I have a soft spot in my heart for psychodynamic psychotherapy. While its science generally lags behind its more modern cousin, cognitive-behavioral therapy (CBT), it’s the “old timey” therapy based upon theories that are similar to psychoanalytic thinking and good ole Freud himself. One of my friends in graduate school was a big believer and proponent of it as well, and my respect for her and her ability to affect change with her clients at the time is largely all the proof a practitioner really needs.
Of course, the field of psychology demands more these days, as does an increasingly educated public. It’s all fine and well to have hundreds of published case studies supporting a certain type of psychotherapy, but science wants to see randomized controlled clinical trials. That’s what makes the headlines, and that’s what gives you some respect amongst other researchers.
The American Journal of Psychiatry provided just such evidence in last month’s issue, with the publication of a psychodynamic therapy versus CBT smackdown — which is best for generalized anxiety disorder (GAD)? GAD is the garden-variety type of anxiety that most people get diagnosed for when they feel chronic, pervasive, and uncontrollable worry, often accompanied by somatic (physical) complaints, for no particular reason. So much so, it starts to affect their ability to go to work, concentrate on their job or school, and keep up with their friends and significant others.
The smackdown was a simple design — two treatment groups, one who received psychodynamic psychotherapy, and the other who received cognitive-behavioral therapy (CBT). Although it wasn’t a huge, multi-center study (sorry, no pharmaceutical funding here, so you have to rely on resources normally available to most researchers), it did 57 subjects, roughly divided equally between the two groups. Each treatment group had up to 30 once-weekly treatment sessions — the way most psychotherapy is normally delivered in the real world. Yes, the study lacked a placebo arm, but this is often the case in psychotherapy studies where wait-list control groups have been criticized for not being an adequate placebo. So one could still make the argument that neither treatment approach is any better than talking to someone untrained in psychotherapy, once weekly.
CBT has already been shown in previous research to be an effective treatment options for people with generalized anxiety disorder. However, prior to the current study, no study has directly compared the effectiveness of psychodynamic therapy with CBT in a controlled clinical trial like this.
The results should not surprise you. Psychodynamic psychotherapy was shown to be just as effective as CBT in the treatment of generalized anxiety disorder, on the primary measures the researchers used:
For the primary outcome measure (HAM-A) and two other measures of anxiety (the Beck Anxiety Inventory and the Hospital Anxiety and Depression Scale anxiety scale) and for interpersonal problems (Inventory of Interpersonal Problems), no significant differences in outcome between the two treatments were found.
CBT was found to be superior than psychodynamic psychotherapy, however, on a few other, secondary measures the researchers used, specifically those that measured trait anxiety (State-Trait Anxiety Inventory), worrying (Penn State Worry Questionnaire), and depression (BDI).
One of the interesting characteristics of psychotherapy studies versus those typically carried out for psychiatric drugs is the sheer number of psychological measures researchers use to measure the effectiveness of the treatment. For instance, it’s not uncommon in a clinical drug trial for researchers to use such measures as number of people who “relapse” during treatment, or a single psychological measure (like a measure of depression, such as the Beck Depression Inventory or the Hamilton-D).
This study used seven different measures, not only at the end of treatment, but at a 6-month followup (something else many drug studies fail to do). Virtually of the measures employed showed significant improvement on anxiety and depression measures, not only at the end of treatment, but also virtually unchanged at the 6-month followup (e.g., the treatment was long-lasting).
This study demonstrates that psychodynamic psychotherapy is an effective alternative for the treatment of generalized anxiety disorder, when compared to the more commonly-used CBT. The researchers encourage more studies like this one, and I couldn’t agree more. It’s a timely reminder of the value of the different types of psychotherapies available, not just the kind that might be in vogue at the moment.
Leichsenring F, Salzer S, Jaeger U, Kächele H, Kreische R, Leweke F, Rüger U, Winkelbach C, Leibing E. (2009). Short-term psychodynamic psychotherapy and cognitive-behavioral therapy in generalized anxiety disorder: a randomized, controlled trial. Am J Psychiatry, 166(8), 875-81.