Shedler.ampsy.2010.pdf

The Efficacy of Psychodynamic Psychotherapy University of Colorado Denver School of Medicine Empirical evidence supports the efficacy of psychodynamic over time. Finally, I consider evidence that nonpsychody- therapy. Effect sizes for psychodynamic therapy are as namic therapies may be effective in part because the more large as those reported for other therapies that have been skilled practitioners utilize interventions that have long actively promoted as “empirically supported” and “evi- been central to psychodynamic theory and practice.
dence based.” In addition, patients who receive psychody-namic therapy maintain therapeutic gains and appear to Distinctive Features of
continue to improve after treatment ends. Finally, nonpsy- Psychodynamic Technique
chodynamic therapies may be effective in part because themore skilled practitioners utilize techniques that have long Psychodynamic or psychoanalytic psychotherapy1 re- been central to psychodynamic theory and practice. The fers to a range of treatments based on psychoanalytic perception that psychodynamic approaches lack empirical concepts and methods that involve less frequent meetings support does not accord with available scientific evidence and may be considerably briefer than psychoanalysis and may reflect selective dissemination of research find- proper. Session frequency is typically once or twice per week, and the treatment may be either time limited or openended. The essence of psychodynamic therapy is exploring those aspects of self that are not fully known, especially as process, psychoanalysis, psychodynamic therapy, meta- they are manifested and potentially influenced in the ther- Undergraduate textbooks too often equate psychoan- here is a belief in some quarters that psychodynamic alytic or psychodynamic therapies with some of the more concepts and treatments lack empirical support or outlandish and inaccessible speculations made by Sigmund that scientific evidence shows that other forms of Freud roughly a century ago, rarely presenting mainstream treatment are more effective. The belief appears to have psychodynamic concepts as understood and practiced to- taken on a life of its own. Academicians repeat it to one day. Such presentations, along with caricatured depictions another, as do health care administrators, as do health care in the popular media, have contributed to widespread mis- policymakers. With each repetition, its apparent credibility understanding of psychodynamic treatment (for discussion grows. At some point, there seems little need to question or of how clinical psychoanalysis is represented and misrep- revisit it because “everyone” knows it to be so.
resented in undergraduate curricula, see Bornstein, 1988, The scientific evidence tells a different story: Consid- 1995; Hansell, 2005; Redmond & Shulman, 2008). To help erable research supports the efficacy and effectiveness of dispel possible myths and facilitate greater understanding psychodynamic therapy. The discrepancy between percep- of psychodynamic practice, in this section I review core tions and evidence may be due, in part, to biases in the features of contemporary psychodynamic technique.
dissemination of research findings. One potential source of Blagys and Hilsenroth (2000) conducted a search of bias is a lingering distaste in the mental health professions the PsycLit database to identify empirical studies that com- for past psychoanalytic arrogance and authority. In decades pared the process and technique of manualized psychody- past, American psychoanalysis was dominated by a hierar- namic therapy with that of manualized cognitive behavioral chical medical establishment that denied training to non- therapy (CBT). Seven features reliably distinguished psy- MDs and adopted a dismissive stance toward research. This chodynamic therapy from other therapies, as determined by stance did not win friends in academic circles. When em- empirical examination of actual session recordings and pirical findings emerged that supported nonpsychodynamictreatments, many academicians greeted them enthusiasti-cally and were eager to discuss and disseminate them.
I thank Mark Hilsenroth for his extensive contributions to this article; When empirical evidence supported psychodynamic con- Marc Diener for providing some of the information reported here; Robert cepts and treatments, it was often overlooked.
Feinstein, Glen Gabbard, Michael Karson, Kenneth Levy, Nancy McWil-liams, Robert Michels, George Stricker, and Robert Wallerstein for their This article brings together findings from several em- comments on drafts of the article; and the 500-plus members of the pirical literatures that bear on the efficacy of psychody- Psychodynamic Research Listserv for their collective wisdom and sup- namic treatment. I first outline the distinctive features of psychodynamic therapy. I next review empirical evidence Correspondence concerning this article should be addressed for the efficacy of psychodynamic treatment, including to Jonathan Shedler, Department of Psychiatry, University of Colo-rado Denver School of Medicine, Mail Stop A011-04, 13001 East 17th evidence that patients who receive psychodynamic therapy Place, Aurora, CO 80045. E-mail: jonathan@shedler.com not only maintain therapeutic gains but continue to improve 1 I use the terms psychoanalytic and psychodynamic interchangeably.
February–March 2010 ● American Psychologist 2010 American Psychological Association 0003-066X/10/$12.00 Psychodynamic therapists actively focus on and exploreavoidances.
3. Identification of recurring themes and
patterns. Psychodynamic therapists work to identify
and explore recurring themes and patterns in patients’
thoughts, feelings, self-concept, relationships, and life ex-
periences. In some cases, a patient may be acutely aware of
recurring patterns that are painful or self-defeating but feel
unable to escape them (e.g., a man who repeatedly finds
himself drawn to romantic partners who are emotionally
unavailable; a woman who regularly sabotages herself
when success is at hand). In other cases, the patient may be
unaware of the patterns until the therapist helps him or her
recognize and understand them.
4. Discussion of past experience (develop-
mental focus). Related to the identification of recur-
ring themes and patterns is the recognition that past expe-
rience, especially early experiences of attachment figures,
affects our relation to, and experience of, the present.
