherapy services nationally, we have adopted a manual-guided, psychoanalytically based therapy to broaden our tertiary clinical psychoanalytic service and accommodate trends in mental health service provision, whilst protecting the quality and integrity of our psychotherapy. DIT helped us continue providing relevant and beneficial psychoanalytic and psychodynamic services to individual patients despite limitations of the financially challenged NHS, NICE guidelines and Payment by Results. We outline the progress and outcomes for patients with complex mental health presentations, include individual case discussion and our experience of using the DIT approach within a traditionally longer term psychoanalytic psychotherapy service.     

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.     

Outcome of psychodynamic child psychotherapy in routine practice

The aim of the present naturalistic study was to explore the effectiveness of psychodynamic child psychotherapy in routine practice. The sample comprised 207 psychotherapies with children 4–12?years of age with a broad range of mental health problems. Data on two measures, children’s global assessment scale (CGAS) and strength and difficulties questionnaire (SDQ), were collected pre-post therapy. Within-group changes were analysed using repeated measures mixed-models ANOVA. Individual changes were examined by means of clinical significance. The analyses revealed improvement in general functioning, decrease in problem severity and problem impact on the child’s everyday life, as well as an increase in prosocial behaviour. For CGAS, an interaction effect was discovered suggesting a larger improvement for younger children (4–6?years) than for older children (10–12?years). After therapy, 38% (n 76) achieved clinically significant improvement. Time-limited psychotherapy proved favourable for children assigned to that particular treatment modality. The study generated similar results as previous well-controlled trials, revealing statistically significant results in a large sample and in spite the use of non-specific outcome measures. The study provides everyday evidence to the effectiveness of child psychodynamic treatment with parallel parental work for a broad range of child mental health problems.     

Aktuelle Entwicklungen der psychodynamischen Psychotherapieforschung

The effectiveness of psychodynamic psychotherapy has been a “hot topic” in scientific and healthcare related debates in recent years. During this time a significant amount of new evidence supporting the effectiveness of psychodynamic psychotherapy has been published. The paper provides an overview on current psychodynamic psychotherapy research, with a focus on meta-analytic findings and randomized effectiveness trials. The results in the literature show robust evidence for the effectiveness of psychodynamic therapies for a wide range of psychiatric disorders. The methodological quality of current studies is good and comparative trials with other forms of psychotherapy yield mostly equivalent results. However, further studies are needed with regard to different mental disorders as well as effectiveness studies in everyday practice.     

Broken Bounds: Contemporary reflections on the antisocial tendency

When embarking on research into the effectiveness of psychoanalytic psychotherapy in the NHS or the application of psychoanalytic principles, researchers come up against a number of hurdles: many clinicians still see empirical research as antithetical or disruptive to the practice of psychoanalytic psychotherapy; psychoanalytic psychotherapy has previously fared poorly in evidence-based policy guidelines and this can discourage ambition, and there are technical problems of research design, measurement and standardization. Nevertheless, in a political climate which stresses service evaluation, measurable outcomes and empirical evidence, psychoanalytic psychotherapy must participate to survive. There may be gains from conducting research beyond simply meeting the requirement to provide evidence of effectiveness. Research may be viewed by some clinicians as an unwelcome intruder but it may have the potential to offer triangulation, the perspective of the ‘third’, and so strengthen the foundations of clinical practice and the development of psychoanalytic thought.     

Can psychiatry residents be attracted to analytic training? A survey of five residency programs

In the face of fewer psychiatrist applicants for psychoanalytic training, determining the interest of current psychiatric residents in psychoanalysis and psychodynamic psychiatry is a pressing concern. To gauge this interest, an anonymous online survey was sent to residents from five psychiatry residency programs in the Midwest and South. Seventy-five residents responded, for a return rate of 42%. The data suggest that residents value psychoanalytic concepts and most plan to incorporate the practice of psychodynamic psychotherapy into their careers after graduation; however, residents have little confidence in their level of skill and the adequacy of their training. While 46% express interest in further psychodynamic psychotherapy training, only 22% express interest in psychoanalytic training. Most cite the cost and time involved as reasons they would not pursue further training. This study demonstrates that psychiatric residents have strong interest in and respect for psychodynamic psychotherapy and psychoanalysis. The data suggest that psychiatric residents are a viable pool of applicants for psychoanalytic training, especially if barriers to training can be reduced and creative ways for psychoanalysts to engage residents can be fostered.     

