The Empirical Evidence for Psychoanalysis
Although not widely reported, the effectiveness of psychoanalysis has been researched repeatedly in recent decades. There is now a growing body of evidence that shows that psychoanalytic treatments are as effective as—and sometimes more beneficial than—cognitive behavioral therapy. Several surveys of the research, like the ones below, have shown large effect sizes with 60-90% of patients deriving meaningful and lasting improvement in their symptoms.
Background: Over the past 40 years, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Four published meta-analyses of STPP, using different methods and samples, have found conflicting results. Objective: This review evaluated the efficacy of STPP relative to minimal treatment and non-treatment controls for adults with common mental disorders. Method: We searched CCDANCTR-Studies and CCDANCTR-References on 25/4/2005, CENTRAL, MEDLINE, CINAHL, EMBASE, PsycINFO, DARE and Biological Abstracts were also searched. We contacted triallists and checked references from papers retrieved. Results: 23 studies of 1431 randomized patients with common mental disorders were included. These studies evaluated STPP for general, somatic, anxiety, and depressive symptom reduction, as well as social adjustment. Outcomes for most categories of disorder suggested significantly greater improvement in the treatment versus the control groups, which were generally maintained in medium and long term follow-up. However, only a small number of studies contributed data for each category of disorder, there was significant heterogeneity between studies, and results were not always maintained in sensitivity analyses. Conclusions: STPP shows promise, with modest to moderate, often sustained gains for a variety of patients. However, given the limited data and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.
Background: Since the mid-1970s, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders havebeen developed and studied. Early published meta-analyses of STPP, using different methods and samples, have yielded conflicting results,although some meta-analyses have consistently supported an empirical basis for STPP. This is an update of a review that was last updated in 2006. Objective: To evaluate the efficacy of STPP for adults with common mental disorders compared with wait-list controls, treatments as usual and minimal contact controls in randomized controlled trials (RCTs). To specify the differential effects of STPP for people with different disorders (e.g. depressive disorders, anxiety disorders, somatoform disorders, mixed disorders and personality disorder) and treatment characteristics (e.g. manualized versus non-manualized therapies). Method: The Cochrane Depression, Anxiety and Neurosis Group's Specialized Register (CCDANCTR) was searched to February 2014, this register includes relevant randomized controlled trials from The Cochrane Library (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, DARE and Biological Abstracts (all years toJuly 2012) and all relevant studies (identified to 2012) were fully incorporated in this review update. We checked references from papersretrieved. We contacted a large group of psychodynamic researchers in an attempt to find new studies. Results: We included 33 studies of STPP involving 2173 randomized participants with common mental disorders. Studies were of diverse conditions in which problems with emotional regulation were purported to play a causative role albeit through a range of symptom presentations. These studies evaluated STPP for this review's primary outcomes (general, somatic, anxiety and depressive symptom reduction), as well as interpersonal problems and social adjustment. Except for somatic measures in the short-term, all outcome categories suggestedsignificantly greater improvement in the treatment versus the control groups in the short-term and medium-term. Effect sizes increased inlong-term follow-up, but some of these effects did not reach statistical significance. A relatively small number of studies (N < 20) contributed data for the outcome categories. There was also significant heterogeneity between studies in most categories, possibly due to observed differences between manualised versus non-manualized treatments, short versus longer treatments, studies with observer-rated versus self report outcomes, and studies employing different treatment models. Conclusions: There has been further study of STPP and it continues to show promise, with modest to large gains for a wide variety of people. However, given the limited data, loss of significance in some measures at long-term follow-up and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability ofestimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.
Review: There is extensive scientific evidence, collected over several decades, that psychodynamic and psychoanalytic treatment is an effective and clinically useful approach for treating many complex psychiatric problems such as severe character disorders, traumas, borderline personality disorder, anxiety, and depression. On this basis, experts agree that psychodynamic and psychoanalytic treatment is empirically based and a standard part of contemporary psychiatric practice. In fact, standard practice guidelines issued by major organizations such as the American Psychiatric Association include psychodynamic psychotherapy among other evidence-based treatment options. Since the late 1960s, over 300 randomized control trials have been published which show conclusively that psychodynamic treatment is superior to inactive comparison groups and is not inferior to other active evidence-based treatments. These findings support the notion that psychodynamic treatment is as effective as other forms of active treatment. They also demonstrate the efficacy of psychodynamic and psychoanalytic treatments in reducing symptom severity and improving quality of life across a broad and diverse range of patient populations and treatment settings. The work conducted by these research groups has helped address basic questions about whether psychoanalytic treatment “works” when compared to other treatment approaches for certain disorders. Improvements in these trials have been defined in various ways, from general symptom domains (e.g., depression, anxiety), to interpersonal functioning (e.g., severity of interpersonal problems, relationships quality), perceived quality of life, and specific clinically relevant behaviors (e.g., self-harm, substance use). A more limited number of studies have targeted outcomes that are more central to psychoanalytic models of the mind, most notably reflective functioning and mentalization capacities, level of personality organization, and maturity of defense mechanisms.
