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Research on Psychodynamic Therapies

In recent decades we have seen an explosion of research on psychoanalytically-influenced therapies and psychoanalytic concepts. A psychodynamic research listserv, founded over 15 years ago, has over 1,000 researcher members, pointing to the great interest in understanding the evidence regarding psychodynamic therapy.

Brief Psychodynamic Therapies

A major topic of this research has been the efficacy of psychoanalysis and psychoanalytically-influenced psychodynamic therapies (“PDTs”: Levy et al., 2011; Shedler, 2010). One common finding for time-limited or briefer therapies is that most therapies appear to help some people to approximately an equivalent extent. Thus, randomized controlled trials (RCT) comparing an active psychotherapy to some type of control condition (say, being placed on a waiting list) typically find the active psychotherapy leading to better outcomes than the control. In contrast, RCTs comparing two distinct types of time-limited psychotherapy to each other often find little difference in outcomes between the psychotherapies.

Consistent with this, a number of studies and meta-analyses (efforts to provide a quantitative synthesis of a body of studies on a single topic) comparing time-limited PDTs to other therapies, such as cognitive-behavioral therapy (CBT), often find little difference. For example, a 2017 meta-analysis examined 23 RCTs that compared a psychodynamic therapy with a different therapy, most often CBT, though two compared psychodynamic therapy to treatment with psychotropic drugs such as antidepressants (Steinert et al., 2017). While there was no limit to the length of therapy or number of sessions, the majority of studied therapies lasted 20 sessions or less, while only a small number lasted longer than 40 sessions. The study found that PDT was equivalent to the comparison therapy in terms of target symptoms and several other types of outcomes. The study found some limited evidence that psychodynamic therapy may have led to better outcomes than CBT in terms of psychosocial functioning at follow-up after therapy ended.

Long-Term Psychodynamic Therapy

Whereas the above meta-analysis focused on time-limited PDT, another body of work has examined long-term PDT, to assess whether its outcomes are equivalent to or superior to those of other therapies (Leichsenring et al., 2013; Woll & Schönbrodt, 2019). Woll and Schönbrodt (2019) conducted a series of meta-analytic studies to examine these issues in the treatment of complex mental disorders. They found that long-term PDT had small but statistically significant better outcomes than other therapies for many outcomes (psychiatric symptoms, target problems, social functioning, and overall effectiveness). They found no differences for personality functioning.

Psychodynamic Outcome Measures

Other researchers argue that the measures of personality functioning in studies like those in Woll and Schönbrodt’s (2019) meta-analysis are not adequate to assess the types of changes in personality functioning that are produced by long-term PDT. For example, Shedler and Westen developed a tool, the Shedler-Westen Assessment Procedure (SWAP), for psychotherapists to assess their patients’ personalities in a standard format using theory-free language that allowed psychodynamic aspects of patient functioning to be evaluated by those who were not conversant  or comfortable with psychoanalytic theory and language (Shedler, 2002; Shedler & Westen, 1998; Westen et al., 2003; Westen & Shedler, 1999, 2000a, 2000b). While we are not familiar with any large-scale outcome studies utilizing the SWAP, preliminary data suggest that it may be useful in assessing changes occurring in psychotherapy that are not well addressed by more standard measures like those utilized in most PDT efficacy studies.

Psychodynamic Treatment of Personality Disorders

Personality disorders are forms of emotional disturbance that involve longstanding maladaptive patterns of thought, internal experience, emotional regulation, and social behaviors. Personality disorders often cause serious difficulties in work life and interpersonal relationships. Much work in developing psychoanalysis and psychodynamic psychotherapies has focused on approaches to treating personality disorders. 

A recent meta-analysis examined RCTs comparing psychodynamic therapy (PDT) for personality disorders to either a control condition (most often, treatment as usual) or to other active therapies (usually either CBT or Dialectical Behavior Therapy) (Keefe et al., 2019). The comparison to control conditions found that PDT exhibited superior outcomes to control conditions for many outcomes, including core personality disorder symptoms, general psychiatric symptoms, suicidality, and psychosocial functioning. While every study entering this meta-analysis found PDT superior to control conditions on interpersonal problems, the combined analysis was not statistically significant because of extreme variability in outcomes (“heterogeneity,” researchers call this) between studies.

When PDT was compared to other active psychotherapies for personality disorders, it was essentially equivalent in outcomes to these other therapies (Keefe et al., 2019). This equivalence continued into follow-up up to 14 months after therapy ended. Thus, evidence suggests that PDT is one of several effective psychotherapies for personality disorders, but that so far it has not shown itself to be superior. Future studies should examine whether certain patients with personality disorders may best be treated with PDT or with other therapies.

Psychotherapy Process Research

While many researchers examining psychodynamic therapy focus upon the efficacy of PDTs, other researchers focused upon the processes whereby psychodynamic therapy produces changes in patients (Bucci, 2005; Soldz, 1990). For example, over a long career, Bucci has attempted to integrate psychoanalytic thinking with contemporary cognitive science. Much of her work focused upon understanding a cyclical processes in psychoanalytic therapies whereby affective arousal leads to description of internal experiences (dreams and fantasies) or the telling of stories (narratives) which in turn lead to a process of reflection and the connection of affective experiences to symbolic experiences (Bucci, 1994, 1997, 2002).