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.     

Clinical encounters with children in the Trump era

There is an emerging research and conceptual literature on the impact of the 2016 United States election of Donald Trump on the psychoanalytic psychotherapy process; however, the focus of this growing body of literature has been primarily with adults. Issues related to the election of Donald Trump, and the current political climate, also continue to arise in clinical encounters with children. These moments highlight the complexities of intersectionality, intersubjectivity, power dynamics, and self-disclosure. This article describes several clinical scenarios with American youth – reports from the front lines of a new political reality – drawn from the perspectives of trainees learning psychodynamic therapy, a private practitioner conducting an assessment for a young asylum seeker, and a school psychologist working in a private school for children with learning disabilities. We consider the fears and preoccupations that arise among children and their caregivers and the feelings that are provoked in the clinician, both in response to their clients and to the election itself. Traditional psychoanalytic paradigms of limiting self-disclosure and maintaining the therapeutic frame are challenged by the intensely personal nature of contemporary politics. This paper explores a contemporary phenomenon – the tension between therapeutic attending to internal experience and symbolisation, repression, and integration, while also considering a harsh, political external reality – through the lens of centuries of psychoanalytic work conducted in the face of war, trauma, and oppression. Children and adolescents who present for treatment or other forms of clinical intervention require a flexible therapeutic approach that acknowledges their unique position in history and the ways in which their distress is exacerbated by real and perceived political threats.     

Succession and survival in psychotherapy organizations

Abstract: This paper examines the world of psychotherapy by applying a systemic and psychodynamic understanding of the family business as a way of understanding the dilemmas and challenges of leadership succession. Oedipal factors are explored as an important theme within the succession process. This exploration is set within the context of what function psychotherapy has performed in society over the last thirty years. The hypothesis is that the first generation of leaders aimed to provide containment for the individual citizen at a time of failed dependency in society. The suggestion is that this gave way to the primary task for the second generation, which has been to focus on the therapist in training. The challenge for the third generation is to develop a meaningful role for psychotherapy today and to ensure survival at a time when other shorter therapies such as CBT are gaining ascendancy over longer term psychoanalytic psychotherapy.     

A fertile matrix: the birth of the Forensic Psychotherapy Society

This paper traces some aspects of the fertile matrix within which, over many years, the application of a psychoanalytic perspective to clinical work with the most severely mentally ill, difficult and at times frightening patients in secure and community settings has evolved and now led to the recent inauguration of the Forensic Psychotherapy Society (FPS), a new Member Institution of the British Psychoanalytic Council. The Society provides both a framework for a national, multidisciplinary professional training in psychodynamic forensic psychotherapy and the potential launching pad for an active post-qualification organisation supporting CPD and all other forms of professional development. The particular contributions to the birth of the FPS of the Forensic Psychotherapy Department at West London Mental Health NHS Trust, partly because we know it best but also because it is part of the largest forensic psychiatric service in the United Kingdom, are described.     

Is three a crowd? A perspective on countertransference challenges in psychoanalytic couple psychotherapy

Two seemingly unrelated characteristics of psychoanalytic couple psychotherapy may be better understood when juxtaposed. First, countertransference in psychoanalytic couple psychotherapy holds particularly strong intensity. Second, format decisions are central to couple psychotherapy. The use of conjoint and concurrent formats, or variations thereof, has been key in the historical development of couple psychotherapy and remains an area of much debate. Some couple psychotherapists use the format of couple psychotherapy flexibly, using variations of conjoint or concurrent couple psychotherapy, while others adhere strictly to working conjointly. Decisions regarding whether to undertake concurrent or conjoint therapy are not generally linked to countertransference; this article demonstrates that reading decisions regarding format through consideration of countertransference offers a needed perspective for the therapist. Case studies published by psychoanalytic couple therapists are analysed through this prism to demonstrate that changing the format may serve to dilute countertransference. One particular manifestation of countertransference, linked to oedipal dynamics, is explored: countertransferential intensity for couple psychotherapists potentially relates to being faced with their internal parental couple and their unresolved Oedipal strivings. Possible unconscious motivations to change the format of couple psychotherapy need to be carefully considered, as format changes may mask an avoidance of bearing the countertransference.     