DOI: 10.1097/HRP.0b013e318294f5fd
Background: The effectiveness of psychoanalysis is still a controversial issue, despite increasing research efforts. Objective: To investigate the empirical evidence for psychoanalysis by means of a systematic review of the literature and a meta-analysis of the research data. Method: A systematic literature search was undertaken to find studies regarding the effectiveness of psychoanalysis, published between 1970 and 2011. A meta-analysis was performed. Results: Fourteen studies (total n = 603) were included in the meta-analysis. All but one were pre/post cohort studies. At treatment termination, the mean pre/post effect size across all outcome measures was 1.27 (95% confidence interval [CI], 1.03-1.50; p < .01). The mean pre/post effect size for symptom improvement was 1.52 (95% CI, 1.20-1.84; p < .01), and for improvement in personality characteristics 1.08 (95% CI, 0.89-1.26; p < .01). At follow-up the mean pre/follow-up effect size was 1.46 across all outcome measures (95% CI, 1.08-1.83; p < .01), 1.65 for symptom change (95% CI, 1.24-2.06; p < .01), and 1.31 for personality change (95% CI, 1.00-1.62; p < .01). Conclusions: A limited number of mainly pre/post studies, presenting mostly completers analyses, provide empirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders, but the lack of comparisons with control treatments is a serious limitation in interpreting the results. Further controlled studies are urgently needed.
DOI: 10.1080/10673220902742476
Background: There is a gap in the research literature on the effectiveness of long-term psychoanalytic therapies (LPT). Objective: To present a systematic review of studies dealing with LPT effectiveness and published from 1970 onward. Method: A systematic literature search for studies dealing with the effectiveness of individual LPT in ambulatory, adult patients. Data about the overall effectiveness of LPT, its impact on symptom reduction, and its effect on personality changes were pooled both at treatment termination and at follow-up, using effect sizes (ESs) and success rates. Results: We found 27 studies (n = 5063). Psychotherapy yielded large mean ESs (0.78 at termination; 0.94 at follow-up) and high mean overall success rates (64% at termination; 55% at follow-up) in moderate/mixed pathology. The mean ES was larger for symptom reduction (1.03) than for personality change (0.54). In severe pathology, the results were similar. Psychoanalysis achieved large mean ESs (0.87 at termination; 1.18 at follow-up) and high mean overall success rates (71% at termination; 54% at follow-up) in moderate pathology. The mean ES for symptom reduction was larger (1.38) than for personality change (0.76). Conclusions: Our data suggest that LPT is effective treatment for a large range of pathologies, with moderate to large effects.
DOI: 10.1037/ccp0000207
Method: In a randomized clinical trial, we compared the efficacy of cognitive–behavioral therapy (CBT) and psychodynamic therapy for adult outpatient depression on measures of psychopathology, interpersonal functioning, pain, and quality of life. There were 341 Dutch adults (70.1% female, mean age = 38.9, SD = 10.3) meeting Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM–IV) criteria for a major depressive episode and with a Hamilton Depression Rating Scale (HAM-D) score ≥14, who were randomized to 16 sessions of individual manualized CBT or short-term psychodynamic supportive psychotherapy. Severely depressed patients (HAM-D >24) received additional antidepressant medication according to a protocol. Outcome measures included the Brief Symptom Inventory, Beck Anxiety Inventory, Outcome Questionnaire, a visual analogue scale for pain, and EuroQol. Data were analyzed with mixed model analyses using intention-to-treat samples. Noninferiority margins were prespecified as Cohen’s d = −0.30. Results: Across treatment conditions, 45–60% of the patients who completed posttreatment assessment showed clinically meaningful change for most outcome measures. We found no significant differences between the treatment conditions on any of the outcome measures at both posttreatment and follow-up. Noninferiority of psychodynamic therapy to CBT was shown for posttreatment and follow-up anxiety measures as well as for posttreatment pain and quality of life measures, but could not be consistently demonstrated for the other outcomes. Conclusions: This is the first study that shows that psychodynamic therapy can be at least as efficacious as CBT for depression on important aspects of patient functioning other than depressive symptom reduction. These findings extend the evidence-base of psychodynamic therapy for depression, but replication is needed by means of rigorously designed noninferiority trials.
