Psychodynamically-informed clinicians and researchers seem to draw a great deal of ire from their critics. Perhaps these criticisms have been rightly earned through the years as some psychoanalytic scholars and practitioners have sat silently perched behind troubled patients, or holed up in upscale uptown offices or academic ivory towers, or walled off in selective psychoanalytic institutes that denied training to non-MD practitioners. Some felt no need to systematically quantify and present their work. Some asserted absolute certainty in their methods, so why should they have to prove them with scientific "doublespeak" to anyone arguing that research doesn't capture the complexity of deep psychological work. They talked in obscure professional jargon about Oedipal complexes and neuroses and libidinal cathexis. They seemed to forget how important it was to communicate with the people that mattered, the everyday people in the world suffering with broken
dreams and broken hearts that relied on them for help.
A more modern approach to psychodynamic therapy
Psychoanalysis was created over 100 years ago. Over that century, a lot of people whose names don't end with Freud have done a great body of work, development, practice, and public service. A more contemporary approach to psychodynamic/psychoanalytic practice recognizes that human beings are unique and have their own stories, but also appreciates that scientifically informed observation and accountability is crucial for mental health care. Contemporary psychodynamic researchers and practitioners acknowledge the importance of controlling cost-effectiveness while also realizing that the real-life concerns of human beings cannot nor should not be dismissed with a casual quick-fix. A responsible psychodynamic approach realizes that while deep, meaningful, and lasting change takes time; it doesn't mean that one has to sacrifice extravagant proportions of time or take out a new mortgage to pay a therapy bill. Contemporary psychodynamic thinkers understand the importance of emotions and relationships in our lives and recognize the need for clear communication with others (professionals and general public alike) in everyday language free of jargon-riddled psychobabble.
Psychotherapy isn't a laboratory experiment
In the past couple of years, a movement has been building to compile and integrate the empirical evidence base for psychodynamic therapies as demonstrated in controlled clinical trials. This practice is tricky and comes with a number of limitations.
First, experimental trials depend on firmly embedded experimental controls. Psychotherapy, however, isn't a controlled delivery service. It's not some mechanically administered procedure or intervention rendered in metered doses. While there are some methods to attempt to standardize intervention (through adherence to treatment manuals or the use of videotaped monitoring), psychotherapy still capitalizes on the adaptability and complexity of real human beings.
Second, true clinical trials rely on "double-blind" procedures. This means that the experimenter and the subject do not know which intervention is being rendered (e.g. neither the doctor nor the patient knows whether the patient is getting a placebo or the real pill). In psychotherapy research, this is impossible as both the clinician and the patient are aware of the procedures being conducted. Just because we don't have randomized control trial data for the use of airbags on humans in high speed car crashes doesn't mean we don't have other data collection methods to study their effectiveness.
Third, psychotherapy takes time. Even in some of the briefest of psychotherapy interventions (8 sessions is generally considered brief...a course which encompasses about two months time), time introduces a host of uncontrollable experimental "noise". And to be meaningful, psychotherapy change must be lasting, which means that a single well-performed clinical trial and informed follow-up can take years of effort.
A growing evidence base for psychodynamic therapy
However, efforts have been and continue to be made to fit psychotherapy research into these somewhat ill-fitting methodological molds, and researchers have made great strides in compiling evidence in top tier academic journals for psychodynamic therapy approaches. For example, in 2008, authors Falk Leichsening and Sven Rabung published a meta-analysis on the effectiveness of long-term psychodynamic psychotherapy in the Journal of the American Medical Association. In 2010, Jonathan Shedler published a review article in American Psychologist highlighting the major process elements of contemporary psychodynamic therapy and reviewing studies showing empirical support for the approach. In 2011, Andrew Gerber and colleagues conducted a rigorous quality evaluation of randomized controlled trials of psychodynamic psychotherapy in the American Journal of Psychiatry (see also here). Like all studies, these reports have their own limitations which have been thoroughly commented on elsewhere. These reports do illustrate, however, three major conclusions:
- 1. Based on studies using traditional research methods standards governing clinical trials, psychodynamic therapy generally shows superiority to "inactive" comparison groups (this type of comparison is a standard by which Division 12 of the American Psychological Association has traditionally used to describe a treatment as "empirically validated").
- 2. In comparison with well-conducted comparison treatments (like cognitive-behavioral therapy) there is generally not enough evidence to assert differential efficacy for either treatment. Like taking cold medicine may be better than not taking it, but deciding between the "best" of the many types of cold medicine on the pharmacy shelf is often too difficult to say for certain and may depend on different factors for each person.
- 3. A number of clinical trials of adequate quality do exist to support the efficacy and effectiveness of psychodynamic therapy. Still, these trials all have limitations and more research with improved methods and more diverse samples needs to be conducted (as is true with all mental health interventions).
Critiques of psychodynamic therapy research: Fast and furious
Still, publications highlighting empirical support for psychodynamic treatments invariably seem quick to draw pointed and vociferous critiques. Dr. Coyne's recent blog post "Is Long-Term Psychodynamic Psychotherapy Worthwhile?" describes some of his critiques and extols the virtues of an in press meta-analytic review of long-term psychodynamic psychotherapy clinical trials. In critiquing or looking at critiques of meta-analyses, I'm always aware of the great opening monologue of Woody Allen's classic film Annie Hall: "There's an old joke...two elderly women are at a Catskill mountain resort, and one of 'em says, 'Boy, the food at this place is really terrible.' The other one says, 'Yeah, I know; and such small portions.'" The critiques of meta-analyses and systematic reviews generally follow the exact same logic: Boy, the studies they review are really terrible. Yeah, I know, and they didn't include enough of them! I'm generally loathe to make those critiques, but it's important to examine some of the claims being made in the post and look at what actually appears in the published meta-analysis.