Psychodynamic therapists explore early experiences, the
Jonathan
relation between past and present, and the ways in which the past tends to “live on” in the present. The focus is noton the past for its own sake, but rather on how the pastsheds light on current psychological difficulties. The goal isto help patients free themselves from the bonds of past transcripts (note that the features listed below concern experience in order to live more fully in the present.
process and technique only, not underlying principles that 5. Focus on interpersonal relations. Psy-
inform these techniques; for a discussion of concepts and chodynamic therapy places heavy emphasis on patients’ principles, see Gabbard, 2004; McWilliams, 2004; Shedler, relationships and interpersonal experience (in theoretical terms, object relations and attachment). Both adaptive and 1. Focus on affect and expression of emo-
nonadaptive aspects of personality and self-concept are tion. Psychodynamic therapy encourages exploration
forged in the context of attachment relationships, and psy- and discussion of the full range of a patient’s emotions. The chological difficulties often arise when problematic inter- therapist helps the patient describe and put words to feel- personal patterns interfere with a person’s ability to meet ings, including contradictory feelings, feelings that are troubling or threatening, and feelings that the patient may 6. Focus on the therapy relationship. The
not initially be able to recognize or acknowledge (this relationship between therapist and patient is itself an im- stands in contrast to a cognitive focus, where the greater portant interpersonal relationship, one that can become emphasis is on thoughts and beliefs; Blagys & Hilsenroth, deeply meaningful and emotionally charged. To the extent 2002; Burum & Goldfried, 2007). There is also a recogni- that there are repetitive themes in a person’s relationships tion that intellectual insight is not the same as emotional and manner of interacting, these themes tend to emerge in insight, which resonates at a deep level and leads to change some form in the therapy relationship. For example, a (this is one reason why many intelligent and psychologi- person prone to distrust others may view the therapist with cally minded people can explain the reasons for their dif- suspicion; a person who fears disapproval, rejection, or ficulties, yet their understanding does not help them over- abandonment may fear rejection by the therapist, whether knowingly or unknowingly; a person who struggles with 2. Exploration of attempts to avoid dis-
anger and hostility may struggle with anger toward the tressing thoughts and feelings. People do a great
therapist; and so on (these are relatively crude examples; many things, knowingly and unknowingly, to avoid aspects the repetition of interpersonal themes in the therapy rela- of experience that are troubling. This avoidance (in theo- tionship is often more complex and subtle than these ex- retical terms, defense and resistance) may take coarse amples suggest). The recurrence of interpersonal themes in forms, such as missing sessions, arriving late, or being the therapy relationship (in theoretical terms, transference evasive. It may take subtle forms that are difficult to and countertransference) provides a unique opportunity to recognize in ordinary social discourse, such as subtle shifts explore and rework them in vivo. The goal is greater of topic when certain ideas arise, focusing on incidental flexibility in interpersonal relationships and an enhanced aspects of an experience rather than on what is psycholog- capacity to meet interpersonal needs.
ically meaningful, attending to facts and events to the 7. Exploration of fantasy life. In contrast to
exclusion of affect, focusing on external circumstances other therapies in which the therapist may actively structure rather than one’s own role in shaping events, and so on.
sessions or follow a predetermined agenda, psychodynamic February–March 2010 ● American Psychologist therapy encourages patients to speak freely about whatever meta-analyses have similarly supported the efficacy of psy- is on their minds. When patients do this (and most patients chotherapy. The influential review by Lipsey and Wilson require considerable help from the therapist before they can (1993) tabulated results for 18 meta-analyses concerned truly speak freely), their thoughts naturally range over with general psychotherapy outcomes, which had a median many areas of mental life, including desires, fears, fanta- effect size of 0.75. It also tabulated results for 23 meta- sies, dreams, and daydreams (which in many cases the analyses concerned with outcomes in CBT and behavior patient has not previously attempted to put into words). All modification, which had a median effect size of 0.62. A of this material is a rich source of information about how meta-analysis by Robinson, Berman, and Neimeyer (1990) the person views self and others, interprets and makes summarized the findings of 37 psychotherapy studies con- sense of experience, avoids aspects of experience, or inter- cerned specifically with outcomes in the treatment of de- feres with a potential capacity to find greater enjoyment pression, which had an overall effect size of 0.73. These are relatively large effects. (For a review of psychotherapy The last sentence hints at a larger goal that is implicit efficacy and effectiveness research, see Lambert & Ogles, in all of the others: The goals of psychodynamic therapyinclude, but extend beyond, symptom remission. Success- ful treatment should not only relieve symptoms (i.e., get rid To provide some points of reference, it is instructive of something) but also foster the positive presence of to consider effect sizes for antidepressant medications. An psychological capacities and resources. Depending on the analysis of U.S. Food and Drug Adminstration (FDA) person and the circumstances, these might include the databases (published and unpublished studies) reported in capacity to have more fulfilling relationships, make more the New England Journal of Medicine found effect sizes of effective use of one’s talents and abilities, maintain a 0.26 for fluoxetine (Prozac), 0.26 for sertraline (Zoloft), realistically based sense of self-esteem, tolerate a wider 0.24 for citalopram (Celexa), 0.31 for escitalopram (Lexa- range of affect, have more satisfying sexual experiences, pro), and 0.30 for duloxetine (Cymbalta). The overall mean understand self and others in more nuanced and sophisti- effect size for antidepressant medications approved by the cated ways, and face life’s challenges with greater freedom FDA between 1987 and 2004 was 0.31 (Turner, Matthews, and flexibility. Such ends are pursued through a process of Linardatos, Tell, & Rosenthal, 2008).3 A meta-analysis self-reflection, self-exploration, and self-discovery that reported in the prestigious Cochrane Library (Moncrieff, takes place in the context of a safe and deeply authentic Wessely, & Hardy, 2004) found an effect size of 0.17 for relationship between therapist and patient. (For a jargon- tricyclic antidepressants compared with active placebo (an free introduction to contemporary psychodynamic thought, active placebo mimics the side effects of an antidepressant see That Was Then, This Is Now: Psychoanalytic Psycho- drug but is not itself an antidepressant).4 These are rela- therapy for the Rest of Us [Shedler, 2006a, which is freely tively small effects. Methodological differences between available for download at http://psychsystems.net/shedler.
medication trials and psychotherapy trials are sufficiently great that effect sizes may not be directly comparable, and How Effective Is Psychotherapy in
the findings should not be interpreted as conclusive evi-dence that psychotherapy is more effective. Effect sizes for General?
antidepressant medications are reported to provide refer- In psychology and in medicine more generally, meta-anal- ence points that will be familiar to many readers (for more ysis is a widely accepted method for summarizing and comprehensive listings of effect size reference points, see, synthesizing the findings of independent studies (Lipsey & e.g., Lipsey & Wilson, 1993; Meyer et al., 2001).
