Psychodynamic psychotherapy is often the overlooked stepchild in modern psychotherapeutic circles. While still regularly taught and practiced, it’s a therapeutic style that’s largely fallen out of favor in the U.S. with the rise of shorter-term therapies, such as cognitive behavioral therapy (CBT), which typically have a stronger research base.
New research published yesterday in JAMA (the Journal of the American Medical Association) suggests that, in a large-scale meta-analysis of 23 previously published studies on the efficacy of psychodynamic therapy, it can be a very effective therapeutic technique, especially in complex cases (such as those involving a personality disorder).
What is psychodynamic psychotherapy and what are its defining characteristics? As the accompanying JAMA editorial notes, psychodynamic therapy is:
“A therapy that involves careful attention to the therapist-patient interaction, with carefully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the therapist’s contribution to the two-person field.” Identification and interpretation of transference and resistance are distinctive features of psychoanalytic psychotherapies that are commonly misunderstood.
Transference is defined as, “those perceptions of, and responses to, a person in the here and now that more appropriately reflect past feelings about, or responses to, important people earlier in one’s life, especially parents and siblings.” Transference occurs regularly in everyday life outside a psychotherapy setting. A strong reaction to a person or situation in which the intensity of the emotion is more than what would be attributable to the current situation may be a clue to the presence of transference.
Resistance is the “patient’s attempt to protect herself or himself by avoiding the anticipated emotional discomfort that accompanies the emergence of conflictual; dangerous; or painful experiences, feelings, thoughts, memories, needs, and desires.
Of course, as regular readers of World of Psychology know, a meta-analysis can be a powerful tool to combine the data from many different studies to look at larger, general effects of a specific treatment. But it also has a significant drawback (as all metanalyses do), in that it is only as good as the selection criteria chosen for what studies to include in the analysis. And then the actual studies analyzed.
Reviewing the studies in this analysis gives one a little pause in feeling the cards were stacked for a positive outcome. One third of the studies included medication being prescribed at the same time as the psychodynamic therapy. Over half didn’t use a control or comparison group, or used one that included a different type of psychodynamic therapy (which isn’t a true “comparison” group to determine the efficacy of psychodynamic therapy versus something else). Some studies included group therapy, while others were focused solely on individual (two very different types, with two very different type of dynamics). One of the largest studies included featured government-subsidized long-term therapy (could free therapy ever produce a negative outcome?).
Although I didn’t go through all 23 studies, in my random sample of the studies used, I found additional concerns in a few (e.g., comparison of two groups who weren’t homogeneous at the onset of the study). And although done in other meta-analyses, I question the wisdom of including studies without regard to geographic region (e.g., comparing psychodynamic therapy and diagnosis done in Nordic countries with that done in Israel with that done in New York, as though all cultures and training were the same). Not all studies analyzed even included a psychiatric or psychological outcome measure.
Utilizing flawed studies can produce flawed results. One can argue that the data don’t lie, despite the flaws. I’d agree, up to a point. This meta-analysis shows that, contrary to many clinicians’ opinions, psychodynamic psychotherapy can be an effective modality, especially in cases of chronic depression or anxiety, or personality disorders such as borderline personality disorder. It cannot say whether it’s better than other long-term psychotherapies (virtually all psychotherapy techniques and approaches can be used for years, although many are focused on short-term symptom relief and change). And the analysis says nothing to the placebo effect of just being with another human being for a year or more.
Read the news story: Long-term Psychotherapy Indicated for Complex Disorders
Read the JAMA editorial on the study (subscription required): Psychodynamic Psychotherapy and Research Evidence: Bambi Survives Godzilla?
Leichsenring, F. & Rabung, S. (2008). Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis. JAMA, 300(13), 1551-1565.