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Effectiveness of Psychoanalytic Psychotherapies

 

ARTICLE IN THE GUARDIAN ABOUT THE ADVANTAGES OF PSYCHOANALYTIC THERAPIES OVER CBT

Therapy Wars: the Revenge of Freud by Oliver Burkeman, Jan. 7, 2015
Very thoughtful and thorough article in the Guardian looking at the resurgence of psychoanalysis in light of increasing concerns about the effectiveness of CBT.
 
“Depending on how you interpret the evidence, it would seem we can do countless complex things – from performing mental arithmetic, to hitting a car’s brakes to avoid a collision, to making a choice of marriage partner – before becoming aware that we’ve done them. This doesn’t mesh well with a basic assumption of CBT – that, with training, we can learn to catch most of our unhelpful mental responses in the act. Rather, it seems to confirm the psychoanalytic intuition that the unconscious is huge, and largely in control; and that we live, unavoidably, through lenses created in the past, which we can only hope to modify partially, slowly and with great effort.”

2 NEW IMPORTANT STUDIES ON THE EFFECTIVENESS OF PSYCHOANALYTIC PSYCHOTHERAPY

Frontolimbic neural circuit changes in emotional processing and inhibitory control associated with clinical improvement following transference-focused psychotherapy in borderline personality disorder by Perez et al. (2015).

This study, just published in the journal Psychiatry and Neurosciences, shows dramatic neurological changes that occurred in response to a trial of psychoanalytic therapy (referred to as “transference-focused psychotherapy” with patients presenting with borderline personality disorder  The changes in the brain that were identified correlated with improvements in psychological difficulties associated with borderline personality disorder, especially “affective lability” or the tendency to experience intense fluctuations of emotion.

This study is so important because it uses a highly objective measure of improvement (neurological structures as detected by fMRI) to show that psychotherapy that focuses on the transference, a hallmark of psychoanalytic treatments, is helpful for people struggling with the emotional over-reactivity that typically comes with borderline personality concerns.

 

Pragmatic randomized controlled trial of long-term psychodynamic psychotherapy of treatment-resistance depression: The Tavistock Adult Depression Study by Peter Fonagy, et al. (2015).

This study goes a long way towards shattering myths about psychoanalytic treatments and how they compare to other, more short-term and problem-solving models. The majority of studies on effectiveness have looked primarily at improvement at termination. This is one of very few following patients’ progress post-termination.

The study compares patients with depression receiving long-term psychodynamic psychotherapy (LTPP) with those receiving treatments typically recommended through the British National Health Service, such as medication, CBT, supportive counseling (TAU). Although, at termination, LTPP with TAU was more effective than TAU alone to a non-significant extent, as time went on following termination (i.e., up to 42 months after), the effects of the LTPP increased to a highly significant degree (with probabilities as low as p<.0002)!!

For example, at the 42-month follow up, 10% of the TAU group did not meet the criteria for depression anymore whereas 44% of the LTPP group did not meet the criteria for depression anymore.


THE EFFECTIVENESS OF PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

 

The Efficacy of Psychodynamic Psychotherapy by Jonathan Schedler (2009). American Psychologist


Psychoanalytic Psychotherapy: what’s the evidence? a literature review from the British Psychoanalytic Council, 2015


The Effectiveness of Long-Term Psychodynamic Psychotherapy: A Meta-Analysis. by Falk Leichsenring and Sven Rabung (2008). in JAMA


The scientific legacy of Sigmund Freud: Toward a psychodynamically informed psychological science. by Drew Westen (1998). Psychoanalytic Inquiry


The empirical status of psychodynamic psychotherapy – an update: Bambi’s alive and kicking by Falk Liebensring, F. Leweke, H. Klein & C. Steinert in Psychotherapy and Psychosomatics, v. 84 (3), 2014


The current state of the empirical evidence for psychoanalysis: a meta-analytic approach by S. de Maat et al., Harvard Review of Psychiatry, v. 21 (3), 2013.

Despite procedural limitations in the research on psychoanalysis, this meta-analysis – perhaps the only one analyzing research on psychoanalysis proper, found “empirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders.”


The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies By S. de Maat et al., Harvard Review of Psychiatry, v. 17(1), 2009.

In reviewing 27 studies examining long-term psychoanalytic therapies, the reviewers found large effect sizes for symptom reduction and moderate effect sizes for personality change in patients with moderate and severe pathology, and found that effect sizes were largely sustained between termination and post-termination follow-up.


The effectiveness of psychoanalytic psychotherapy: the role of treatment duration, frequency of sessions, and the therapeutic relationship. by N. Freedman et al. in the Journal of the American Psychoanalytic Association, v. 47(3), 1999.

“Findings indicated (1) an incremental gain in effectiveness scores from six to over twenty-four months of therapy; (2) an incremental gain with greater session frequency from one to two or three weekly sessions; (3) facilitation of effectiveness by the experience of a positive relationship with the therapist; (4) an interplay between clinical syndrome and treatment conditions” (underlines added).


EFFECTIVENESS OF PSYCHOANALYTIC TREATMENTS WITH CHILDREN AND ADOLESCENTS

Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base by Midgely, N.  & E. Kennedy (2011). Journal of Child Psychotherapy, vol 37 (3).

In this systematic review of 34 studies (including 9 randomized control studies), the reviewers determined that “there is increasing evidence to suggest the effectiveness of psychoanalytic psychotherapy for children and adolescents.”


Short-term Psychoanalytic Child Therapy for Anxious Children: A Pilot Study by Gottken et al. (in Psychotherapy, 2014, v. 51 No 1, pp. 148-58)

The study randomly assigned 30 children ages 4 to 10 years old with anxiety concerns to either a group receiving 20 sessions of psychoanalytic child therapy or a wait list. Over 60% of the children receiving psychoanalytic child therapy no longer had significant anxiety concerns after treatment.