Wilson, 2001; Rosenthal, 1991; Rosenthal & DiMatteo,2001). Meta-analysis makes the results of different studies comparable by converting findings into a common metric, This score, known as the standardized mean difference, is used to summarize the findings of randomized control trials. More broadly, the allowing findings to be aggregated or pooled across studies.
concept effect size may refer to any measure that expresses the magnitude A widely used metric is effect size, which is the difference of a research finding (Rosenthal & Rosnow, 2008).
between treatment and control groups, expressed in stan- 3 The measure of effect size in this study was Hedges’ g (Hedges, dard deviation units.2 An effect size of 1.0 means that the 1982) rather than Cohen’s d (Cohen, 1988), which is more commonlyreported. The two measures are based on slightly different computa- average treated patient is one standard deviation healthier tional formulas, but in this case the choice of formula would have on the normal distribution or bell curve than the average made no difference: “Because of the large sample size (over 12,000), untreated patient. An effect size of 0.8 is considered a large there is no change in going from g to d; both values are .31 to two effect in psychological and medical research, an effect size decimal places” (R. Rosenthal, personal communication to Marc Die- of 0.5 is considered a moderate effect, and an effect size of 4 Although antidepressant trials are intended to be double-blind, the 0.2 is considered a small effect (Cohen, 1988).
blind is easily penetrated because the adverse side effects of antidepres- The first major meta-analysis of psychotherapy out- sant medications are physically discernible and widely known. Study come studies included 475 studies and yielded an overall participants and their doctors can therefore figure out whether they are effect size (various diagnoses and treatments) of 0.85 for receiving medication or placebo, and effects attributed to medication maybe inflated by expectancy and demand effects. Use of “active” placebos patients who received psychotherapy compared with un- better protects the blind, and the resulting effect sizes are approximately treated controls (Smith, Glass, & Miller, 1980). Subsequent half as large as those otherwise reported.
February–March 2010 ● American Psychologist How Effective Is Psychodynamic
treatment was 16 weeks), the mean follow-up period was 13 Therapy?
weeks and the effect size was 1.0. The authors concluded thatboth treatments demonstrated effectiveness. A more recent A recent and especially methodologically rigorous meta- review of short-term (average of 30.7 sessions) psychody- analysis of psychodynamic therapy, published by the namic therapy for personality disorders included data from Cochrane Library,5 included 23 randomized controlled seven randomized controlled trials (Messer & Abbass, in trials of 1,431 patients (Abbass, Hancock, Henderson, & press). The study assessed outcome at the longest follow-up Kisely, 2006). The studies compared patients with a period available (an average of 18.9 months posttreatment) range of common mental disorders6 who received short- and reported effect sizes of 0.91 for general symptom im- term (Ͻ 40 hours) psychodynamic therapy with controls provement (N ϭ 7 studies) and 0.97 for improvement in (wait list, minimal treatment, or “treatment as usual”) interpersonal functioning (N ϭ 4 studies).
and yielded an overall effect size of 0.97 for general Two recent studies examined the efficacy of long- symptom improvement. The effect size increased to 1.51 term psychodynamic treatment. A meta-analysis re- when the patients were assessed at long-term follow-up ported in the Journal of the American Medical Associ- (Ͼ 9 months posttreatment). In addition to change in ation (Leichsenring & Rabung, 2008) compared long- general symptoms, the meta-analysis reported an effect term psychodynamic therapy (Ͼ 1 year or 50 sessions) size of 0.81 for change in somatic symptoms, which with shorter term therapies for the treatment of complex increased to 2.21 at long-term follow-up; an effect size mental disorders (defined as multiple or chronic mental of 1.08 for change in anxiety ratings, which increased to disorders, or personality disorders) and yielded an effect 1.35 at follow-up; and an effect size of 0.59 for change size of 1.8 for overall outcome.8 The pretreatment to in depressive symptoms, which increased to 0.98 at posttreatment effect size was 1.03 for overall outcome, follow-up.7 The consistent trend toward larger effect which increased to 1.25 at long-term follow-up (p Ͻ sizes at follow-up suggests that psychodynamic therapy .01), an average of 23 months posttreatment. Effect sizes sets in motion psychological processes that lead to on- increased from treatment completion to follow-up for all going change, even after therapy has ended.
five outcome domains assessed in the study (overall A meta-analysis published in Archives of General Psy- effectiveness, target problems, psychiatric symptoms, chiatry included 17 high-quality randomized controlled trials personality functioning, and social functioning). A sec- of short-term (average of 21 sessions) psychodynamic therapy ond meta-analysis, reported in the Harvard Review of and reported an effect size of 1.17 for psychodynamic therapy Psychiatry (de Maat, de Jonghe, Schoevers, & Dekker, compared with controls (Leichsenring, Rabung, & Leibing, 2009), examined the effectiveness of long-term psy- 2004). The pretreatment to posttreatment effect size was 1.39, chodynamic therapy (average of 150 sessions) for adult which increased to 1.57 at long-term follow-up, which oc- outpatients with a range of diagnoses. For patients with curred an average of 13 months posttreatment. Translating mixed/moderate pathology, the pretreatment to posttreat- these effect sizes into percentage terms, the authors noted that ment effect was 0.78 for general symptom improvement, patients treated with psychodynamic therapy were “better off which increased to 0.94 at long-term follow-up, an average of with regard to their target problems than 92% of the patients 3.2 years posttreatment. For patients with severe personality before therapy” (Leichsenring et al., 2004, p. 1213).
