The efficacy of psychodynamic psychotherapy.

Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.” In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Methods and mechanisms in the efficacy of psychodynamic psychotherapy.

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler summarized a large body of research that shows psychodynamic therapy to have a substantial effect size, comparable to that for many empirically supported treatments. This is an important finding, in part refuting the concerns raised by Bornstein (2001, 2002) regarding the future of psychodynamic approaches had there been no substantial changes in how practitioners and researchers approached the science to demonstrate efficacy. Further, Shedler showed that the efficacy of psychoanalytic psychotherapy is due to therapeutic methods commonly employed in cognitive behavior therapy (CBT), one of the most frequently cited empirically supported approaches for a wide range of psychological conditions. From a methodological perspective, there are some important limitations to the claim of psychodynamic psychotherapy’s comparable efficacy to other empirically supported approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

When it comes to evaluating psychodynamic therapy, the devil is in the details.

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). As Shedler noted, some researchers have reflexively and stridently dismissed psychodynamic therapy (PT) as ineffective without granting outcome studies on this modality a fair hearing. We applaud Shedler’s efforts to bring PT into the scientific mainstream and hope that his article encourages investigators to evaluate claims regarding PT’s efficacy with a more objective eye. Nevertheless, as Shedler also observed, one reason for the scientific community’s premature dismissal of PT is traceable to some psychodynamic practitioners’ historical antipathy toward controlled research and propensity to overstate PT’s efficacy. Regrettably, Shedler falls prey to the latter error by glossing over key methodological details, ignoring crucial findings that run counter to his position, and overstating the quality and quantity of the evidence base for PT. Because of space constraints, we focus only on a handful of the more serious shortcomings of Shedler’s analysis (a more complete review of these issues is available from the first author on request). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Science or ideology?

Responds to the comments by D. McKay (see record 2011-02175-008); B. D. Thombs, L. R. Jewett, and M. Bassel (see record 2011-02175-009); M. D. Anestis, J. C. Anestis, and S. O. Lilienfeld (see record 2011-02175-010); and W. W. Tryon and G. S. Tryon (see record 2011-02175-011) on the current author's original article, "The efficacy of psychodynamic psychotherapy" (see record 2010-02208-012). The academic psychology literature is filled with pronouncements about psychodynamic theory, often stated in authoritative tones, that present a picture of psychodynamic treatment that is unrecognizable to me and to other contemporary psychodynamic practitioners. Several of the comments about my article perpetuate this tradition and, I am sorry to say, introduce disinformation into the pages of the American Psychologist. Before addressing some specifics, I want to say a few words about my understanding of how such misrepresentations can find their way into scholarly academic journals. Three of the four comments on my article appear to have the intent of reasserting the master narrative by creating a smokescreen of doubt and confusion (Anestis, Anestis, & Lilienfeld, 2011; McKay, 2011; Thombs, Jewett, & Bassel, 2011). Two of the four comments (McKay, 2011; Tryon & Tryon, 2011) cite a metaanalysis indicating that there is no empirical support for the concept of “symptom substitution.” Two of the comments (Anestis et al., 2011; Thombs et al., 2011) note that the effect size from the meta-analysis by Leichsenring and Rabung (2008)—one of eight meta-analyses showing substantial benefits for psychodynamic therapy reported in my Table 1 (Shedler, 2010)—has been the target of criticism and reflects a computational error. Three of the comments (Anestis et al., 2011; McKay, 2011; Thombs et al., 2011) imply that the methods used in empirical studies of psychodynamic therapies are somehow inadequate relative to studies of other evidence-based therapies. Unlike the other comments, the comment of Tryon and Tryon (2011) appears to be a sincere effort to engage with my arguments. What disturbs me about the three other comments is not that the authors disagree with my conclusions but that they portray themselves as objective investigators who desire only to promote good science. While Anestis et al. (2011), McKay (2011), and Thombs et al. (2011) imply or explicitly state that I am the one who marshals evidence selectively, from my angle of vision they appear to value only evidence that supports an a priori agenda while ignoring, dismissing, or attacking evidence that does not. If so, this is not science, but ideology masquerading as science. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is there room for criticism of studies of psychodynamic psychotherapy?

