Examining the Evidence for Psychodynamic Therapy

By Alan Swope, Spring 2011 - Online Exlusive

When Nancy McWilliams was president of Division 39 of APA, The Division of Psychologist-Psychoanalysts, she made a strong plea for more research on psychodynamic psychotherapy. The cultural conversation has shifted away from authoritative pronouncements to “show me the evidence.” Clearly, a move in the right direction. Fortunately, a growing corps of researchers has taken on the task with some very promising results. I will briefly review articles by Leichsenring and Rabung (2008), and Shedler (2010), articles which argue for the efficacy of psychodynamic therapy.

An indication of the seminal importance of these two studies is that the Leichsenring and Rabung article was reprinted in the prestigious Journal of the American Medical Association in 2008 and Shedler’s article was summarized in the December 9, 2010, edition of the Scientific American. Leichsenring and Rabung, briefly, conducted a meta-analysis that compared long-term psychodynamic psychotherapy (>1 year) with briefer therapies for the treatment of complex mental disorders. The effect size, later corrected for computational error (Leichsenring & Rabung, 2009), was still a sizable 0.65.

Shedler is especially interesting as a new breed of psychoanalyst-researcher who comes unencumbered by outmoded ideas from the annals of psychoanalysis, ideas that are still taught in undergraduate (and graduate) psychology courses as representative of psychoanalytic thinking. In a paper entitled: That was then, this is now: Psychoanalytic therapy for the rest of us (2006), Shedler takes pains to carve away the misconceptions about psychoanalysis in a section called “What it isn’t.” You can find this paper at http://psychsystems.net/shedler.html. You may be surprised to learn of how much baggage psychoanalytic theoreticians and practitioners have let go. A sample of “What it isn’t:” It is not a theory about id, ego, and superego; it is not a theory “about ‘fixations,' or sexual and aggressive instincts, or repressed memories, or the Oedipus complex, or penis envy, or castration anxiety (p. 4).” This, clearly, is not your grandfather's psychoanalysis.

In fact, in his American Psychologist article, Shedler has little to say about theory. He focuses on process and technique only, referring the reader to McWilliams (2004), for example, to learn about concepts and principles. Shedler himself does discuss some of the foundational concepts of psychoanalysis in the 2006 paper cited above. In the American Psychologist article, he lists seven basic processes and techniques that he claims are distinctive in psychodynamic therapy and found across empirical studies. A few of these are: Focus on the full range of the patient’s emotions with an emphasis on emotional insight; explore attempts to avoid distressing thoughts and feelings (akin to the analysis of resistance); and establish a developmental focus, explore how the past helps us understand current problems. As a practitioner of psychodynamic psychotherapy, I found that Shedler's seven processes and techniques capture important elements of my technique. He doesn't list empathy, emotional attunement, use of humor, creativity--all of which are important--but one could argue that these elements are key to any successful psychotherapy relationship.

Two other highlights of Shedler’s article are worth mentioning. One is his assertion that psychodynamic therapy is about more than symptom resolution. He asserts that goals such as more fulfilling relationships, making better use of one’s talents and abilities, and a better understanding of others are explicit in psychodynamic thinking. He encourages researchers to assess the positive capacities and resources that can change with psychotherapy.

Another highlight of the article is the consideration of effect sizes of psychodynamic psychotherapies. Shedler cites evidence that the benefits of psychodynamic therapy actually increase with time while the benefits of non-psychodynamic therapies decay over time. If this finding holds up in future studies, it could provide support for the oft-heard claim that the patient in psychodynamic therapy internalizes the “analytic attitude” of the therapist. Patients are capable of continuing their self-examination and reflection after therapy ends.

Several criticisms of Shedler's 2010 article are printed in the Comment section of the February-March 2011 American Psychologist. Shedler's reply follows and, I believe, it effectively deals with the points raised. When it comes to “show me the evidence,” it seems the debate still hinges on what actually constitutes “evidence.” Shedler asserts that a double standard is being applied by his critics. Readers are encouraged to read the article and comments and form their own opinions about this vital debate.

References
Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. Journal of the American Medical Association, 300, 1551-1565.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65, 98-109.

Leichsenring, F. & Rabung, S. (2008). Analyzing effectiveness of long-term psychodynamic psychotherapy: In reply. Journal of the American Medical Association, 301, 932-933.