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Psychodynamic Psychotherapy

Psychodynamic Psychotherapy

Short- and long-term psychodynamic psychotherapies are effective for several psychiatric disorders, as described in 2 recent mental health publications and by Glen Gabbard, MD, an international expert on the therapies.

“A kind of prejudice exists against dynamic therapy, as if there haven’t been randomized control trials that show its effectiveness,” said Gabbard, author of Psychodynamic Psychiatry in Clinical Practice, Fourth Edition, Brown Foundation Chair of Psychoanalysis and professor of psychiatry at Baylor College of Medicine.

Many psychiatrists, residents, and other mental health professionals believe that psychodynamic therapy lacks empirical support or that other psychotherapies are more effective, according to Gabbard. Nevertheless, part of the responsibility for those misconceptions rests with psychoanalysts and psychodynamic therapists themselves.

Gabbard explained that they were “far too complacent for years and years” and did not “get their act together to do rigorous research on dynamic therapy and analysis.” Consequently, research on psychodynamic therapy has “lagged behind that of cognitive-behavioral therapy and is still catching up.”

Now there is increasing investigation among proponents of psychodynamic therapy. They are calling attention to existing efficacy data and encouraging others to design studies, said Gabbard, a member of Psychiatric Times’ editorial board and director of the Baylor Psychiatry Clinic.

Several studies have supported the use of psychodynamic therapy for personality disorders, major depression, anxiety disorders, and some eating disorders, he said, as well as posttraumatic stress disorder, panic disorder, somatoform disorders, and substance use disorders.

September’s Harvard Mental Health Letter1 discussed some cumulative evidence for psychodynamic psychotherapy.

“There is now enough research to support the claim that psychodynamic therapy is an evidence-based treatment with effect sizes similar to or superior to those reported for other psychotherapies,” the undisclosed authors said in the article.

The article included summarizations and discussions of both randomized controlled studies and meta-analyses.2-5

Shedler’s review

Earlier in 2010, American Psychologist, the journal of the American Psychological Association, published a review article by Jonathan Shedler, PhD, associate professor of psychiatry at the University of Colorado Denver, School of Medicine, which explored the efficacy of psychodynamic psychotherapy.6

Shedler described distinctive features of psychodynamic technique—focus on affect and expression of emotion; exploration of attempts to avoid distressing thoughts and feelings; identification of recurring themes and patterns; discussion of past experiences to shed light on current psychological difficulties; focus on interpersonal and therapy relationships; and exploration of fantasy life.

He also emphasized that being an effective psychopharmacologist involves many of the same skills that psychoanalytic psychotherapy requires, such as the ability to build rapport and “to understand the patient’s fantasies and resistances that almost invariably get stirred up around taking psychotropic medication.”

Beyond those aspects, Shedler’s article discussed the efficacy of both psychotherapy and psychodynamic therapy.

“The cumulative body of data that Shedler covers is very persuasive,” Gabbard said, explaining that it consists primarily of summarizing meta-analyses.

Shedler reviewed 8 meta-analyses (comprising 160 studies) of psychodynamic therapy, plus 10 meta-analyses of other psychological treatments and antidepressant medications. He focused on effect size: 0.8 is considered a large effect; 0.5, a moderate effect; and 0.2, a small effect. The overall mean effect size for antidepressant medications approved by the FDA between 1987 and 2004 was 0.31. The effect sizes for psychodynamic therapy and other psychotherapies were much higher.

One methodologically rigorous meta-analysis of psychodynamic therapy, published by the Cochrane Library, included 23 randomized controlled trials of 1431 patients with a range of common mental disorders.2 The studies compared patients who received short-term (less than 40 hours) psychodynamic therapy with controls (wait list, minimal treatment, or treatment as usual). The overall effect size was 0.97 for general symptom improvement. The effect size increased by 50%, to 1.51, when pa-tients were reevaluated 9 or more months after therapy ended.

Extended release

Several studies of psychodynamic therapy have indicated that the benefits of this therapy increase with time, even after completion of treatment—the so-called extended-release phenomenon.

“After treatment completion, there is an internalization of the therapist-patient relationship whereupon the patient goes on thinking and reflecting in a specific way that he or she learned in therapy,” Gabbard said. “That’s been my experience as a clinician.”

Gabbard described how many of his patients return years after completing therapy and report that not only did they benefit, but they also have continued to make profound changes since therapy ended. When confronted with a difficult situation, they reflect back on previous discussions with Gabbard that occurred during treatment.

“So there is a process set in motion of a particular way of reflecting and thinking about one’s experience and feelings and relationships that goes on and on,” Gabbard said.

Emerging research

Asked about emerging research involving psychodynamic therapy, Gabbard said, “A lot of imaging research and neurobiological research is confirming long-standing psychoanalytic ideas. For example, neurobiological research repeatedly points out that most of mental life is unconscious, which is a premise of psychodynamic therapy. It also is showing that genes alone don’t determine who we are. Rather, it is genes in interaction with early environmental influences that produce who the person is. Certain kinds of trauma can turn genes on and off. This is a fundamental psychoanalytic developmental notion that is now being confirmed by rigorous research.”

References

References

1. Merits of psychodynamic therapy. The research suggests that benefits of this therapy increase with time. Harv Ment Health Lett. 2010;27:1-3.
2. Abbass AA, Hancock JT, Henderson J, Kisely S. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006;(4):CD004687.
3. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry. 2004;61:1208-1216.
4. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA. 2008;300:1551-1565.
5. de Maat S, de Jonghe F, Schoevers R, Dekker J. The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies. Harv Rev Psychiatry. 2009;17:1-23.
6. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98-109.

 
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