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler declared unequivocally that “empirical evidence supports the efficacy of psychodynamic therapy” (p. 98). He did not mention any specific criticisms that have been made of evidence on psychodynamic psychotherapies or address possible distinctions between evidence for short-term versus long-term psychodynamic psychotherapies. Instead, he attributed dissenting views to biases in evidence dissemination and review, which he suggested are rooted in a “lingering distaste in the mental health professions professions for past psychoanalytic arrogance and authority” related to a “hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research” (Shedler, 2010, p. 98). Shedler (2010) justified his blanket dismissal of criticisms of evidence supporting psychodynamic psychotherapy on the basis of several published meta-analyses. The validity of conclusions from metaanalyses depends on the quality of the evidence synthesized, the nature of the studies included, and the rigor of the statistical analyses employed. Many meta-analyses, however, are not performed rigorously, which can result in treatment efficacy estimates that obscure important intertrial differences and that are unlikely to be replicated in clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Revue de L’évaluation des psychothérapies et de la psychanalyse: fondements et enjeux.

Reviews the book, L’évaluation des psychothérapies et de la psychanalyse: fondements et enjeux (The evaluation of psychotherapies and psychoanalysis: Foundations and issues) by Georges Fischman (2009). This collective book was written following an epistemology seminar directed by Dr. Fischman. This seminar, held at the Sainte-Anne hospital in Paris, gathered a group of experts in order to discuss the issue of psychotherapy assessment, with a particular focus on psychoanalysis and psychodynamic therapies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Middle-class waifs. The psychodynamic treatment of affectively disturbed children.

Reviews the book, Middle-class waifs. The psychodynamic treatment of affectively disturbed children by Elaine V. Siegel (see record 1991-98014-000). Most of this book is devoted to case histories of children and their parents who have relatively severe emotional problems yet can be sufficiently responsive to psychotherapy so that positive changes occur. Particularly impressive are the ways in which the author, in her therapeutic role, overcomes the resistances presented by both children and parents. She is clearly an excellent therapist, who would probably be effective regardless of orientation, and her manner of working with people has applicability for all psychotherapists. Her appreciation of the necessary balance in understanding the needs of children and their parents is an exemplary model of what it really means to respect the personhood of patients. One of the intriguing possibilities in this book is the case that is made for the broad applicability of psychoanalytic theory and treatment. During a time in which psychodynamic work is being criticized as taking too long, costing too much, and producing too little, the author offers quite a convincing demonstration of its value. The negative consequences of increased disparagement of this approach are also made apparent, so that a definite step is taken to restore the worth of treatment options. Any limitations of this book are minor, relative to the excellent portrayal of the process of psychotherapy with difficult patients that too often frighten or overwhelm people who could help them if the helpers would let themselves discover how. This work by a master clinician definitely points the way. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Individual psychodynamic psychotherapy of schizophrenia: Empirical evidence for the practicing clinician.

Practicing psychodynamically oriented clinicians need empirical evidence to support the use of individual psychodynamic psychotherapy for the treatment of individuals with schizophrenia. The purpose of this article is to provide psychodynamically oriented clinicians with that needed empirical evidence. A review of the meta-analytic research on the use of individual psychodynamic psychotherapy was conducted. It is concluded that strong empirical support exists for the use of individual psychodynamic psychotherapy in the treatment of schizophrenia. In addition, several suggestions are made to help clinicians apply the meta-analytic evidence to their daily clinical work. Limitations of the available evidence are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beyond brand names of psychotherapy: Identifying empirically supported change processes.

