The Efficacy of Psychodynamic Psychotherapy, Shedler (2010)

Psychotherapy

“The essence of psychodynamic therapy is exploring those aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship.” Psychodynamic techniques contain the following distinctive features.

(1) Focus on affect and expression of emotion. Psychodynamic therapists recognize that “intellectual insight is not the same as emotional insight, which resonates at a deep level and leads to change (this is one reason why many intelligent and psychologically minded people can explain the reasons for their difficulties, yet their understanding does not help them overcome those difficulties).”

(2) Exploration of attempts to avoid distressing thoughts and feelings. Psychodynamic therapists explore the many things people do, “knowingly and unknowingly, to avoid aspects of experience that are troubling.”

(3) Identification of recurring patterns and themes. “Psychodynamic therapists work to identify and explore recurring themes and patterns in patients’ thoughts, feelings, self-concept, relationships, and life experiences.”

(4) Discussion of past events. “Related to the identification of recur-ring themes and patterns is the recognition that past expe-rience, especially early experiences of attachment figures, affects our relation to, and experience of, the present. Psychodynamic therapists explore early experiences, the relation between past and present, and the ways in which the past tends to ‘live on’ in the present. The focus is not on the past for its own sake, but rather on how the past sheds light on current psychological difficulties. The goal is to help patients free themselves from the bonds of past experience in order to live more fully in the present.”

(5) Focus on interpersonal relations. “Psychodynamic therapy places heavy emphasis on patients’ relationships and interpersonal experience (in theoretical terms, object relations and attachment). Both adaptive and nonadaptive aspects of personality and self-concept are forged in the context of attachment relationships, and psychological difficulties often arise when problematic interpersonal patterns interfere with a person’s ability to meet emotional needs.”

(6) Focus on the therapy relationship. “The relationship between therapist and patient is itself an important interpersonal relationship, one that can become deeply meaningful and emotionally charged. To the extent that there are repetitive themes in a person’s relationships and manner of interacting, these themes tend to emerge in some form in the therapy relationship.”

(7) Exploration of fantasy life. “In contrast to other therapies in which the therapist may actively structure sessions or follow a predetermined agenda, psychodynamic therapy encourages patients to speak freely about whatever is on their minds. When patients do this (and most patients require considerable help from the therapist before they can truly speak freely), their thoughts naturally range over many areas of mental life, including desires, fears, fantasies, dreams, and daydreams (which in many cases the patient has not previously attempted to put into words). All of this material is a rich source of information about how the person views self and others, interprets and makes sense of experience, avoids aspects of experience, or interferes with a potential capacity to find greater enjoyment and meaning in life.”

More than just symptom-reduction. “The goals of psychodynamic therapy include, but extend beyond, symptom remission. Successful treatment should not only relieve symptoms (i.e., get rid of something) but also foster the positive presence of psychological capacities and resources. Depending on the person and the circumstances, these might include the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a realistically based sense of self-esteem, tolerate a wider range of affect, have more satisfying sexual experiences, understand self and others in more nuanced and sophisti-cated ways, and face life’s challenges with greater freedom and flexibility. Such ends are pursued through a process of self-reflection, self-exploration, and self-discovery that takes place in the context of a safe and deeply authentic relationship between therapist and patient.”

The Efficacy of Psychotherapy in General

Effect size is a commonly used measure of “the difference between treatment and control groups, expressed in standard deviation units.” In psychological and medical research, an effect size of .8 is considered large, .5 medium, and .2 small.

Meta-analyses have found that psychotherapy tends to have a large effect size. A 1993 review of 18 meta-analyses focusing on general psychotherapy outcomes found a median effect size of .75; it also reviewed 23 meta-analyses “concerned with outcomes in CBT and behavior modification” and found a median effect size of .62. A 1990 meta-analysis focusing on outcomes for patients treated for depression found a median effect size of .73.

These effect sizes of antidepressant medications are much lower. A FDA analysis found the following effect sizes: 0.26 for fluoxetine (Prozac), 0.26 for sertraline (Zoloft), 0.24 for citalopram (Celexa), 0.31 for escitalopram (Lexa-pro), and 0.30 for duloxetine (Cymbalta).

The Efficacy of Psychodynamic Psychotherapy

A 2004 meta-analysis of 17 randomized controlled trials found the following effect sizes for patients who received short-term psychodynamic psychotherapy (21 sessions): 1.39 immediately after treatment and 1.57 13 months after treatment.

A 2006 meta-analysis of 23 randomized controlled trials found the following effect sizes for patients who received short-term psychodynamic psychotherapy (40 or less hours): .97 for general symptoms improvement immediately after treatment and 1.51 9 months after treatment.

A 2008 meta-analysis found the following effect sizes for patients receiving long-term psychodynamic psychotherapy (150 sessions): for patients with moderate pathology, .78 immediately after treatment and .94 3.2 years after treatment; for patients with severe pathology, .94 immediately after treatment and 10.02 5.2 years after treatment.

