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.     

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.     

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.     

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.     

Psychodynamisches Fallseminar im Masterstudiengang

Stimulated by the discussion about the direct training of psychotherapists, this article presents the concept of a psychodynamic case seminar held by the author in the context of a Master of Science degree in clinical psychology and psychotherapy at the University of Kassel. The seminar was spread over 3 days during which the catalogue of questions on the report to the experts for an application for health insurance was discussed and elaborated on the basis of case examples. To obtain a certificate of performance the students were required to write their own case study at the end of the course. The author outlines the possibilities and limitations of the instruction concerning psychodynamic theories and methods in a university context. In addition, the criticism of the previous training is considered in order to show the necessity for reform.The direct training of psychotherapists opens up an opportunity for retention and further development of psychoanalytically oriented therapies. Particularly because the student’s interest in the seminar was obvious and it is reasonable to expose the students to psychodynamic thinking even at an early stage. At the same time the seminar clearly showed how big the prejudices towards psychoanalytical theories and therapies are. On the one hand there are utopian opinions that a psychotherapy procedure can be quickly learnt and that changes in patients can be achieved in a short time but on the other hand psychotherapeutic methods are devalued because their effectiveness should be doubted for lack of scientific evidence. Reform of the professional training could present the possibility for early prevention of prejudices and to encourage research projects.     

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.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Examining the role and functions of self-development in healthcare therapy trainings: A review of the literature with a modest proposal for the use of learning agreements

Many healthcare trainings with a psychodynamic orientation encourage or require students to commit to a process of personal development, such as provided through attending individual psychotherapy and/or an experiential ‘as if therapy’ group. This paper reviews recent literature about training in psychodynamically oriented practices within counselling psychotherapy, psychiatry, the creative arts therapies and clinical psychology. The results indicate that the mandatory personal development dimension of therapy training needs urgent reassessment. Results of studies consistently call for further research about the direct benefits of personal development on students’ development of skills for therapy practice. There is minimal evidence to indicate what self-development through individual psychotherapy can specifically deliver in terms of eventual professional competence. To address some aspects of the current lacuna, this paper summarises the recommendations for training programmes available from the current research, and makes a modest proposal for the use of learning agreements, rather than only mandated hurdle requirements, to ensure that the incremental steps by which the student attains expected requirements is negotiated and agreed within regularised, and widely accepted university course procedures.     

Expanding the single-case study: a proposed psychoanalytic research program

This paper offers a proposed program of research using single-case time-series methods that can be used by practicing clinicians. The paper is written for psychodynamically oriented clinicians who want to get involved in psychotherapy research and make contributions to the scientific literature. How to measure treatment outcomes and psychodynamic constructs are discussed. With few exceptions, conducting single-case time-series research using psychodynamic psychotherapy has far more advantages than disadvantages.     

The Effectiveness of Brief Versus Intermediate Duration Psychodynamic Psychotherapy in the Treatment of Adjustment Disorder

Treatment studies and particularly psychotherapeutic treatment studies of patients suffering from an adjustment disorder are very scarce, leading to insufficient evidence regarding the efficacy of treatment in this population. Whereas timely psychotherapy is known to be of benefit in the treatment of adjustment disorders, the ideal duration of psychotherapeutic interventions is not known. This study examined whether a brief 12-session focused psychodynamic psychotherapy may be as efficient as a longer intermediate-term (1?year) psychodynamic psychotherapy in treating patients suffering from an adjustment disorder. Subjects (n?=?66) were randomly assigned to either brief or intermediate psychotherapy. They were assessed by self-report measures and clinician’s evaluation at baseline, end of therapy, and 9?months after therapy was terminated. The results showed a good overall improvement in the whole group. Furthermore, brief psychotherapy was found to be as good as intermediate psychotherapy both at the end of treatment and at follow-up. Although our study was not designed to confirm the efficacy of dynamic psychotherapy in the treatment of adjustment disorders, our results suggest that brief interventions may be good enough in adjustment disorder, thus allowing treatment of a greater number of patients without compromising for the quality and suitability of treatment.     

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.     

Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.     

Psychoanalytisch-orientierte Fokaltherapie der Depression bei Krebskranken

Emotional distress connected to a cancer disease may result in comorbid mental and especially depressive disorders. Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy of depression in cancer patients there is a lack of empirical studies which meet the criteria of evidence-based psychotherapy research. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy. As far as we know no manual for psychodynamic treatment of cancer patients has yet been published. In this article a manual for a 20-session short-term psychodynamic treatment is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. The SE treatment manual of depressions in cancer patients presented here is an adaptation of the general SET manual as well as the SE manual for depression. In the first part the general principles of SE therapy are presented. In the second part a manual specifically adapted to the treatment of depressive cancer patients is described. The treatment manual is presently being used in a large-scale randomized controlled multi-centered study comparing short-term psychodynamic psychotherapy and treatment as usual.     

Zukunft der Psychotherapie in der Psychiatrie

The conceptual development of the German mental health system can only be understood against the background of the specific historical development process; therefore, the emigration of psychodynamic psychotherapists during the Third Reich as well as the complicated reintegration of psychotherapy into psychiatry during the postwar period are of particular relevance. The current discussion concerning the relationship of psychiatry and psychotherapy is characterized by the development of new techniques and methods and the concept of modular psychiatry, whereas the traditional complex psychotherapeutic procedures are becoming less important. In the future, the development of clinical and scientific research should focus on psychotherapy in old age as well as adolescence psychotherapy, the combination of psychopharmacological and psychotherapeutic treatment and issues concerning chronic courses as well as resistance to therapy.     

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.     

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.     

Vierzig Jahre Richtlinien-Psychotherapie in Deutschland

On the 3rd of May 1967, 40 years ago, the Federal Comittee of Physicians and Health Services enacted the guidelines for ?analytic and psychodynamic psychotherapy in the medical care by panel doctors“ (?Psychotherapy Guidelines“). That short text (three and a half DIN A4 pages) was the starting point of a sheer revolutionary development. It became the basis of a health care system, which allows the total financing of relative comprehensive psychotherapeutic treatments in a worldwide unique context.     

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.     

Implementation and Evaluation of Evidence-Based Psychotherapeutic Practices for Youth in a Mental Health Organization

The current initiative and program evaluation study is a demonstration of the research to practice process in youth-focused psychotherapy. We collaborated within a community-university partnership to create practice and research infrastructure in order to develop, implement, and evaluate two new models of service founded on evidence-based psychotherapeutic practice parameters. The two new service models incorporated validated interventions to address behavior problems in elementary age children, and depression in adolescents, which were delivered in separate but similarly run intensive outpatient programs within a mental health setting. We utilized a rigorous training, technical assistance, fidelity monitoring, and outcome measurement strategy to promote the integrity and quality of services provided. The resultant programs were delivered with acceptable to high fidelity and effects on youth and parenting measures collected during program and from pre to post showed a decrease in targeted problems in youth and positive benefits for families. This initiative and program evaluation adds to the accumulating research-to-practice literature in children’s mental health.