Every once in a while a paper emerges from the literature, which has a major impact on the delivery of treatment in a particular area. A recent article in American Psychologist titled  The Efficacy of Psychodynamic Psychotherapy by Dr. Jonathan Shedler, Associate Professor of Psychiatry at University of Colorado School of Medicine, may be such a contribution

 

Bias Against Positive Psychodynamic Research Findings

Dr. Shedler introduces his piece by noting that many people including academicians, healthcare administrators, and health care policy makers believe that psychodynamic concepts and treatments lack empirical support or that scientific evidence shows that other forms of treatment are more effective. He states and eventually demonstrates that scientific evidence proves quite the opposite in that considerable research supports the efficacy and effectiveness of psychodynamic therapy.  One of few things  that Dr. Shedler postulates without evidence, is that the reason for this bias, is related to American psychoanalysis being “dominated by a hierarchical medical establishment that denied training to non MDs and adopted a dismissive stance toward research.” He believes that these circumstances led to academicians embracing empirical findings of non psychodynamic treatment and overlooking evidence that supported psychodynamic concepts and treatment.

Distinctive Features of Psychodynamic Technique

Inherent to this paper is a description of the characteristics of psychodynamic (which are equated with psychoanalytic) therapy. He notes that the essence of this therapy is exploring those aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship. He distills the following seven features concerning process and technique which have reliably distinguished psychodynamic therapy from other therapies (especially CBT) based on empirical examinations of actual session recordings and transcripts.

1-    Focus on affect and expression of emotion

2-    Exploration of attempts to avoid distressing thoughts and feelings (often referred to as defense and resistance)

3-    Identification of recurring themes and patterns

4-    Discussion of past experience (developmental focus)

5-    Focus on interpersonal relations

6-    Focus on the therapy relationship (often referred to as transference and countertransference)

7-    Exploration of fantasy life

He states that the goals of psychodynamic therapy include, but extend beyond symptom remission. This would mean that successful treatment should not only relieve symptoms but also foster the positive presence of psychological capacities and resources.

This idea would have particular resonance in research that is subsequently presented which shows the long lasting effects of psychodynamic therapy beyond just the improvement of symptoms.

Method of Analysis the Research Data

Shendler describes the technique of  meta–analysis which he relied upon in writing this paper, as a widely accepted method for summarizing and synthesizing the findings of independent studies. Meta-analysis makes the results of different studies comparable by converting findings into a common metric such as effect size, which is the difference between treatment and control groups expressed in standard deviation units. An effect size of 1.0 would mean that the average treated patient is one standard deviation healthier on the normal distribution or bell curve than the average untreated patient. At the other end of the scale an effect size of 0.2 is considered a small effect.

Effectiveness of Psychodynamic Psychotherapy.

A review of major meta analysis of psychotherapy outcome studies from more than 500 individual studies by different authors is presented and showed an overall effect size of between 0.75 and 0.85 compared to untreated controls. As a point of reference, the effect sizes for antidepressant medication (usually comparing active drugs vs. placebo ) was reported as running between 0.17 (for the older tricyclic medications) to only as high as 0.31 for some of the new antidepressants.

Findings Hold Up in Looking at a Variety of Disorders

 

In specifically looking at the effectiveness of psychodynamic therapy through this method of meta analysis, Shedler sited mostly recent studies from the past several years with a range of common mental disorders seen in patients who received short term (less than 40 hours) of psychodynamic therapy using controls or waiting list, minimal treatment or treatment as usual. There was an effect size of 0.97 for general symptoms improvement, which increased to 1.51 when patients were, assessed at follow-up, more than 9 months after treatment. There were other studies showing similar results when specifically looking at the improvement in somatic symptoms and health care utilization all related to psychodynamic therapy. Similar results were also found in looking at the efficacy of psychodynamic therapy in treatment for personality disorders, eating disorders, and substance related disorders.

Even Better Effects At Long term Follow-up

In the most recent and rigorous studies of the evaluation of psychodynamic therapy, the recurring findings are that the benefits of psychodynamic therapy not only endure but actually increase with time. This is a finding that is reported to have emerged from at least five independent meta analysis. In contrast the benefits of other non-psychodynamic therapies tend to decay over time, particularly for the most common disorders such as depression and generalized anxiety. The trend towards larger effect sizes at longer term follow-up were felt to suggest that psychodynamic treatment sets in motion psychological processes that lead to ongoing change, even after therapy has ended.

Role of Psychodynamic Processes in Non Psychodynamic Therapy

One of the most revealing and interesting aspects of this paper is the analysis of the role psychodynamic processes in non psychodynamic therapy. For example, Shedler discusses available evidence, which indicates that the mechanisms of change in cognitive therapy may not be “the cognitions” which are presumed by the theory. He notes that studies that look beyond “brand names“ (just labeling the type of therapy),  by examining session videotapes or transcripts, indicate that the active ingredients of other therapies include unacknowledged psychodynamic elements.

Putting the Microscope on CBT

He describes an instrument called the Psychotherapy Process Q-Sort ( PQS) which consists of 100 variables that assess therapist technique and other aspects of the therapy process which can be used to objectively analyze sessions. In looking at archival session of both CBT and psychodynamic therapy researchers could analyze where therapists were in fact adhering to the usual protocol of the therapy which they believed they were doing. The findings showed that therapists adherence to the psychodynamic protocol predicted successful outcome in both psychodynamic and cognitive therapy.  Therapists adherence to the CBT protocol showed little or no relationship to outcome in either forms of stated therapy.  This finding was replicated by a another study that employed a different methodology and also found that psychodynamic interventions, not CBT interventions, predicted successful outcome in both  cognitive and psychodynamic treatments.

In one study of the manualized CBT it was found that the identification of  “working alliance“ (also known as therapeutic alliance), which is an essential feature of psychodynamic therapy, predicted improvement in all outcome measures.  Also in the same study, the psychodynamic process of “experiencing” (which refers to talking about ideas with or without emotions, referring to inner feelings or self understanding)  predicted patients improvement on all outcome measures. A subsequent study of manualized CBT found that interventions aimed at cognitive change predicted poorer outcome whereas discussion of interpersonal relations and exploration of past experiences with early caregivers, both core features of psychodynamic technique, predicted successful outcome.

What Are The Implications of These Findings?

This outstanding paper is an eye opener. While there  are hardly any original ideas put forth but yet the author has essentially nominated psychodynamic psychotherapy as the evidence based  treatment of choice for many conditions. It also makes an implicit  case for our new US   health care system to financially support the use of this form of treatment.

There will need to be a continued flow of this kind of research and meta analysis

There is also the question of determining who are best therapists to administer this treatment and how should they be credentialed?

The author may have been correct in his opening assertions that earlier efforts of  the medical establishment to attempt to control psychoanalytic therapy may have contributed to the bias to against accepting the emerging  research presented in Shedler’s  paper. However, that does not change the imperative that patients with mental disorders need to be skillfully screened for underlying medical conditions. Also, for some patients properly prescribed psychotropic drugs will be the treatment of choice, with or without psychotherapy. For a certain subset of patients this can life saving.

Dr. Shedler’s paper is stirring up quite a tempest. This has led him to try to establish a dialog on some of these issues on the Internet. He has set up a facebook discussion group in order to facilitate this discussion.

I also encourage interested parties to feel free to comment on this blog below.