There is considerable debate about which empirical research methods best advance clinical outcomes in psychotherapy. The prevailing tendency has been to test treatment packages using randomized, controlled clinical trials. Recently, focus has shifted to considering how studying the process of change in naturalistic treatments can be a useful complement to controlled trials. Clinicians self-identifying as psychodynamic treated 17 panic disorder patients in naturalistic psychotherapy for an average of 21 sessions. Patients achieved statistically significant reductions in symptoms across all domains. Rates of remission and clinically significant change as well as effect sizes were commensurate with those of empirically supported therapies for panic disorder. Treatment gains were maintained at 6-month follow-up. Intensive analysis of the process of the treatments revealed that integrative elements characterized the treatments: Adherence to cognitive-behavioral process was most characteristic, adherence to interpersonal and psychodynamic process, however, was most predictive of positive outcome. Specific process predictors of outcome were identified using the Psychotherapy Process Q-Set. These findings demonstrate how process research can be used to empirically validate change processes in naturalistic treatments as opposed to treatment packages in controlled trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The supervisory encounter: A guide for teachers of psychodynamic psychotherapy and psychoanalysis.

Review of book: The Supervisory Encounter: A Guide for Teachers of Psychodynamic Psychotherapy and Psychoanalysis by Daniel Jacobs, Paul David and Donald J. Meyer, New Haven, CT: Yale University Press, 1985, 285 pp. Reviewed by Alan Z. Skolnikoff. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Techniques of Working With Resistance.

The editors of this book (see record 1987-97162-000) provide an excellent selection of writings ranging from the early seminal chapters to modern views. Freud's early formulation of resistance as being all those forces within the patient that oppose the treatment process was quite clear and direct. The writings sampled in this volume suggest that although we have not really gone beyond the essence of that statement, the elaborations and detailing add significantly to the clinical theory and practice of psychoanalysis. The selections are entirely clinical in nature, which calls attention to a foundational fact of life for psychodynamically oriented treatment that has received almost no systematically controlled research within psychoanalysis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Who can do what, therapeutically, with whom, in what way?

Mary Connors has treated us to a survey of therapeutic goals of various psychotherapy theories from two differing traditions: the psychodynamic and the cognitive–behavioral. She then describes methodologies that have been developed to achieve the diversely formulated therapeutic goals. She questions whether the bifurcation of therapeutic approaches that have been developed and have been maintained within each of the two therapeutic schools is necessary or, in fact, whether such might even be deleterious to our patients. She argues for importation of cognitive–behavioral goals and techniques within psychodynamically oriented treatments (and presumably would be supportive of infusion of psychodynamic methods and understanding within cognitive–behavioral treatments). However, from our view, each of these theoretical perspectives—and this includes the psychoanalytic and the cognitive–behavioral—that has been considered by Mary Connors is conceptualized at the same level of abstraction. They are what we have termed structure theories, in contrast to process theories. Connors' paper presents two major questions, which are considered here: What constitutes psychotherapeutic effect, and can we conceptualize an approach to therapeutic work that effectively encompasses the use of the wide variety of methodologies that purport to achieve it? (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Unique and common mechanisms of change across cognitive and dynamic psychotherapies.

The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Do personality problems improve during psychodynamic supportive–expressive psychotherapy? Secondary outcome results from a randomized controlled trial for psychiatric outpatients with personality disorders.

Studies involving patients with personality disorders (PDs) have not focused on improvement of core aspects of the PD. The authors examined changes in quality of object relations, interpersonal problems, psychological mindedness, and personality traits in a sample of 156 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed.) PD diagnoses being randomized to either manualized or nonmanualized dynamic psychotherapy. Effect sizes adjusted for symptomatic change and reliable change indices were calculated. The authors found that both treatments were equally effective at reducing personality pathology. Only in neuroticism did the nonmanualized group do better during the follow-up period. The largest improvement was found in quality of object relations. For the remaining variables, only small and clinically insignificant magnitudes of change were found. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beyond the illusion of structural change: A process priming approach to psychotherapy outcome research.

Psychoanalytically oriented psychotherapy outcome research has yet to differentiate between a psychological structure that is present but temporarily inactive and genuine change in that underlying structure. Thus, a decrease in maladaptive responding following treatment may sometimes reflect illusory structural change, with the patient remaining vulnerable to relapse in situations that activate the underlying pathogenic structure. Genuine structural change would be better assessed by deliberately seeking and failing to find evidence of the enduring presence of a pathogenic structure under conditions that typically activate that structure, using both implicit (e.g., free response) and explicit (self-report) outcome measures. Because implicit and explicit measures are differentially affected by situational variables (e.g., mood, mindset priming), rigorous psychotherapy research must use experimental techniques and multimodal assessments to assess outcome under the conditions most likely to evoke a pathological reaction in a seemingly recovered individual. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The relationship between adult attachment style and therapeutic alliance in individual psychotherapy: A meta-analytic review.