pathology, the pretreatment to posttreatment effect was 0.94, A newly released meta-analysis examined the efficacy which increased to 1.02 at long-term follow-up, an average of of short-term psychodynamic therapy for somatic disorders (Abbass, Kisely, & Kroenke, 2009). It included 23 studies These meta-analyses represent the most recent and involving 1,870 patients who suffered from a wide range of methodologically rigorous evaluations of psychody- somatic conditions (e.g., dermatological, neurological, car- namic therapy. Especially noteworthy is the recurring diovascular, respiratory, gastrointestinal, musculoskeletal, finding that the benefits of psychodynamic therapy not only genitourinary, immunological). The study reported effectsizes of 0.69 for improvement in general psychiatric symp-toms and 0.59 for improvement in somatic symptoms.
5 More widely known in medicine than in psychology, the Cochrane Among studies that reported data on health care utilization, Library was created to promote evidence based practice and is considered 77.8% reported reductions in health care utilization that a leader in methodological rigor for meta-analysis.
6 These included nonpsychotic symptom and behavior disorders were due to psychodynamic therapy—a finding with po- commonly seen in primary care and psychiatric services, for example, tentially enormous implications for health care reform.
nonbipolar depressive disorders, anxiety disorders, and somatoform dis- A meta-analysis reported in the American Journal of orders, often mixed with interpersonal or personality disorders (Abbass et Psychiatry examined the efficacy of both psychodynamic 7 The meta-analysis computed effect sizes in a variety of ways. The psychotherapy (14 studies) and CBT (11 studies) for person- findings reported here are based on the single method that seemed most ality disorders (Leichsenring & Leibing, 2003). The meta- conceptually and statistically meaningful (in this case, a random effects analysis reported pretreatment to posttreatment effect sizes model, with a single outlier excluded). See the original source for more using the longest term follow-up available. For psychody- fine-grained analyses (Abbass et al., 2006).
namic therapy (mean length of treatment was 37 weeks), the The atypical method used to compute this effect size may provide an inflated estimate of efficacy, and the effect size may not be comparable mean follow-up period was 1.5 years and the pretreatment to to other effect sizes reported in this review (for discussion, see Thombs, posttreatment effect size was 1.46. For CBT (mean length of February–March 2010 ● American Psychologist Illustrative Effect Sizes From Meta-Analyses of Treatment Outcome Studies General psychotherapy
CBT and related therapies
CBT and behavior therapy, various disorders CBT for depression, panic, and generalized Dialectical behavior therapy, primarily for Antidepressant medication
FDA-registered studies of antidepressants Tricyclic antidepressants versus active placebo Psychodynamic therapy
Various disorders, general symptom improvement Various disorders, change in target problems Somatic disorders, change in general psychiatric Long-term psychodynamic therapy vs. shorter term therapies for complex mental disorders, overall Long-term psychoanalytic therapy, pretreatment to a Median effect size across 18 meta-analyses (from Lipsey & Wilson, 1993, Table 1.1). b Median effect size across 23 meta-analyses (from Lipsey & Wilson, 1993, Table 1.2). c Pretreatment to posttreatment (within-group) comparison.
endure but increase with time, a finding that has now Studies supporting the efficacy of psychodynamic ther- emerged from at least five independent meta-analyses (Ab- apy span a range of conditions and populations. Randomized bass et al., 2006; Anderson & Lambert, 1995; de Maat et controlled trials support the efficacy of psychodynamic ther- al., 2009; Leichsenring & Rabung, 2008; Leichsenring et apy for depression, anxiety, panic, somatoform disorders, al., 2004). In contrast, the benefits of other (nonpsychody- eating disorders, substance-related disorders, and personality namic) empirically supported therapies tend to decay over disorders (Leichsenring, 2005; Milrod et al., 2007).
time for the most common disorders (e.g., depression, Findings concerning personality disorders are partic- generalized anxiety; de Maat, Dekker, Schoevers, & de ularly intriguing. A recent study of patients with borderline Jonghe, 2006; Gloaguen, Cottraux, Cucharet, & Blackburn, personality disorder (Clarkin, Levy, Lenzenweger, & Kern- 1998; Hollon et al., 2005; Westen, Novotny, & Thompson- berg, 2007) not only demonstrated treatment benefits that equaled or exceeded those of another evidence-based treat- Table 1 summarizes the meta-analytic findings de- ment, dialectical behavior therapy (Linehan, 1993), but scribed above and adds additional findings to provide fur-ther points of reference. Except as noted, effect sizes listedin the table are based on comparisons of treatment and 9 The exceptions to this pattern are specific anxiety conditions such as control groups and reflect response at the completion of panic disorder and simple phobia, for which short-term, manualized treat- treatment (not long-term follow-up).
ments do appear to have lasting benefits (Westen et al., 2004).