One thing that is striking about these studies is that the effect sizes increase after treatment, suggesting that “psychodynamic therapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended.” “In contrast, the benefits of other (nonpsychody-namic) empirically supported therapies tend to decay over time for the most common disorders.”

Shedler notes that “[s]tudies supporting the efficacy of psychodynamic therapy span a range of conditions and populations. Randomized controlled trials support the efficacy of psychodynamic ther-apy for depression, anxiety, panic, somatoform disorders, eating disorders, substance-related disorders, and personality disorders.” Regarding personality disorders, he points to a 2007 study of patients with borderline personality disorder which found that psychodynamic psychotherapy produced results that equaled or exceeded dialectical behavior therapy; significantly, only the patients who received psychodynamic psychotherapy “showed changes in underlying psychological mechanisms (intrapsychic processes) believed to mediate symptom change in borderline patients (specifically, changes in reflective function and attachment organization.”

Psychodynamic Processes in Other Therapies

Shedler points out that the “active ingredients” of a therapy are not always what the practitioner believes them to be. He cites one study showing that changing cognitions does not appear to be what causes CBT to be successful. “Even in controlled studies designed to compare manualized treatments,” he writes, “therapists interact with patients in different ways, implement interventions differently, and introduce processes not specified by the treatment manuals.”

Studies that have looked beyond “brand names” and examined “session videotapes or transcripts” have found that the “active ingredients” of many non-psychodynamic therapies “include unacknowledged psychodynamic elements.”

In some studies, researchers “measured therapists’ adherence to each therapy prototype without regard to the treatment model the therapists believed they were applying.” Researchers found that “[t]herapist adherence to the psychodynamic prototype predicted successful outcome in both psychodynamic and cognitive therapy.” Meanwhile, “[t]herapist adherence to the CBT prototype showed little or no relation to outcome in either form of therapy.”

The Flight of the Dodo

Shedler next discusses studies showing that all major therapies produce roughly equivalent results. There are many ways to explain these results. Shedler focuses on one specific limitation of these studies: “the mismatch between what psychodynamic therapy aims to accomplish and what outcome studies typically measure.”

As stated before, the aim of psychodynamic therapy extends beyond mere symptom-reduction. Most studies on therapy, however, look only at symptom-reduction.

The Shedler-Westen Assessment Procedure (SWAP) was developed to assess “the kinds of inner capacities and resources that psychotherapy may develop.” “Many forms of treatment, including medi-cations, may be effective in alleviating acute psychiatric symptoms, at least in the short run. However, not all therapies aim at changing underlying psychological processes such as those assessed by the SWAP.”

The SWAP defines a mentally healthy individual as follows:

• Is able to use his/her talents, abilities, and energy effectively and productively. 
• Enjoys challenges; takes pleasure in accomplishing things. 
• Is capable of sustaining a meaningful love relationship characterized by genuine intimacy and caring. 
• Finds meaning in belonging and contributing to a larger community (e.g., organization, church, neighborhood). 
• Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others. 
• Is empathic; is sensitive and responsive to other people’s needs and feelings. 
• Is able to assert him/herself effectively and appropriately when necessary. 
• Appreciates and responds to humor. 
• Is capable of hearing information that is emotionally threatening (i.e., that challenges cherished beliefs, perceptions, and self-perceptions) and can use and benefit from it. 
• Appears to have come to terms with painful experiences from the past; has found meaning in and grown from such experiences. 
• Is articulate; can express self well in words. 
• Has an active and satisfying sex life. 
• Appears comfortable and at ease in social situations. 
• Generally finds contentment and happiness in life’s activities. 
• Tends to express affect appropriate in quality and intensity to the situation at hand. 
• Has the capacity to recognize alternative viewpoints, even in matters that stir up strong feelings. 
• Has moral and ethical standards and strives to live up to them. 
• Is creative; is able to see things or approach problems in novel ways. 
• Tends to be conscientious and responsible. 
• Tends to be energetic and outgoing. 
• Is psychologically insightful; is able to understand self and others in subtle and sophisticated ways. 
• Is able to find meaning and satisfaction in the pursuit of long-term goals and ambitions. 
• Is able to form close and lasting friendships characterized by mutual support and sharing of experiences.

Shedler writes that more research is needed to verify the SWAP, two preliminary studies “suggest that psychodynamic therapy may not only alleviate symptoms but also develop inner capacities and resources that allow a richer and more fulfilling life.” Such measures “could be incorporated in future randomized controlled trials, scored by independent assessors blind to treatment condition, and used to assess such outcomes. Whether or not all forms of therapy aim for such outcomes, or researchers study them, they are clearly the outcomes desired by many people who seek psychotherapy.”