DOI: 10.1002/wps.20267
Objective: This pragmatic randomized controlled trial tested the effectiveness of long-term psychoanalytic psychotherapy (LTPP) as an adjunct to treatment-as-usual according to UK national guidelines (TAU), compared to TAU alone, in patients with long-standing major depression who had failed at least two different treatments and were considered to have treatment-resistant depression. Method: Patients (N=129) were recruited from primary care and randomly allocated to the two treatment conditions. They were assessed at 6-monthly intervals during the 18 months of treatment and at 24, 30 and 42 months during follow-up. The primary outcome measure was the 17-item version of the Hamilton Depression Rating Scale (HDRS-17), with complete remission defined as a HDRS-17 score ≤8, and partial remission defined as a HDRS-17 score ≤12. Secondary outcome measures included self-reported depression as assessed by the Beck Depression Inventory - II, social functioning as evaluated by the Global Assessment of Functioning, subjective wellbeing as rated by the Clinical Outcomes in Routine Evaluation - Outcome Measure, and satisfaction with general activities as assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire. Results: Complete remission was infrequent in both groups at the end of treatment (9.4% in the LTPP group vs. 6.5% in the control group) as well as at 42-month follow-up (14.9% vs. 4.4%). Partial remission was not significantly more likely in the LTPP than in the control group at the end of treatment (32.1% vs. 23.9%, p=0.37), but significant differences emerged during follow-up (24 months: 38.8% vs. 19.2%, p=0.03; 30 months: 34.7% vs. 12.2%, p=0.008; 42 months: 30.0% vs. 4.4%, p=0.001). Both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. Conclusions: These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression. End-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit.
Background: The place of long-term psychodynamic psychotherapy (LTPP) within psychiatry is controversial. Convincing outcome research for LTPP has been lacking. Objective: To examine the effects of LTPP, especially in complex mental disorders, ie, patients with personality disorders, chronic mental disorders, multiple mental disorders, and complex depressive and anxiety disorders (ie, associated with chronic course and/or multiple mental disorders), by performing a meta-analysis. Method: Only studies that used individual psychodynamic psychotherapy lasting for at least a year, or 50 sessions; had a prospective design; and reported reliable outcome measures were included. Randomized controlled trials (RCTs) and observational studies were considered. Twenty-three studies involving a total of 1053 patients were included (11 RCTs and 12 observational studies). Results: According to comparative analyses of controlled trials, LTPP showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, a between-group effect size of 1.8 (95% confidence interval [CI], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups (P = .002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across various and particularly complex mental disorders (range, 0.78-1.98). Conclusions: There is evidence that LTPP is an effective treatment for complex mental disorders. Further research should address the outcome of LTPP in specific mental disorders and should include cost-effectiveness analyses.
9) Leichsenring, F., et al. (2015). The empirical status of psychodynamic psychotherapy – an update: Bambi’s alive and kicking. Psychotherapy and Psychosomatics, 84(3), 129-48.
DOI: 10.1159/000376584
Background: The Task Force on Promotion and Dissemination of Psychological Procedures proposed rigorous criteria to define empirically supported psychotherapies. According to these criteria, 2 randomized controlled trials (RCTs) showing efficacy are required for a treatment to be designated as 'efficacious' and 1 RCT for a designation as 'possibly efficacious'. Applying these criteria modified by Chambless and Hollon, this article presents an update on the evidence for psychodynamic therapy (PDT) in specific mental disorders. Method: A systematic search was performed using the criteria by Chambless and Hollon for study selection, as follows: (1) RCT of PDT in adults, (2) use of reliable and valid measures for diagnosis and outcome, (3) use of treatment manuals or manual-like guidelines, (4) adult population treated for specific problems and (5) PDT superior to no treatment, placebo or alternative treatment or equivalent to an established treatment. Results: A total of 39 RCTs were included. Following Chambless and Hollon, PDT can presently be designated as efficacious in major depressive disorder (MDD), social anxiety disorder, borderline and heterogeneous personality disorders, somatoform pain disorder, and anorexia nervosa. For MDD, this also applies to the combination with pharmacotherapy. PDT can be considered as possibly efficacious in dysthymia, complicated grief, panic disorder, generalized anxiety disorder, and substance abuse/dependence. Evidence is lacking for obsessive-compulsive, posttraumatic stress, bipolar and schizophrenia spectrum disorder(s). Conclusions: Evidence has emerged that PDT is efficacious or possibly efficacious in a wide range of common mental disorders. Further research is required for those disorders for which sufficient evidence does not yet exist.