February–March 2010 ● American Psychologist also showed changes in underlying psychological mecha- theoretical premises or the specific interventions that derive nisms (intrapsychic processes) believed to mediate symp- from them. For example, the available evidence indicates tom change in borderline patients (specifically, changes in that the mechanisms of change in cognitive therapy (CT) reflective function and attachment organization; Levy et al., are not those presumed by the theory. Kazdin (2007), 2006). These intrapsychic changes occurred in patients reviewing the empirical literature on mediators and mech- who received psychodynamic therapy but not in patients anisms of change in psychotherapy, concluded, “Perhaps who received dialectical behavior therapy.
we can state more confidently now than before that what- Such intrapsychic changes may account for long-term ever may be the basis of changes with CT, it does not seem treatment benefits. A newly released study showed endur- to be the cognitions as originally proposed” (p. 8).
ing benefits of psychodynamic therapy five years after There are also profound differences in the way ther- treatment completion (and eight years after treatment ini- apists practice, even therapists ostensibly providing the tiation). At five-year follow-up, 87% of patients who re- same treatment. What takes place in the clinical consulting ceived “treatment as usual” continued to meet diagnostic room reflects the qualities and style of the individual ther- criteria for borderline personality disorder, compared with apist, the individual patient, and the unique patterns of 13% of patients who received psychodynamic therapy interaction that develop between them. Even in controlled (Bateman & Fonagy, 2008). No other treatment for person- studies designed to compare manualized treatments, thera- ality pathology has shown such enduring benefits.
pists interact with patients in different ways, implement These last findings must be tempered with the caveat interventions differently, and introduce processes not spec- that they rest on two studies and therefore cannot carry as ified by the treatment manuals (Elkin et al., 1989). In some much evidential weight as findings replicated in multiple cases, investigators have had difficulty determining from studies conducted by independent research teams. More verbatim session transcripts which manualized treatment generally, it must be acknowledged that there are far more was being provided (Ablon & Jones, 2002).
empirical outcome studies of other treatments, notably For these reasons, studies of therapy “brand names” CBT, than of psychodynamic treatments. The discrepancy can be highly misleading. Studies that look beyond brand in sheer numbers of studies is traceable, in part, to the names by examining session videotapes or transcripts may indifference to empirical research of earlier generations of reveal more about what is helpful to patients (Goldfried & psychoanalysts, a failing that continues to haunt the field Wolfe, 1996; Kazdin, 2007, 2008). Such studies indicate and that contemporary investigators labor to address.
that the active ingredients of other therapies include unac- A second caveat is that many psychodynamic outcome studies have included patients with a range of symptoms One method of studying what actually happens in and conditions rather than focusing on specific diagnostic therapy sessions makes use of the Psychotherapy Process categories (e.g., those defined by diagnostic criteria speci- Q-Sort (PQS; Jones, 2000). This instrument consists of 100 fied in the Diagnostic and Statistical Manual of Mental variables that assess therapist technique and other aspects Disorders [4th edition, DSM-IV; American Psychiatric As- of the therapy process based on specific actions, behaviors, sociation, 1994]). The extent to which this is a limitation is and statements made during sessions. In a series of studies, open to debate. A concern often raised about psychother- blind raters scored the 100 PQS variables from archival, apy efficacy studies is that they use highly selected and verbatim session transcripts for hundreds of therapy hours unrepresentative patient samples and, consequently, that from outcome studies of both brief psychodynamic therapy their findings do not generalize to real-world clinical prac- and CBT (Ablon & Jones, 1998; Jones & Pulos, 1993).10 tice (e.g., Westen et al., 2004). Nor is there universal In one study, the investigators asked panels of inter- agreement that DSM–IV diagnostic categories define dis- nationally recognized experts in psychoanalytic therapy crete or homogeneous patient groups (given that psychiat- and CBT to use the PQS to describe “ideally” conducted ric comorbidity is the norm and that diagnosable com- treatments (Ablon & Jones, 1998). On the basis of the plaints are often embedded in personality syndromes; Blatt expert ratings, the investigators constructed prototypes of & Zuroff, 2005; Westen, Gabbard, & Blagov, 2006). Be ideally conducted psychodynamic therapy and CBT. The that as it may, an increasing number of studies of psy- two prototypes differed considerably.
chodynamic treatments do focus on specific diagnoses The psychodynamic prototype emphasized unstruc- (e.g., Bateman & Fonagy, 2008; Clarkin et al., 2007; Cui- tured, open-ended dialogue (e.g., discussion of fantasies jpers, van Straten, Andersson, & van Oppen, 2008; Leich- and dreams); identifying recurring themes in the patient’s senring, 2001, 2005; Milrod et al., 2007).
experience; linking the patient’s feelings and perceptions topast experiences; drawing attention to feelings regarded by A Rose by Another Name:
the patient as unacceptable (e.g., anger, envy, excitement); Psychodynamic Process in Other
pointing out defensive maneuvers; interpreting warded-off Therapies
The “active ingredients” of therapy are not necessarily 10 The cognitive therapy study was a randomized controlled trial for those presumed by the theory or treatment model. For this depression; the psychodynamic therapy studies were panel studies formixed disorders and for posttraumatic stress disorder, respectively. See reason, randomized controlled trials that evaluate a therapy the original source for more detailed descriptions (Ablon & Jones, 1998; as a “package” do not necessarily provide support for its February–March 2010 ● American Psychologist or unconscious wishes, feelings, or ideas; focusing on the (Stage 4), engages in an exploration of his or her inner experience therapy relationship as a topic of discussion; and drawing (Stage 5), and gains awareness of previously implicit feelings and connections between the therapy relationship and other meanings [emphasis added] (Stage 6). The highest stage (7) refers to an ongoing process of in-depth self-understanding. (Caston- The CBT prototype emphasized dialogue with a more specific focus, with the therapist structuring the interaction Especially noteworthy is the phrase “gains awareness and introducing topics; the therapist functioning in a more of previously implicit feelings and meanings.” The term didactic or teacher-like manner; the therapist offering ex- implicit refers, of course, to aspects of mental life that are plicit guidance or advice; discussion of the patient’s treat- not initially conscious. The construct measured by the scale ment goals; explanation of the rationale behind the treat- hearkens back to the earliest days of psychoanalysis and its ment and techniques; focusing on the patient’s current life central goal of making the unconscious conscious (Freud, situation; focusing on cognitive themes such as thoughts and belief systems; and discussion of tasks or activities In this study of manualized cognitive therapy for (“homework”) for the patient to attempt outside of therapy depression, the following findings emerged: (a) Working alliance predicted patient improvement on all outcome In three sets of archival treatment records (one from a measures; (b) psychodynamic process (“experiencing”) study of cognitive therapy and two from studies of brief predicted patient improvement on all outcome measures; psychodynamic therapy), the researchers measured thera- and (c) therapist adherence to the cognitive treatment pists’ adherence to each therapy prototype without regard model (i.e., focusing on distorted cognitions) predicted to the treatment model the therapists believed they wereapplying (Ablon & Jones, 1998).
