Psychodynamic psychotherapy brings lasting benefits, new study finds

Psychodynamic therapy focuses on the psychological roots of emotional suffering. Its hallmarks are self-reflection and self-examination, and the use of the relationship between therapist and patient as a window into problematic relationship patterns in the patient's life. Its goal is not only to alleviate the most obvious symptoms but to help people lead healthier lives.

"The American public has been told that only newer, symptom-focused treatments like cognitive behavior therapy or medication have scientific support," said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. "The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last."

To reach these conclusions, Shedler reviewed eight meta-analyses comprising 160 studies of psychodynamic therapy, plus nine meta-analyses of other psychological treatments and antidepressant medications. Shedler focused on effect size, which measures the amount of change produced by each treatment. An effect size of 0.80 is considered a large effect in psychological and medical research. One major meta-analysis of psychodynamic therapy included 1,431 patients with a range of mental health problems and found an effect size of 0.97 for overall symptom improvement (the therapy was typically once per week and lasted less than a year). The effect size increased by 50 percent, to 1.51, when patients were re-evaluated nine or more months after therapy ended. The effect size for the most widely used antidepressant medications is a more modest 0.31. The findings are published in the February issue of American Psychologist, the flagship journal of the American Psychological Association.

The eight meta-analyses, representing the best available scientific evidence on psychodynamic therapy, all showed substantial treatment benefits, according to Shedler. Effect sizes were impressive even for personality disorders -- deeply ingrained maladaptive traits that are notoriously difficult to treat, he said. "The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended," Shedler said. "In contrast, the benefits of other 'empirically supported' therapies tend to diminish over time for the most common conditions, like depression and generalized anxiety."

"Pharmaceutical companies and health insurance companies have a financial incentive to promote the view that mental suffering can be reduced to lists of symptoms, and that treatment means managing those symptoms and little else. For some specific psychiatric conditions, this makes sense," he added. "But more often, emotional suffering is woven into the fabric of the person's life and rooted in relationship patterns, inner contradictions and emotional blind spots. This is what psychodynamic therapy is designed to address."

Shedler acknowledged that there are many more studies of other psychological treatments (other than psychodynamic), and that the developers of other therapies took the lead in recognizing the importance of rigorous scientific evaluation. "Accountability is crucial," said Shedler. "But now that research is putting psychodynamic therapy to the test, we are not seeing evidence that the newer therapies are more effective."

Shedler also noted that existing research does not adequately capture the benefits that psychodynamic therapy aims to achieve. "It is easy to measure change in acute symptoms, harder to measure deeper personality changes. But it can be done."

The research also suggests that when other psychotherapies are effective, it may be because they include unacknowledged psychodynamic elements. "When you look past therapy 'brand names' and look at what the effective therapists are actually doing, it turns out they are doing what psychodynamic therapists have always done -- facilitating self-exploration, examining emotional blind spots, understanding relationship patterns." Four studies of therapy for depression used actual recordings of therapy sessions to study what therapists said and did that was effective or ineffective. The more the therapists acted like psychodynamic therapists, the better the outcome, Shedler said. "This was true regardless of the kind of therapy the therapists believed they were providing."