Objective: For chronic depression, the effectiveness of brief psychotherapy has been limited. This study is the first comparing the effectiveness of long-term cognitive-behavioural therapy (CBT) and long-term psychoanalytic therapy (PAT) of chronically depressed patients and the effects of preferential or randomized allocation. Method: A total of 252 adults met the inclusion criteria (aged 21-60 years, major depression, dysthymia, double depression for at least 24 months, Quick Inventory of Depressive Symptoms [QIDS] >9, Beck Depression Inventory II [BDI] >17, informed consent, not meeting exclusion criteria). Main outcome measures were depression self-rating (BDI) and rating (clinician-rated QIDS [QIDS-C]) by independent, treatment-blinded clinicians. Full remission rates (BDI ≤12, QIDS-C ≤5) were calculated. An independent center for data management and biostatistics analyzed the treatment effects and differences using linear mixed models (multilevel models and hierarchical models). Results: The average BDI declined from 32.1 points by 12.1 points over the first year and 17.2 points over 3 years. BDI overall mean effect sizes increased from d = 1.17 after 1 year to d = 1.83 after 3 years. BDI remission rates increased from 34% after 1 year to 45% after 3 years. QIDS-C overall effect sizes increased from d = 1.56 to d = 2.08, and remission rates rose from 39% after 1 year to 61% after 3 years. We found no significant differences between PAT and CBT or between preferential and randomized allocation. Conclusions: Psychoanalytic as well as cognitive-behavioural long-term treatments lead to significant and sustained improvements of depressive symptoms of chronically depressed patients exceeding effect sizes of other international outcome studies.
DOI: 10.1521/pdps.2014.42.3.377
The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce society's burden of disease in the long run.
DOI: 10.1016/j.psc.2012.01.001
Findings reviewed in this article show that PT (psychodynamic therapy) should be included in treatment guidelines for depression. BPT (brief psychoanalytic therapy) in particular has been found to be superior to control conditions, equally effective as other active psychological treatments, with treatment effects that are often maintained in the long run, conferring resistance to relapse. Moreover, BPT is as effective as pharmacotherapy in the acute treatment of mild to moderate depression, and, either as monotherapy or combined with medication, BPT is associated with better long-term outcome compared with pharmacotherapy alone. PT is accepted by many depressed patients as a viable and preferred treatment. Furthermore, LTPT and PA have shown promise in treating patients with complex psychological disorders characterized by mood problems, often with comorbid personality problems. Finally, although studies suggest that effects of PT may be achieved somewhat slower compared with other forms of psychotherapy as well as medication in the acute treatment of depression, LTPT appears to be more clinically effective and perhaps more cost effective in the long run, particularly for chronically depressed patients. As noted, these conclusions need to be interpreted within the context of important limitations. Compared with other treatments, the evidence base for PT in depression remains relatively small, despite a respectable research tradition supporting psychodynamic assumptions with regard to the causation of depression. Moreover, and perhaps most importantly, although more studies now include longer follow-up assessments, our knowledge about the long-term effects of so-called evidence-based treatments of depression remains sketchy at best. In this context, the growing evidence for the efficacy and effectiveness of LTPT is promising. Overall, it is clear that the future of the treatment of depression may lie in a combined disorder- and person-centered, tailored-made approach, which takes into account, particularly in chronic depression, the broader interpersonal context and life history of the individual. It is clear that psychodynamic therapies have an important role to play in this respect.
13) Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.
DOI: 10.1037/a0018378
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.
DOI: 10.1192/bji.2017.4
This paper summarizes the core scientific claims of psychoanalysis and rebuts the prejudice that it is not “evidence-based'“ I address the following questions. (A) How does the emotional mind work, in health and disease? (B) Therefore, what does psychoanalytic treatment aim to achieve? (C) How effective is it?
DOI: 10.1176/appi.ajp.2017.17010057
Objective: Pharmacotherapy, cognitive-behavioral therapy (CBT), and psychodynamic therapy are most frequently applied to treat mental disorders. However, whether psychodynamic therapy is as efficacious as other empirically supported treatments is not yet clear. Thus, for the first time the equivalence of psychodynamic therapy to treatments established in efficacy was formally tested. The authors controlled for researcher allegiance effects by including representatives of psychodynamic therapy and CBT, the main rival psychotherapeutic treatments (adversarial collaboration). Method: The authors applied the formal criteria for testing equivalence, implying a particularly strict test: a priori defining a margin compatible with equivalence (g=0.25), using the two one-sided test procedure, and ensuring the efficacy of the comparator. Independent raters assessed effect sizes, study quality, and allegiance. A systematic literature search used the following criteria: randomized controlled trial of manual-guided psychodynamic therapy in adults, testing psychodynamic therapy against a treatment with efficacy established for the disorder under study, and applying reliable and valid outcome measures. The primary outcome was “target symptoms” (e.g., depressive symptoms in depressive disorders). Results: Twenty-three randomized controlled trials with 2,751 patients were included. The mean study quality was good as demonstrated by reliable rating methods. Statistical analyses showed equivalence of psychodynamic therapy to comparison conditions for target symptoms at post-treatment (g=−0.153, 90% equivalence CI=−0.227 to −0.079) and at follow-up (g=−0.049, 90% equivalence CI=−0.137 to −0.038) because both CIs were included in the equivalence interval (−0.25 to 0.25). Conclusions: Results suggest equivalence of psychodynamic therapy to treatments established in efficacy. Further research should examine who benefits most from which treatment.