“Among the 27 completers, 66.67% (n = 18) no longer met criteria for any anxiety disorder . . . while no children remitted across the wait-list interval. Parent-reported child internalizing and total problems significantly declined during treatment relative to wait-list. Child and teacher reports also revealed significant pre-post symptom reductions on internalizing and total problems. Diagnostic and symptom remission rates were maintained at 6-month follow-up except on child reports.”

The authors conclude: “This preliminary study adds to a growing database showing that psychodynamic treatments may offer an effective line of treatment for childhood internalizing symptoms and disorders. . .”

 


 

PSYCHOANALYTIC THERAPIES AND THEIR IMPACT ON THE BRAIN

Tracking Functional Brain Changes in Patients with Depression under Psychodynamic Psychotherapy Using Individualized Stimuli by Wiswede, D. et al, 2014, in PLoS-One.

This unusually ambitious study looked at the impact of psychodynamic psychotherapy on specific brain functions that correlate with depression.   After an eight-month course of psychodynamic therapy focused on ‘intrapsychic conflict and ‘dysfunctional interpersonal relations,’ 18 adults with long-term depression had marked changes in brain functions associated with emotional regulation and reactivity – specifically the amygdala and the basal ganglia.

Changes in pre-frontal limbic function in major depression after 15 months of long-term psychotherapy by Anna Buchheim et al., in PLOS-One, 2012

This study found neurological changes in patients undergoing long-term psychodynamic psychotherapy, changes that correlated with reduced depression.


RESEARCH COMPARING PSYCHOANALYTIC WITH OTHER TYPES OF THERAPY

Psychodynamic Emotional Regulation in View of Wolpe’s Desensitization Model

2016 study published in the American Journal of Psychology by Mikhail Rabinovich analyzes multiple studies of psychoanalytic treatment of anxiety utilizing elaborate statistical analyses reveals that the analytic treatment of anxiety incorporates a number of empirically supported techniques for amelioration of anxiety, such as desensitization and gradual exposure.  Rabinovich writes, “It is shown that despite the antiresearch image of psychoanalytic psychotherapy, its foundations obey evidence-based principles.”

Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study

2007 study by Clarkin, Levy, Lenzenweger & Kernberg comparing DBT, a structured transference-focused (i.e., psychodynamic) therapy and supportive therapy in the treatment of 90 patients diagnosed with Borderline Personality Disorder. The researchers found that, while all three types of treatment were helpful, the transference-focused therapy was effective in the most domains that were measured (suicidality, irritability, anger, impulsivity, verbal assaultiveness and physical aggression) compared with the other two types of therapy.

 

Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients – a three-year follow-up study by D. Huber et al. in Zeitschrift für Psychosomatische Medizin und Psychotherapie, 2012, 58(3).

Cognitive-behavioral therapy versus other therapies: Redux by T. Baardseth et al. in Clinical Psychology Review, v. 33(3), 2013.

A meta-analytic study concluding that “[t]here were no differences between CBT treatments and bona fide non-CBT treatments across disorder-specific and non-disorder specific symptom measures. These analyses, in combination with previous meta-analytic findings, fail to provide corroborative evidence for the conjecture that CBT is superior to bona fide non-CBT treatments.”

The Effects of Cognitive-Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-analysis by Johnsen, T & Friborg, O. (2015) in Psychological Bulletin

Looking at 70 studies conducted between 1977 and 2014 on the effectiveness of CBT on depression, this meta-analysis shows a dramatically waning impact. The authors suggest that this may be due to the diminishment of a placebo effect of CBT, an effect that was stronger when, almost 40 years ago, the treatment was relatively new.

Focal psychodynamic therapy, cognitive behavior therapy and optimized treatment as usual in outpatients with anorexia nervosa: a randomized controlled study by Stephan Zipfel et al. in The Lancet (2014).

Where is the Evidence for ‘Evidence-Based’ Therapies: Expert Clinicians Know Better Than to Follow Manuals by Jonathan Shedler on the Psychology Today website, 2013

“No research findings ever suggested that manualized CBT was more effective than psychodynamic therapy. It was just more often studied in research settings. There is a world of difference between saying that a treatment has not been extensively researched and saying it has been empirically invalidated. But academic researchers routinely blurred this distinction.”

Bamboozled by Bad Science: the first myth about ’empirically-based therapy.’ by Jonathan Shedler on the Psychology Today website, 2013

“Claims that ‘evidence-based’ therapy is more effective than real-world therapy lack scientific basis. Academic researchers have been selling a myth—one that enhances the careers and reputations of academic researchers, but not necessarily the well-being of patients.”

A Tale of Two Therapies by Steph Yin (2015). Motherboard.com

“[M]any psychodynamic proponents argue that evidence-based assessments might lead researchers to dismiss potentially useful therapies that simply haven’t been studied enough. ‘Absence of evidence does not equal evidence of absence’ said Michael Thase, a psychiatrist and professor at the University of Pennsylvania.” from A Tale of Two Therapies

 


OTHER RESOURCES ON RESEARCH ABOUT PSYCHOANALYTIC THERAPIES

Free on-line issue of Psychoanalytic Inquiry: Toward an empirically informed 21st century psychoanalysis

Contemporary Psychoanalysis, 2014, vol. 50 issues 1-2

A special edition of Contemporary Psychoanalysis on Research supporting Psychoanalytic/Psychodynamic treatments.

 

Empirical Studies Bibliography – APsaA

For more studies and papers about the effectiveness of psychodynamic treatments, the American Psychoanalytic Association has compiled a comprehensive list of empirical research on this topic on their website.

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