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What Evidence is There to Support the Usefulness of Psychodynamic/ Psychoanalytic Treatment?

There is extensive scientific evidence, collected over several decades, that psychodynamic psychotherapy is an effective and clinically useful approach for treating many complex psychiatric problems, including severe character disorders, trauma, borderline personality disorder, anxiety, and depression (Leichsenring et al. 2015). Grounded in this empirical base, psychodynamic psychotherapy is a standard part of contemporary psychiatric practice (Oldham 2005). Standard practice guidelines issued by professional organizations such as the American Psychiatric Association (APA) include psychodynamic psychotherapy among other evidence-based treatment options (APA Practice Guidelines).

Psychodynamic Treatment for Prevalent Psychiatric Disorders

Strong evidence supporting psychodynamic psychotherapy for the treatment of many common disorders suggests that the changes experienced by patients in psychodynamic therapy may be deeper and more enduring as compared to other treatments (Bateman and Fonagy 1999), (Bateman and Fonagy 2001), (Bateman and Fonagy 2009); (Clarkin et al. 2007); (Driessen et al. 2015); (Fowler et al. 2004); (Leichsenring and Rabung 2008), (Leichsenring and Rabung 2011); (Leichsenring et al. 2015); (Luyten, Blatt, and Fonagy 2014); (Shedler 2010); (Werbart, Forsström, and Jeanneau 2012).

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Research has also shown that longer duration of treatment is correlated with a reduction in symptoms (Bateman and Fonagy 2008). Longer-term psychodynamic treatments have been shown to lead to greater relief and more sustained change compared to shorter-term treatments (deMaat et al. 2009); (Leichsenring and Rabung 2008); (Leichsenring and Rabung 2011); (Leichsenring et al. 2015).

Randomized Controlled Trials (RCTs)

Many in the research community have supported the idea that statistical methodologies such as randomized controlled trials (RCTs) are a valuable means for determining the empirical evidence of any treatment (Fonagy et al. 2015); (Gerber et al. 2011); (Leichsenring et al. 2015); (Wachtel 2010). Published RCTs show conclusively that psychodynamic treatment is superior to inactive comparison groups and is not inferior to other active evidence-based treatments (Barber et al. 2012); (Barkham et al. 1999); (Cooper et al. 2003); (deJonghe et al. 2004); (Driessen et al. 2013); (Leichsenring, Klein, and Salzer 2014); (Levy et al. 2006); (Svartberg, Stiles, and Seltzer 2004). These findings support the notion that psychodynamic treatment is as effective as other forms of active treatment.

Meta-analysis and Effect Sizes

Meta-analysis is a statistical method that groups multiple empirical studies together to increase the statistical power of findings linked to a particular treatment. Statistical power refers to the ability of an investigation to detect meaningful differences between treatment conditions (Tabachnick and Fidell 1996). If a treatment under study is in fact truly effective, a study with higher statistical power has a greater probability of detecting this fact. Over the past several years, many meta-analyses have demonstrated the efficacy of psychotherapy interventions (Abbass et al. 2006); (Abbass, Kisely, and Kroenke 2009); (Anderson and Lambert 1995); (Crits-Christoph 1992); (de Maat et al. 2006); (de Maat et al. 2009); (Leichsenring and Leibing 2003); (Leichsenring, Rabung, and Leibing 2004); (Leichsenring and Rabung 2008); (Smith, Glass, and Miller 1980).

A widely accepted way of determining the effectiveness of psychotherapy in meta-analyses is calculating an effect size. An effect size allows researchers to compare different outcomes in varied types of psychotherapy by converting diverse findings into a common unit of measurement. An effect size of 0.8 is considered a large effect, an effect size of 0.5 is considered moderate, and an effect size of 0.2 is considered a small effect (Cohen 1988).

In general, the effect sizes for commonly treated psychiatric conditions, comparing psychodynamic psychotherapy to typical control conditions (minimal treatment, waitlist) range from approximately 0.7 after a short-term treatment (fewer than 40 hours) to more than 2.0 approximately one year after treatment has ended. The effect sizes for specific clinical conditions such as depression and anxiety were 0.98 and 1.35 respectively after therapy ended. Even though the effect sizes are strong after fewer than 40 hours of psychodynamic treatment, they increase substantially after formal treatment ends (Bateman and Fonagy 2008); (Chisea and Fonagy 2003), (Chisea et al. 2004); (Leichsenring and Rabung 2008); (Leichsenring and Rabung 2011); (Leichsenring et al. 2015). Research focusing on the psychodynamic treatment of depression has reported medium to large effect sizes [Average 0.73] (Fonagy 2015); (Shedler et al. 2010) that are significantly greater than the average effect sizes of 0.31 reported in research focusing on the use of antidepressant medications alone to treat depression (Turner et al. 2008).

A recent meta-analysis of psychodynamic psychotherapy included 54 studies (more than half were RCTs) of nearly 4,000 patients (Driessen et al. 2015). The studies primarily compared psychodynamic treatment for common psychiatric conditions such as depression and anxiety disorders with alternate psychotherapies and/or medication. They reported a range of moderate effect sizes (0.49-0.69) for improvement in depressive symptoms, general psychopathology, and quality of life. In addition, Driessen and colleagues (2015) reported a small effect size (0.35) for improvement in anxiety at the end of treatment and a large effect size (0.76) for improvement in anxiety at follow-up ranging from 2 weeks to 4.6 years after treatment had ended. The finding that effect sizes increase at follow-up supports other studies that have shown that the improvements (via patient report) from psychodynamic psychotherapy are enduring and lead to continued change after formal treatment has ended (Hilsenroth, Ackerman, and Blagys 2001).

Psychodynamic Treatment Compared to Cognitive Behavioral Therapy

Evidence supports the effectiveness of psychodynamic treatment alongside other, shorter treatment approaches such as Cognitive Behavioral Therapy (CBT). Although CBT is an effective therapy and works for certain psychiatric conditions, it is not the only therapy with clinical and empirical support. Experienced, well-trained therapists have been found to use both CBT and psychodynamic techniques in their clinical work with patients (Blagys and Hilsenroth 2000); (Hilsenroth et al. 2005). In addition, there is a large body of current research evidence that demonstrates little to no difference in effectiveness between CBT and other common forms of treatment, including psychodynamic therapy (Clarkin et al. 2007); (Leichsenring et al. 2015); (Thoma et al. 2012); (Luyten, Blatt, and Fonagy 2014). In fact, most studies that have compared CBT and psychodynamic therapy with either no treatment conditions or treatment-as-usual conditions have found both CBT and psychodynamic therapy to be equally effective (Cooper et al. 2003); (Driessen et al. 2013); (Leichsenring, Klein, and Salzer 2014); (Levy et al. 2006). 

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