Safran and colleagues have also examined psychotherapy process. They have focused upon times of increased strain in the therapeutic relationship, which they called “alliance ruptures” (Eubanks et al., 2018; Safran et al., 2011). They argued that much of the work in effective psychotherapies involves the therapist and patient collaborating to understand and repair these ruptures.

Both Bucci and Safran go further and argue that the psychodynamic processes they describe and study are important aspects of all effective psychotherapies, whether those therapies are explicitly psychodynamic or not. Shedler (2010) builds upon other research to argue that many of the processes that are associated with effective cognitive-behavioral therapy are best understood using psychodynamic concepts rather than the proposed mechanisms of CBT effectiveness (identification and modification of irrational cognitive schemas).

Interdisciplinary Psychodynamic Research

Other researchers explore the intersection between psychoanalytic thinking and contemporary neuroscience (Solms, 2019). They argue that many of the findings of contemporary brain studies are consistent with psychoanalytic concepts, while the brain studies can help refine psychoanalytic thinking. For the last 20 years, the journal Neuropsychoanalysis has explored the interface of psychoanalysis and brain research.

Still other researchers use psychoanalytic theories and concepts to enhance our understanding of social and cultural phenomenon. This used to be known as social psychoanalysis. In recent years, it has become known as the field of Psychosocial Studies in Europe. Soldz and Andersen (2012) edited a special issue of the Journal of Research Practice which provides an introduction to this and related work. At BGSP, our Psychoanalysis, Society, and Culture program explores this field. 

References:

Bucci, W. (1994). The multiple code theory and the psychoanalytic process: A framework for research. The Annual of Psychoanalysis, 22, 239–259.

Bucci, W. (1997). Psychoanalysis and cognitive science: A multiple code theory. (pp. xiv, 362). Guilford Press.

Bucci, W. (2002). From subsymbolic to symbolic—And back: Therapeutic impact of the referential process. In Symbolization and desymbolization: Essays in honor of Norbert Freedman. (pp. 50–74). Other Press.

Bucci, W. (2005). Process research. In E. S. Person, A. M. Cooper, & G. O. Gabbard (Eds.), The American psychiatric publishing textbook of psychoanalysis (pp. 317–333). American Psychiatric Publishing, Inc.

Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508–519. https://doi.org/10.1037/pst0000185

Keefe, J. R., McMain, S. F., McCarthy, K. S., Zilcha-Mano, S., Dinger, U., Sahin, Z., Graham, K., & Barber, J. P. (2019). A meta-analysis of psychodynamic treatments for borderline and cluster C personality disorders. Personality Disorders: Theory, Research, and Treatment, 11(3), 157–169. https://doi.org/10.1037/per0000382

Leichsenring, F., Abbass, A., Luyten, P., Hilsenroth, M., & Rabung, S. (2013). The Emerging Evidence for Long-Term Psychodynamic Therapy. Psychodynamic Psychiatry, 41(3), 361–384. https://doi.org/10.1521/pdps.2013.41.3.361

Levy, R. A., Ablon, J. S., & Kächele, H. (2011). Psychodynamic psychotherapy research: Evidence-based practice and practice-based evidence. Springer Science & Business Media.

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80.

Shedler, J. (2002). A new language for psychoanalytic diagnosis. Journal of the American Psychoanalytic Association, 50, 429–456.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378

Shedler, J., & Westen, D. (1998). Refining the measurement of Axis II: A Q-sort procedure for assessing personality pathology. Assessment, 5, 333–353.

Soldz, S. (1990). The therapeutic interaction: Research perspectives. In R. A. Wells & V. J. Giannetti (Eds.), Handbook of the brief psychotherapies (pp. 27–53). Plenum.

Soldz, S., & Andersen, L. L. (2012). Expanding subjectivities: Introduction to the special issue on’New Directions in Psychodynamic Research’. Journal of Research Practice, 8(2), 1–8.

Solms, M. (2019, February 8). The scientific standing of psychoanalysis. Therapyroute.Com. https://www.therapyroute.com/article/the-scientific-standing-of-psychoanalysis-by-m-solms

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes. American Journal of Psychiatry, 174(10), 943–953. https://doi.org/10.1176/appi.ajp.2017.17010057

Westen, D., & Shedler, J. (1999). Revising and assessing axis II, Part II: Toward an empirically based and clinically useful classification of personality disorders. American Journal of Psychiatry, 156, 273–285.

Westen, D., & Shedler, J. (2000a). A prototype matching approach to diagnosing personality disorders: Toward DSM-V. Journal of Personality Disorders, 14, 109–126.

Westen, D., & Shedler, J. (2000b). “Theoretical-clinical-empirical approach to classifying axis II disorders”: Reply. American Journal of Psychiatry, 157, 309.

Westen, D., Shedler, J., Durrett, C., Glass, S., & Martens, A. (2003). Personality diagnoses in adolescence: DSM-IV Axis II diagnoses and an empirically derived alternative. American Journal of Psychiatry, 160, 952–966.

Woll, C. F. J., & Schönbrodt, F. D. (2019). A Series of meta-analytic tests of the efficacy of long-term psychoanalytic psychotherapy. European Psychologist, 25(1), 51–72. https://doi.org/10.1027/1016-9040/a000385