poorer outcome. A subsequent study using different meth- odology replicated the finding that interventions aimed at the psychodynamic prototype predicted successful out- cognitive change predicted poorer outcome (Hayes, Cas- come in both psychodynamic and cognitive therapy. Ther-apist adherence to the CBT prototype showed little or no tonguay, & Goldfried, 1996). However, discussion of in- relation to outcome in either form of therapy. The findings terpersonal relations and exploration of past experiences replicated those of an earlier study that employed a differ- with early caregivers— both core features of psychody- ent methodology and also found that psychodynamic inter- namic technique—predicted successful outcome.
ventions, not CBT interventions, predicted successful out- These findings should not be interpreted as indicating come in both cognitive and psychodynamic treatments that cognitive techniques are harmful, and other studies have reported positive relations between CBT technique An independent team of investigators using different and outcome (Feeley, DeRubeis, & Gelfand, 1999; Strunk, research methods also found that psychodynamic methods DeRubeis, Chiu, & Alvarez, 2007; Tang & DeRubeis, predicted successful outcome in cognitive therapy (Caston- 1999). Qualitative analysis of the verbatim session tran- guay, Goldfried, Wiser, Raue, & Hayes, 1996). The study scripts suggested that the poorer outcomes associated with assessed outcomes in cognitive therapy conducted accord- cognitive interventions were due to implementation of the ing to Beck’s treatment model (Beck, Rush, Shaw, & cognitive treatment model in dogmatic, rigidly insensitive Emery, 1979), and the findings had been reported as evi- ways by certain of the therapists (Castonguay et al., 1996).
dence for the efficacy of cognitive therapy for depression (No school of therapy appears to have a monopoly on dogmatism or therapeutic insensitivity. Certainly, the his- Investigators measured three variables from verbatim tory of psychoanalysis is replete with examples of dog- transcripts of randomly selected therapy sessions in a sam- matic excesses.) On the other hand, the findings do indicate ple of 64 outpatients. One variable assessed quality of the that the more effective therapists facilitated therapeutic working alliance (the concept working alliance, or thera- processes that have long been core, centrally defining fea- peutic alliance, is now widely recognized and often con- tures of psychoanalytic theory and practice.
sidered a nonspecific or “common” factor in many forms of Other empirical studies have also demonstrated links therapy; many do not realize that the concept comes di- between psychodynamic methods and successful outcome, rectly from psychoanalysis and has played a central role in whether or not the investigators explicitly identified the psychoanalytic theory and practice for over four decades; methods as “psychodynamic” (e.g., Barber, Crits-Chris- see Greenson, 1967; Horvath & Luborsky, 1993). The toph, & Luborsky, 1996; Diener, Hilsenroth, & Wein- second variable assessed therapist implementation of the berger, 2007; Gaston, Thompson, Gallagher, Cournoyer, & cognitive treatment model (i.e., addressing distorted cog-nitions believed to cause depressive affect). The third vari- 11 See the original source for more complete descriptions of the two able, labeled experiencing, beautifully captures the essence therapy prototypes (Ablon & Jones, 1998).
12 The study is one of the archival studies analyzed by Jones and his associates (Ablon & Jones, 1998; Jones & Pulos, 1993).
experiencing], the client talks about 13 Although the term “experiencing” derives from the humanistic events, ideas, or others (Stage 1); refers to self but without therapy tradition, the phenomenon assessed by the scale—a trajectory of expressing emotions (Stage 2); or expresses emotions but only as deepening self-exploration, leading to increased awareness of implicit or they relate to external circumstances (Stage 3). At higher stages, unconscious mental life—is the core defining feature of psychoanalysis the client focuses directly on emotions and thoughts about self February–March 2010 ● American Psychologist Gagnon, 1998; Hayes & Strauss, 1998; Hilsenroth, Acker- The Shedler–Westen Assessment Procedure (SWAP; man, Blagys, Baity, & Mooney, 2003; Høglend et al., 2008; Shedler & Westen, 2007; Westen & Shedler, 1999a, Norcross, 2002; Pos, Greenberg, Goldman, & Korman, 1999b) represents one method of assessing the kinds of inner capacities and resources that psychotherapy may de- The Flight of the Dodo
velop. The SWAP is a clinician-report (not-self report)instrument that assesses a broad range of personality pro- The heading of this section is an allusion to what has come cesses, both healthy and pathological. The instrument can to be known in the psychotherapy research literature as the be scored by clinicians of any theoretical orientation and Dodo bird verdict. After reviewing the psychotherapy out- has demonstrated high reliability and validity relative to a come literatures of the time, Rosenzweig (1936), and sub- wide range of criterion measures (Shedler & Westen, 2007; sequently Luborsky, Singer, and Luborsky (1975), reached Westen & Shedler, 2007). The SWAP includes an empir- the conclusion of the Dodo bird in Alice in Wonderland: ically derived Healthy Functioning Index comprising the “Everybody has won, and all must have prizes.” Outcomes items listed in Table 2, which define and operationalize for different therapies were surprisingly equivalent, and no mental health as consensually understood by clinical prac- form of psychotherapy proved superior to any other. In the titioners across theoretical orientations (Westen & Shedler, rare instances when studies found differences between ac- 1999a, 1999b). Many forms of treatment, including medi- tive treatments, the findings virtually always favored the cations, may be effective in alleviating acute psychiatric preferred treatment of the investigators (the investigator symptoms, at least in the short run. However, not all allegiance effect; Luborsky et al., 1999).
