Off the Couch

Thoughts about the therapeutic process, and the dynamics of client-therapist interactions.

Does Talk Therapy Really Work?

Is there any evidence that talk therapy really works?

A young woman came to see me on the recommendation of her physician. "I don't know what she thinks you can do for me," she said. "I just can't get myself to do what I need to do. Maybe some cognitive therapy - something that would change my thinking. Maybe that would help."

I asked her to tell me in her own words why her doctor had referred her to me. "I don't have any energy. There's nothing wrong with me physically. I was depressed for awhile, but I'm not anymore. But she thought it might help me to talk to someone. I don't need longterm psychotherapy to understand myself. I just need someone to help me change my thoughts."

I thought of this young woman as I read a wonderful article in the November 2010 issue of Scientific American Mind: "Getting to Know Me: Psychodynamic therapy has been caricatured as navel-gazing, but studies show powerful benefits," by Jonathan Shedler.*

Shedler, who is an associate professor of psychiatry at the University of Colorado School of Medicine and director of psychology at the University of Colorado Hospital Outpatient Psychiatry Service, combines anecdotes from clients and therapists with fascinating research to explain something that those of us who have practiced "insight" therapy (sometimes also called "talk" therapy) have known for a long time: psychodynamic psychotherapy works. It helps clients find solutions not only to specific symptoms but also to difficulties at work, in their social lives, and with self-esteem.

Shedler describes fascinating research evidence that "psychodynamic therapy alleviates symptoms as effectively as newer, more targeted therapies" (like cognitive behavioral therapy).

He also offers evidence "that people who receive psychodynamic therapy actually continue to improve after therapy ends - presumably because the understanding they gain is global." In other words, this kind of therapy helps us learn about ourselves in such a deep and broad way that we can utilize our understanding in a variety of situations; and further, that with the help of therapy, we also learn how to continue to learn more about ourselves even when we are no longer seeing our therapist.

Shedler says that people often shy away from psychodynamic psychotherapy because they assume that it won't help them with their immediate problems and they fear that they will have to make a commitment to years of expensive, time-consuming and unproductive "navel-gazing." He suggests that this is partly the fault of those of us who practice this kind of therapy. We shun research and fail to explain what we are doing. I would add that we also fail to tell our clients that they should start to feel some relief fairly quickly, and that if they are not feeling better, it may be that we're not helping them get to something important in the work. Nor do we always explain, as Shedler does in a beautiful example, why talking about what is happening between therapist and client is an important - sometimes crucial -part of the work.

I encourage you to read Shedler's article yourself; but as an appetizer, I offer this brief highlighting of some of his points:

 Psychodynamic therapy as practiced today is not your father's psychoanalysis. For one thing, Shedler says, clients "do not lie on a couch free-associating as an inscrutable therapist silently looks on, nor must they commit to four or five sessions a week for years on end."

 In this kind of therapy clients get an opportunity to explore and broaden the range of feelings that they are comfortable with. This exploratory process not only helps a person understand subtle and often unnoticed emotions, but also helps them begin to manage strong and often uncomfortable feelings more effectively.

 Research confirms that psychodynamic psychotherapy is highly effective. For example, Shedler writes, "One major study found an ‘effect size'-a measure of treatment benefit - of 0.97" for psychodynamic psychotherapy. "For CBT (cognitive behavioral therapy), 0.68 is a typical effect size. For antidepressant medication, the average effect size is 0.31."

 Shedler describes seven features that researchers have found contribute to the power and effectiveness of psychodynamic psychotherapy: "exploring emotions, examining avoidances, identifying recurring patterns, discussing past experience, focusing on relationships, and examining the patient/therapist relationship."

Obviously, of course, not all psychodynamic psychotherapists are created equal. It is important, when looking for someone to help with your problems, to get recommendations from people you trust, to interview several different therapists, to ask about their training, and finally, to trust your instinct. (For more specifics, check out my post on choosing a psychotherapist). But if you decide to go with a psychodynamically-oriented psychotherapist and friends or family tell you there's no evidence that it works, give them a copy of Shedler's article.

As for the client I described at the beginning of this post, after we had been working together psychodynamically for several months, she came into my office and said, "You know, I am starting to feel better." I told her I was glad and asked if she had any thoughts about what had contributed to the change. "I think it helps to talk about things to someone who listens and doesn't tell me what to think. You're always asking me to try to put into words what I think about something. And that helps me think about what I'm feeling, too. And somehow, that's helping me to feel better."

*The link I have given here only gives a summary of the article - in order to read it in full you have to buy the magazine, either online or in a store; but in my opinion it's worth the price. Not only this article, but many others in the magazine are fascinating and fun reading!

F. Diane Barth, L.C.S.W., is a psychotherapist, teacher, and author in private practice in New York City.

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