The present study examined the relationship between adult attachment style and therapeutic alliance in individual psychotherapy. Search procedures yielded 17 independent samples (total N = 886, average n = 52, standard deviation = 24) for inclusion in the meta-analysis. Results indicated that greater attachment security was associated with stronger therapeutic alliances, whereas greater attachment insecurity was associated with weaker therapeutic alliances, with an overall weighted effect size of r = .17, p .10) with the exception of the source of alliance ratings; results indicated that patient-rated alliance demonstrated a significantly larger relationship with attachment compared with therapist-rated alliance (Qbetween = 3.95, df = 1, p = .047). Implications for clinical practice and future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Behavior therapy: A review.

The questionable effectiveness of traditional psychodynamic psychotherapies and the development of brief new treatment techniques derived from modern learning theory have stimulated interest in applications of conditioning procedures to behavior disorders. A review of this literature revealed that behavior therapies have been applied to many neurotic and psychotic disorders, and have been most successful with disorders involving specific maladaptive behaviors. Conditioning procedures were highly effective with phobic reactions, anxiety reactions, enuresis, stuttering, and tics, but disappointing with alcoholism and some sexual disorders. Cures seemed long-lasting, with remarkably little evidence of the symptom substitution predicted by psychodynamic depth theories. Behavior therapy offers promising opportunities for the application of well-established psychological principles to the treatment of maladaptive behavior. (4 p. ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nomothetic psychoanalysis.

Psychoanalytic theory's roots (in the clinic rather than the laboratory), and aims (depth understanding of the individual) have led to the development of a theoretical perspective that relies primarily on idiographic data and case material to derive and test psychoanalytic hypotheses. In this article, I describe nomothetic psychoanalysis--a framework for conceptualizing and evaluating psychoanalytic ideas that complements and enriches the traditional idiographic approach. Guidelines for conducting nomothetic studies of psychodynamic constructs are provided, and five principles are offered for implementing nomothetic psychoanalysis to maximize its heuristic value and clinical impact. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managing countertransference.

In this article, we review the history and definition of countertransference as well as empirical research on countertransference, its management, and the relation of both to psychotherapy outcome. Three meta-analyses are presented, as well as studies that illustrate findings from the meta-analyses. The first meta-analysis indicated that countertransference reactions are related inversely and modestly to psychotherapy outcomes (overall weighted effect r = ?.16, p = .002, 95% CI [?.26, ?.06], k = 10 studies, N = 769 participants). The second meta-analysis suggested that countertransference management factors that have been studied to date play little to no role in actually attenuating countertransference reactions (r = ?.14, p = .10, 95% CI [?.30, .03], k = 11 studies, N = 1065 participants). However, the final meta-analysis revealed that managing countertransference successfully is related to better therapy outcomes (r = .56, p = .000, 95% CI [.40, .73], k = 7 studies, N = 478 participants). We conclude by summarizing the limitations of the research base and highlighting the therapeutic practices predicated on research. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Reflective-functioning during the process in brief psychotherapies.

Reflective-functioning (RF) is the ability to recognize the existence and nature of mental processes taking place in the self and in others (e.g., intentions and wishes). RF was investigated here as a patient variable during the process in two studies of brief psychotherapy. The first study investigated cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) in the TDCRP sample. The second study investigated psychodynamic psychotherapy (BPDT). The Psychotherapy Process Q-set (PQS) was implemented to identify process correlates associated with high and low RF in order to distinguish which specific components in the psychotherapeutic process are related to RF. Process correlates defining high RF had good outcome, and process correlates defining low RF had poor outcome. RF remained stable or decreased during treatments and was linked with personality characteristics in the patients. (PsycINFO Database Record (c) 2011 APA, all rights reserved)