On the Normal and Pathological Middle-age Crisis—Erich Maria Remarque,a Lost Survivor

The case illustration is from a long-term experience of individual psychoanalytic psychotherapy with a male patient, who started therapy when he was 15-years- old. According to DSM-IV criteria, he was diagnosed with a major depressive disorder. A psychological assessment including a Rorschach test showed a poorly integrated but well-adapted Borderline-Narcissistic personality disorder. Various classes of ant-idepressant drugs were used with equivocal or uncertain effects, and the roots and causes of the patient's negative reactions to medication had to be thoroughly investigated and dealt with during psychotherapy. Pharmacotherapy might succeed in targeting the various symptoms of depressive states, but the psychodynamic approach in a psychotherapeutic relationship widens the scope and works introspectively, allowing the patient insights to understanding the symptoms. The use of a psychotropic agent is usually based on trust and belief in its expected effect, but often the effect is not as expected. The psycho- pharmacological drug is also imbued with manifest and latent meanings which can be reached at in the psychoanalytic report. Such meanings and expectancies, and the consequent reactions affect both the patient and the psychotherapist. They have to be dealt with and overcome by psychoanalytic understanding and intervention, as well as experience and skill in use of the medicine concerned.     

The development of an evidence-based treatment: Regulation-Focused Psychotherapy for Children with externalising behaviours (RFP-C)

There is a critical need for the development, evaluation and implementation of evidence-based psychodynamic treatments for children and adolescents. Currently, there are no empirically supported, manualised psychodynamic treatments for children and adolescents with disruptive behaviour problems. The field of manualised psychodynamic treatments with measurable equivalence or superiority to other established forms of psychotherapy is in its nascent stage. This paper details a novel, manualised, time-limited psychodynamic treatment approach for children who manifest disruptive behaviours and emotional dysregulation. Regulation-Focused Psychotherapy for Children (RFP-C) conceptualises children’s disruptive and acting out behaviours as expressions of maladaptive emotion regulation. Externalising symptoms are conceptualised as attempts to defend against painful emotions and thus protect the child from disturbing feelings such as sadness, shame and guilt. This paper provides the theoretical basis for the treatment approach and through the use of a clinical example demonstrates the systematic application of RFP-C in a single case.     

Methods and mechanisms in the efficacy of psychodynamic psychotherapy

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler summarized a large body of research that shows psychodynamic therapy to have a substantial effect size, comparable to that for many empirically supported treatments. This is an important finding, in part refuting the concerns raised by Bornstein (2001, 2002) regarding the future of psychodynamic approaches had there been no substantial changes in how practitioners and researchers approached the science to demonstrate efficacy. Further, Shedler showed that the efficacy of psychoanalytic psychotherapy is due to therapeutic methods commonly employed in cognitive behavior therapy (CBT), one of the most frequently cited empirically supported approaches for a wide range of psychological conditions. From a methodological perspective, there are some important limitations to the claim of psychodynamic psychotherapy's comparable efficacy to other empirically supported approaches.     

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.     

Effectiveness of Psychodynamic Treatment in Patients with Borderline Personality Disorder

There is some evidence that the efficacy of four types of psychotherapeutic psychotherapy (mentalized-based treatment, transference-focused psychotherapy, psychoanalytic psychotherapy, and cognitive-analytic therapy), is superior to treatment-as-usual. More controlled and randomized studies are needed in order a) to confirm the results of the relatively few investigations that were available, b) to examine the therapeutic relevance and usefulness of correlates and predictors of improvement and remission in borderline patients, and c) to examine possible fruitful combinations with other types of treatment.