Effectiveness of Psychoanalytic Psychotherapies

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.”

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. . .”

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

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.

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.

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.

A literature review

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.”

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.

“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”

“[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

“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 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.”

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.

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.”

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.

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

JUST-PUBLISHED AMERICAN PSYCHOLOGIST STUDY ON THERAPY WITH ADOLESCENTS MISLEADINGLY CLAIMS THAT CBT IS THE MOST EFFECTIVE TREATMENT MODALITY A recent meta-analysis (Weisz, et al., 2017) in the APA’s publication, American Psychologist, exemplifies the kind of bias that has been shown by the American psychology community in favor of CBT and against psychodynamic treatments. This meta-analysis broke the groups into behavioral (including CBT) and non-behavioral treatments of adolescents. They report that the CBTs’ effectiveness had a stronger effect size than the “non-behavioral” treatments. They wrote: “only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports.” At first glance this study seems to be important, as meta-analyses were used to generate large sample sizes. But on closer inspection, the sample size of studies assessing so-called “non-behavioral” treatments was 8 and the “non behavioral” treatments were undefined. In contrast, the CBT group included 73 studies This undermines any scholarly claim to be made by these authors in a widely read psychology journal, and is fundamentally misleading. This is because: 1) it compares a relatively homogenous group of studies with a group of studies that may be quite heterogenous and have different levels of proven effectiveness and validity, and 2) the significant discrepancy in size of the two groups of studies was not adequately taken into account in drawing conclusions from their respective effect sizes. Thus, statistically, the ‘non-behavioral’ group’s having a smaller (but significant) effect size compared to the behavioral group would be expected, regardless of the actual impact of each group of interventions. The case made by the study’s authors that CBT is superior to other forms of treatment is, in fact, not a statistically sound conclusion. This is the kind of study that is hurtful to patients as it supports the incorrect conviction held by many government agencies, insurance companies and the physicians who often make referrals for treatment that CBTs are the most effective form of treatment.

“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.”