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James C. Coyne Ph.D.

Is Long-Term Psychodynamic Psychotherapy Worthwhile?

New Review Raises Doubts

Long-term psychodynamic psychotherapy (LTPP) requires a longer time commitment with more frequent sessions than most other psychotherapies. Does it provide benefits that justify the added expense, which can be considerable?

Some proponents argue that long-term therapy does more than reduce symptoms or resolve problems like depression or anxiety, it transforms peoples' lives. Freud himself actually entertained doubts about this, arguing

´One has the impression that one ought not to be surprised if it should turn out in the end that the difference between a person who has not been analyzed and the behavior of a person after he has been analyzed is not so thorough-going as we aim at making it and as we expect and maintain it to be´ (Freud, 1937/1961)

Some patients in LTPP are seeking a long term trusting relationship. Therapy is the purchase of a special kind of friendship, and consenting adults should be free to spend their time and money in this way.

However, there is a growing clamor from advocates of long term therapy for insurance reimbursement in a time of a need to contain escalating health care costs. So, issues have to be raised whether psychodynamic psychotherapy is worth reimbursing. After all, most people will not seek such long-term treatment, even if it is reimbursed, and so it becomes a potentially costly burden on those who do not want it. But there is the more important issue of comparative effectiveness. There is a wealth of evidence that some forms of psychotherapy work for some conditions, like exposure therapy for posttraumatic stress disorder or cognitive behavior therapy for depression. Such treatments are typically shorter-term and have fewer sessions and are therefore cheaper than LTPP. Can we justify the cost of long-term psychodynamic psychotherapy when there is evidence that shorter-term less expensive therapies work and maybe even be better?

Professor Falk Leichenring

In a recent blog, I examined the case made in British Journal of Psychiatry and JAMA by Falk Leichsenring and Sven Rabung that LTPP is more effective than shorter term therapies. I pointed out that these two papers were redundant - 10 of the 11 studies in the BJP meta-analysis were already included in the JAMA meta-analysis. The meta analyses were also quite flawed. Most of the studies included in them were of exceptionally poor quality, but Leichsenring and Rabung used the wrong means of assessing quality and so missed this. A number of the studies compared LTPP to no formal treatment whatsoever or to a short term treatment that had no empirical support. Such comparisons are not relevant to the question of how LTPP compares to evidence-based psychotherapies. There were vast differences between LTPP and the comparison conditions in the amount of treatment received, with one study notably comparing an unvalidated psychotherapy without any treatment manual to 23 times as many sessions of LTPP! There was often no control for concurrent medication or other treatments. In the JAMA article, there were some voodoo statistics that gave exaggerated. estimates of the efficacy. Leichsenring and Rabung cited the JAMA article in the BJP piece without acknowledging that the estimates of the efficacy of LTPP in JAMA were simply wrong.

Professor Leichsenring is a passionate advocate of LTPP and these two papers were published in the context of his effort to lobby for reimbursement of LTPP by German insurance companies which had previously rejected reimbursement. The reasoning for not reimbursing LTPP was a lack of evidence that LTPP is as effective or more effective than psychotherapies that were already deemed evidence-based and therefore reimbursed. Leichsenring's advocacy gives the appearance of a potential conflict of interest, so that doubts could be raised whether he was providing an objective assessment.

In the spirit of promoting post-publication review and debate, I submitted some of my concerns as a Rapid Response to BJP and they have now been posted at the website. To watch for the likely response from Professor Leichsenring, you can create an electronic alert.

A new meta-analysis of the efficacy of LTPP has appeared in the March 2012 of Clinical Psychology Review. The abstract can be accessed here and the full paper is available by e-mailing the senor author, Professor Arnoud Arntz, I am quite impressed with this paper, not only as a thorough review of the best evidence, but as an example of exceptionally well done and well reported meta-analysis. The article provides exquisitely detailed specification of the research question; the search strategies used to identify studies; the studies that were included and excluded; how studies were evaluated and the strengths and weaknesses that were found; and the overall effect sizes that were obtained.

The quality of this review should not be surprising because one of the authors, Professor John Ioannidis is one of the most eminent methodologists and meta-analysts in the world. I encourage people who want to learn more about meta-analyses to evaluate this paper using readily available criteria and a checklist. I wish I could find more such commendable models of a meta analysis of the efficacy of a psychotherapy in the literature, but I cannot. If anyone can find any that even come close, do let me know.

The authors defined LTPP as having at least 40 sessions and continuing for at least one year. This different from Leichsenring and Rabung's requirement of at least 50 sessions, but the authors noted that weekly sessions may result in a total of less than 50 sessions in a year, allowing for patients´and therapists´ vacations and missed sessions.

The authors struggled with the poor quality of the studies they were able to identify, but came up with an excellent solution. The meta-analysis was conducted with each of the poor quality studies included and then again with each of these studies excluded. As it turned out, whether the studies were included did not influence the results.

Results were unambiguous and negative, in terms of the efficacy of LTPP:

The recovery rate of various mental disorders was equal after LTPP or various control treatments, including treatments without a specialized psychotherapy component. Similarly, no statistically significant differences were found for the domains target problems, general psychiatric problems, personality pathology, social functioning, overall effectiveness or quality of life.

The bottom line is that available evidence suggests that LTPP 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.

Control conditions were heterogeneous and frequently of low quality, e.g. without a specialized psychotherapy component. If anything, this suggests that LTPP is often compared against relatively ineffective "straw man" comparator... LTPP comparisons to specialized non-psychodynamic treatments, like dialectical behavior therapy and schema-focused therapy, suggest that LTPP might not be particularly effective.

All of the studies were conducted by advocates of LTPP and that makes all the more surprising the uniformity of the negative results. After all, investigator allegiance is typically a strong predictor of the outcome of a clinical trial evaluating a psychotherapy. You can better guess the outcome of a clinical trial evaluating a psychotherapy from the allegiance of the investigator than you can from the therapy being evaluated.

Although I am greatly impressed with this meta-analysis, I have doubts about the adequacy of the authors' proposal for evaluations of LTPP versus other evidence-based therapies.

Future studies should compare LTPP to other highly specialized treatments that are equally intensive, like state-of-the art cognitive behaviour therapy in case of eating disorders, or schema-focused therapy or dialectical behaviour therapy in case of borderline personality disorder.

If we have the specific research question of whether LTPP is superior to evidence-based treatments for eating disorder or borderline personality, such a comparative study would be useful and feasible. But 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.

If someone were to design a clinical trial examining the efficacy of treatment for the more typical patient seen in LTPP with 40 sessions or one-year duration of treatment, I doubt that many therapists practicing a comparison evidence-based treatment would want to commit to the necessity of their patients continuing for this length of time. And unless the therapy were provided free, I doubt that many patients would consent to randomization and be retained. So maybe we won't be seeing anytime soon decisive evaluations of the efficacy of LTPP for the patients typically being recruited to it.

About the Author

Jim Coyne, Ph.D., is a clinical health psychologist and Professor in the Department of Psychiatry at the University of Pennsylvania.