This post is in response to Is Long-Term Psychodynamic Psychotherapy Worthwhile? by James C. Coyne


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.

Dr. Coyne sings high praises for the meta-analysis as "a thorough review of the best evidence, [and] as an example of exceptionally well done and well reported meta-analysis" and includes an author who is "one of the most eminent methodologists and meta-analysts in the world."  Unfortunately, Dr. Coyne interprets the conclusion of the paper to read: "The bottom line is that available evidence suggests that LTPP [long-term psychodynamic psychotherapy] is not worthwhile, at least in terms of the conventional ways of evaluating therapies. The authors noted that many of the studies made comparisons between LTPP and a control condition, which is inappropriate if the critical question is whether LTPP is superior to other psychotherapies."  Dr. Coyne also makes greatly exaggerated and unsupported claims that "most patients in LTPP do not have eating disorders or borderline personality disorders. Many patients receiving LTPP, like some of the patients in the studies that these meta-analyses evaluated, are simply neurotic or have mixed anxiety and depression. Psychodynamic psychotherapists are strongly inclined to see all patients as needing long-term treatment, regardless of diagnosis, although few therapists of other orientation would agree."

What the studies really say

First, the new Smit et al meta-analysis criticizes earlier meta-analyses as showing effectiveness of long-term psychodynamic therapy using within-group effect sizes.  Within-group effect size means that researchers look at the amount of change seen in individual people from the start of an intervention to its finish or follow-up.  Indeed, the within-group effect sizes for long-term psychodynamic therapy were quite large (as a rough example: if psychiatric symptoms were SAT scores and long-term psychodynamic therapy were an SAT training program, the average student would expect to increase their score by somewhere around 90-180 points on each section). 

However, the within-group effect size is only one piece of the puzzle in looking at if something works.  Because symptoms may simply go away over time or due to a "placebo effect", research also needs to consider between-group effect sizes between an active treatment and an inactive comparison condition.  The traditional standards for evaluating psychotherapy evidence (as set out by APA Division 12) and for new medications (as set out by the FDA) are that clinical trials be conducted against wait-list, placebo, or inactive comparators.  As Drs. Smit and colleagues acknowledge in their paper, Drs. Leichsenring and Rabung acknowledged this limitation in a follow-up report showing that between-group comparisons of LTPP were lower (as expected), but the effect size was still about half as large as the within-group comparison (again, in terms of SAT points, around a 54 point increase for each section of the test). 

Still, Smit et al take their criticisms one step further to saying that LTPP should only be evaluated against active and established comparison treatments.  This is a good standard to evaluate against, but keep this in mind: it's like comparing Weight Watchers to Jenny Craig to Nutrisystem.  Just because you don't find significant differences between the programs compared to each other DOES NOT mean that the programs being evaluated don't work.  Indeed, Smit et al found no significant differences in changes to psychiatric symptoms, personality pathology, social functioning, or overall effectiveness between long-term psychodynamic therapy and active comparison groups across clinical trials. 

[Note: The authors did still find a significant differential benefit for long-term psychodynamic therapy in studies where the comparison psychotherapy was not a specialized form of treatment (Hedge's g = .57, p =.002).  The authors found no significant deficit of long-term psychodynamic therapy versus other specialized psychotherapies (like DBT) despite their inclusion of a significant outlier study (Giesen-Bloo, et al 2006). Three of the meta-analysis's authors were authors on that outlier study in which the borderline patients in the long-term psychodynamic psychotherapy condition were significantly more self-destructive from the start, and the study therapists were less adherent and confident in their practice with the psychodynamic model they were supposed to be practicing.  The food was terrible.  Yeah, and such small portions!]

Finding more worthwhile questions to investigate

Among many major brands of psychotherapy with demonstrated use and effectiveness, characteristics such as patient preferences, therapist qualities, treatment structure and therapeutic relationship often remain better predictors of treatment success or failure. In the end, psychodynamic therapy, like all major brands of psychotherapy, needs continued quality research on its effects, mechanisms, and benefits. 

At the same time, more psychotherapy research efforts and funding can be directed towards other gainful endeavors such as: improved outcome measurement in areas more broad than acute psychiatric symptom reduction (e.g., psychological and physical health and well-being, social/occupational functioning, and positive/negative health-risk behaviors), methods for increasing access to mental-health care services, identification of effective training/supervision processes, improving existing diagnostic systems to enhance clinical utility, elaboration of the prominent role of personality factors in the clinical process, and advocacy for the equitable reimbursement of mental health service provision.

The most "not worthwhile" things about long-term psychodynamic psychotherapy are the ill-informed and broad sweeping write-offs that it is an ineffective, endless treatment for the "simply neurotic" or "worried well".   

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Portions of this post have previously appeared in the Division 39 newsletter Psychologist-Psychoanalyst.

By Jared DeFife, Ph.D.
© January 15, 2012 (original article link: http://tinyurl.com/7r8whkl)
For information about research, speaking, and Atlanta-based psychotherapy practice, visit www.jareddefife.com

About the Author

Jared DeFife, Ph.D.

Jared DeFife, Ph.D., is a clinical psychologist and assistant professor of psychiatry and behavioral sciences at the Emory University School of Medicine.

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