therapies aim at changing underlying psychological pro- Subsequent research has done little to alter the Dodo cesses such as those assessed by the SWAP. (A working bird verdict (Lambert & Ogles, 2004; Wampold, Minami, version of the SWAP, which generates and graphs T scores Baskin, & Callen Tierney, 2002). For example, studies that for a wide range of personality traits and disorders, can be have directly compared CBT with short-term psychody- namic therapy for depression have failed to show greater Researchers, including psychodynamically oriented efficacy for CBT over psychodynamic therapy or vice versa researchers, have yet to conduct compelling outcome stud- (Cuijpers et al., 2008; Leichsenring, 2001). Leichsenring ies that assess changes in inner capacities and resources, (2001) noted that both treatments appeared to qualify as but two studies raise intriguing possibilities and suggest empirically supported therapies according to the criteria directions for future research. One is a single case study of specified by the American Psychological Association’s Di- a woman diagnosed with borderline personality disorder vision 12 Task Force on Promotion and Dissemination of who was assessed with the SWAP by independent asses- Psychological Procedures (1995; Chambless et al., 1998).
sors (not the treating clinician) at the beginning of treat- Some of the studies compared psychodynamic treatments ment and again after two years of psychodynamic therapy of only eight sessions’ duration, which most practitioners (Lingiardi, Shedler, & Gazzillo, 2006). In addition to would consider inadequate, with 16-session CBT treat- meaningful decreases in SWAP scales that measure psy- ments. Even in these studies, outcomes were comparable chopathology, the patient’s SWAP scores showed an in- (Barkham et al., 1996; Shapiro et al., 1994).
creased capacity for empathy and greater sensitivity to There are many reasons why outcome studies may fail to others’ needs and feelings; increased ability to recognize show differences between treatments even if important differ- alternative viewpoints, even when emotions ran high; in- ences really exist. Others have discussed the limitations and creased ability to comfort and soothe herself; increased unexamined assumptions of current research methods (Gold- recognition and awareness of the consequences of her fried & Wolfe, 1996; Norcross, Beutler, & Levant, 2005; actions; increased ability to express herself verbally; more Westen et al., 2004). Here I focus on one salient limitation: the accurate and balanced perceptions of people and situations; mismatch between what psychodynamic therapy aims to ac- a greater capacity to appreciate humor; and, perhaps most complish and what outcome studies typically measure.
important, she had come to terms with painful past expe- As noted earlier, the goals of psychodynamic therapy riences and had found meaning in them and grown from include, but extend beyond, alleviation of acute symptoms.
them. The patient’s score on the SWAP Healthy Function- Psychological health is not merely the absence of symp- ing Index increased by approximately two standard devia- toms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense A second study used the SWAP to compare 26 pa- of freedom and possibility. Symptom-oriented outcome tients beginning psychoanalysis with 26 patients complet- measures commonly used in outcome studies (e.g., the ing psychoanalysis (Cogan & Porcerelli, 2005). The latter Beck Depression Inventory [Beck, Ward, Mendelson, group not only had significantly lower scores for SWAP Mock, & Erbaugh, 1961] or the Hamilton Rating Scale for items assessing depression, anxiety, guilt, shame, feelings Depression [Hamilton, 1960]) do not attempt to assess such of inadequacy, and fears of rejection but significantly inner capacities (Blatt & Auerbach, 2003; Kazdin, 2008).
higher scores for SWAP items assessing inner strengths Possibly, the Dodo bird verdict reflects a failure of re- and capacities (see Table 2). These included greater satis- searchers, psychodynamic and nonpsychodynamic alike, to faction in pursuing long-term goals, enjoyment of chal- adequately assess the range of phenomena that can change lenges and pleasure in accomplishments, ability to utilize talents and abilities, contentment in life’s activities, empa- February–March 2010 ● American Psychologist Methodological limitations preclude drawing causal conclusions from these studies, but they suggest that psy- Definition of Mental Health: Items From the Shedler– chodynamic therapy may not only alleviate symptoms but Westen Assessment Procedure (SWAP–200; Shedler also develop inner capacities and resources that allow a richer and more fulfilling life. Measures such as the SWAPcould be incorporated in future randomized controlled tri- ● Is able to use his/her talents, abilities, and energy als, scored by independent assessors blind to treatment condition, and used to assess such outcomes. Whether or ● Enjoys challenges; takes pleasure in accomplishing things.
not all forms of therapy aim for such outcomes, or re- ● Is capable of sustaining a meaningful love relationship searchers study them, they are clearly the outcomes desired characterized by genuine intimacy and caring.
by many people who seek psychotherapy. Perhaps this is ● Finds meaning in belonging and contributing to a larger why psychotherapists, irrespective of their own theoretical community (e.g., organization, church, neighborhood).
orientations, tend to choose psychodynamic psychotherapy ● Is able to find meaning and fulfillment in guiding, Discussion
● Is empathic; is sensitive and responsive to other people’s One intent of this article was to provide an overview ofsome basic principles of psychodynamic therapy for read- ● Is able to assert him/herself effectively and appropriately ers who have not been exposed to them or who have notheard them presented by a contemporary practitioner who ● Appreciates and responds to humor.
takes them seriously and uses them clinically. Another was ● Is capable of hearing information that is emotionally to show that psychodynamic treatments have considerable threatening (i.e., that challenges cherished beliefs, perceptions, and self-perceptions) and can use and empirical support. The empirical literature on psychody- namic treatments does, however, have important limita-tions. First, the number of randomized controlled trials for ● Appears to have come to terms with painful experiences from the past; has found meaning in and grown from other forms of psychotherapy, notably CBT, is consider- ably larger than that for psychodynamic therapy, perhapsby an order of magnitude. Many of these trials—specifi- ● Is articulate; can express self well in words.
cally, the newer and better-designed trials—are more meth- ● Has an active and satisfying sex life.
odologically rigorous (although some of the newest psy- ● Appears comfortable and at ease in social situations.
chodynamic randomized controlled trials, e.g., that of ● Generally finds contentment and happiness in life’s Clarkin et al., 2007, also meet the highest standards of methodological rigor). In too many cases, characteristics of ● Tends to express affect appropriate in quality and patient samples have been too loosely specified, treatment methods have been inadequately specified and monitored, ● Has the capacity to recognize alternative viewpoints, and control conditions have not been optimal (e.g., using even in matters that stir up strong feelings.
wait-list controls or “treatment as usual” rather than activealternative treatments—a limitation that applies to research ● Has moral and ethical standards and strives to live up to on empirically supported therapies more generally). Theseand other limitations of the psychodynamic research liter- ● Is creative; is able to see things or approach problems in ature must be addressed by future research. My intent is notto compare treatments or literatures but to review the ● Tends to be conscientious and responsible.
existing empirical evidence supporting psychodynamic ● Tends to be energetic and outgoing.
treatments and therapy processes, which is often underap- ● Is psychologically insightful; is able to understand self and others in subtle and sophisticated ways.
In writing this article, I could not help being struck by ● Is able to find meaning and satisfaction in the pursuit of a number of ironies. One is that academicians who dismiss psychodynamic approaches, sometimes in vehement tones, ● Is able to form close and lasting friendships characterized often do so in the name of science. Some advocate a by mutual support and sharing of experiences.
science of psychology grounded exclusively in the exper-imental method. Yet the same experimental method yieldsfindings that support both psychodynamic concepts (e.g.,Westen, 1998) and treatments. In light of the accumulation thy for others, interpersonal assertiveness and effective- of empirical findings, blanket assertions that psychody- ness, ability to hear and benefit from emotionally threaten- namic approaches lack scientific support (e.g., Barlow & ing information, and resolution of past painful experiences.
Durand, 2005; Crews, 1996; Kihlstrom, 1999) are no For the group completing psychoanalysis, the mean score longer defensible. Presentations that equate psychoanal- on the SWAP Healthy Functioning Index was one standard ysis with dated concepts that last held currency in the psychoanalytic community in the early 20th century are February–March 2010 ● American Psychologist similarly misleading; they are at best uninformed and at Abbass, A., Kisely, S., & Kroenke, K. (2009). Short-term psychodynamic psychotherapy for somatic disorders: Systematic review and meta- A second irony is that relatively few clinical practi- analysis of clinical trials. Psychotherapy and Psychosomatics, 78, 265–274. doi:10.1159/000228247 tioners, including psychodynamic practitioners, are famil- Ablon, J. S., & Jones, E. E. (1998). How expert clinicians’ prototypes of iar with the research reviewed in this article. Many psy- an ideal treatment correlate with outcome in psychodynamic and cog- chodynamic clinicians and educators seem ill-prepared to nitive-behavioral therapy. Psychotherapy Research, 8, 71– 83. doi: respond to challenges from evidence-oriented colleagues, Ablon, J. S., & Jones, E. E. (2002). Validity of controlled clinical trials of students, utilization reviewers, or policymakers, despite the psychotherapy: Findings from the NIMH Treatment of Depression accumulation of high-quality empirical evidence support- Collaborative Research Program. American Journal of Psychiatry, 159, ing psychodynamic concepts and treatments. Just as anti- psychoanalytic sentiment may have impeded dissemination American Psychiatric Association. (1994). Diagnostic and statistical of this research in academic circles, distrust of academic manual of mental disorders (4th ed.). Washington, DC: Author.
Anderson, E. M., & Lambert, M. J. (1995). Short-term dynamically research methods may have impeded dissemination in psy- oriented psychotherapy: A review and meta-analysis. Clinical Psychol- choanalytic circles (see Bornstein, 2001). Such attitudes are ogy Review, 15, 503–514. doi:10.1016/0272-7358(95)00027-M changing, but they cannot change quickly enough.
Barber, J., Crits-Christoph, P., & Luborsky, L. (1996). Effects of therapist Researchers also share responsibility for this state adherence and competence on patient outcome in brief dynamic ther-apy.
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granted that clinical practitioners are the intended con- Barkham, M., Rees, A., Shapiro, D. A., Stiles, W. B., Agnew, R. M., sumers of clinical research (e.g., Task Force on Promo- Halstead, J., . . . Harrington, V. M. G. (1996). Outcomes of time-limited tion and Dissemination of Psychological Procedures, psychotherapy in applied settings: Replication of the second Sheffield 1995), but many of the psychotherapy outcome studies Psychotherapy Project. Journal of Consulting and Clinical Psychology,64, 1079 –1085. doi:10.1037/0022-006X.64.5.1079 and meta-analyses reviewed for this article are clearly Barlow, D. H., & Durand, V. M. (2005). Abnormal psychology: An not written for practitioners. On the contrary, they are integrative approach (4th ed.). Pacific Grove, CA: Brooks/Cole.
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Blagys, M. D., & Hilsenroth, M. J. (2002). Distinctive activities of sults, and inconsistent findings across multiple outcome cognitive– behavioral therapy: A review of the comparative psychother- variables of uncertain clinical relevance. If clinical prac- apy process literature. Clinical Psychology Review, 22, 671–706. doi: titioners are indeed the intended “consumers” of psycho- therapy research, then psychotherapy research needs to Blatt, S. J., & Auerbach, J. S. (2003). Psychodynamic measures of be more consumer relevant (Westen, Novotny, & therapeutic change. Psychoanalytic Inquiry, 23, 268 –307.
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