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the efficacy of psychodynamic psychotherapy jonathan shedler university of colorado denver school of medicine empirical evidence supports the efcacy of psychodynamic over time finally i consider evidence that nonpsychody therapy ...

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                                 The Efficacy of Psychodynamic Psychotherapy
                                                                                    Jonathan Shedler                 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-                                        Distinctive Features of
                    namic therapy maintain therapeutic gains and appear to
                    continue to improve after treatment ends. Finally, nonpsy-                                       Psychodynamic Technique
                    chodynamic therapies may be effective in part because the                                                                                                                           1
                    more skilled practitioners utilize techniques that have long                                             Psychodynamic or psychoanalytic psychotherapy 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
                    ings.                                                                                            week, and the treatment may be either time limited or open
                    Keywords:            psychotherapy               outcome,          psychotherapy                 ended. The essence of psychodynamic therapy is exploring
                    process, psychoanalysis, psychodynamic therapy, meta-                                            those aspects of self that are not fully known, especially as
                    analysis                                                                                         they are manifested and potentially influenced in the ther-
                                                                                                                     apy relationship.
                              here is a belief in some quarters that psychodynamic                                           Undergraduate textbooks too often equate psychoan-
                              concepts and treatments lack empirical support or                                      alytic or psychodynamic therapies with some of the more
                    Tthat scientific evidence shows that other forms of                                               outlandish and inaccessible speculations made by Sigmund
                    treatment are more effective. The belief appears to have                                         Freud roughly a century ago, rarely presenting mainstream
                    taken on a life of its own. Academicians repeat it to one                                        psychodynamic concepts as understood and practiced to-
                    another, as do health care administrators, as do health care                                     day. Such presentations, along with caricatured depictions
                    policymakers. With each repetition, its apparent credibility                                     in the popular media, have contributed to widespread mis-
                    grows. At some point, there seems little need to question or                                     understanding of psychodynamic treatment (for discussion
                    revisit it because “everyone” knows it to be so.                                                 of how clinical psychoanalysis is represented and misrep-
                            The scientific evidence tells a different story: Consid-                                  resented in undergraduate curricula, see Bornstein, 1988,
                    erable research supports the efficacy and effectiveness of                                        1995; Hansell, 2005; Redmond & Shulman, 2008). To help
                    psychodynamic therapy. The discrepancy between percep-                                           dispel possible myths and facilitate greater understanding
                    tions and evidence may be due, in part, to biases in the                                         of psychodynamic practice, in this section I review core
                    dissemination of research findings. One potential source of                                       features of contemporary psychodynamic technique.
                    bias is a lingering distaste in the mental health professions                                            Blagys and Hilsenroth (2000) conducted a search of
                    for past psychoanalytic arrogance and authority. In decades                                      the PsycLit database to identify empirical studies that com-
                    past, American psychoanalysis was dominated by a hierar-                                         pared the process and technique of manualized psychody-
                    chical medical establishment that denied training to non-                                        namictherapywiththatofmanualizedcognitivebehavioral
                    MDsandadoptedadismissivestancetowardresearch.This                                                therapy (CBT). Seven features reliably distinguished psy-
                    stance did not win friends in academic circles. When em-                                         chodynamictherapyfromothertherapies, as determined by
                    pirical findings emerged that supported nonpsychodynamic                                          empirical examination of actual session recordings and
                    treatments, 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-
                            This article brings together findings from several em-                                    liams, Robert Michels, George Stricker, and Robert Wallerstein for their
                    pirical literatures that bear on the efficacy of psychody-                                        comments on drafts of the article; and the 500-plus members of the
                                                                                                                     Psychodynamic Research Listserv for their collective wisdom and sup-
                    namic treatment. I first outline the distinctive features of                                      port.
                    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-
                    evidence that patients who receive psychodynamic therapy                                         rado Denver School of Medicine, Mail Stop A011-04, 13001 East 17th
                                                                                                                     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.
                    98                                                                                                               February–March 2010 ● American Psychologist
                                                                                                                                                ©2010 American Psychological Association 0003-066X/10/$12.00
                                                                                                                                                              Vol. 65, No. 2, 98–109     DOI:10.1037/a0018378
                                                                              Psychodynamic therapists actively focus on and explore
                                                                              avoidances.
                                                                                    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
                                                                              whensuccess 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
              Shedler                                                         the past tends to “live on” in the present. The focus is not
                                                                              on the past for its own sake, but rather on how the past
                                                                              sheds light on current psychological difficulties. The goal is
                                                                              to 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
              2006a):                                                         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-
              anddiscussionofthefullrangeofapatient’semotions.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       emotional needs.
              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
              come those difficulties).                                        knowingly or unknowingly; a person who struggles with
                   2. Exploration of attempts to avoid dis-                   anger and hostility may struggle with anger toward the
              tressingthoughtsandfeelings. Peopledoagreat                     therapist; and so on (these are relatively crude examples;
              manythings, 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                                                                               99
              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
              and meaning in life.                                                 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 therapy             2004).
              include, but extend beyond, symptom remission. Success-                   To provide some points of reference, it is instructive
              ful treatment should not only relieve symptoms (i.e., get rid        to consider effect sizes for antidepressant medications. An
              of something) but also foster the positive presence of               analysis of U.S. Food and Drug Adminstration (FDA)
              psychological capacities and resources. Depending on the             databases (published and unpublished studies) reported in
              person and the circumstances, these might include the
              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          FDAbetween1987and2004was0.31(Turner,Matthews,
              and flexibility. Such ends are pursued through a process of                                                      3 A meta-analysis
                                                                                   Linardatos, Tell, & Rosenthal, 2008).
              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-                                                           4
                                                                                   drug but is not itself an antidepressant). 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
              html]).                                                              great that effect sizes may not be directly comparable, and
              HowEffective Is Psychotherapy in                                     the findings should not be interpreted as conclusive evi-
              General?                                                             dence that psychotherapy is more effective. Effect sizes for
                                                                                   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              2 This score, known as the standardized mean difference, is used to
              comparable by converting findings into a common metric,               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
              Awidely 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,
                                     2 An effect size of 1.0 means that the        1982) rather than Cohen’s d (Cohen, 1988), which is more commonly
              dard deviation units.                                                reported. 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-
                                                                                   ner, January 2008).
              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 may
              patients who received psychotherapy compared with un-                be inflated by expectancy and demand effects. Use of “active” placebos
                                                                                   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.
              100                                                                             February–March 2010 ● American Psychologist
              HowEffective 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 that
                                                                                   both treatments demonstrated effectiveness. A more recent
              Arecent 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
                                   5
              Cochrane Library, 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)
                                                      6
              range of common mental disorders who received short-                 and reported effect sizes of 0.91 for general symptom im-
              term ( 40 hours) psychodynamic therapy with controls                provement (N  7 studies) and 0.97 for improvement in
              (wait list, minimal treatment, or “treatment as usual”)              interpersonal functioning (N  4 studies).
              and yielded an overall effect size of 0.97 for general                    Two recent studies examined the efficacy of long-
              symptomimprovement.Theeffectsize 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-
              ( 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 ( 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                                                   8
                                                                                   size of 1.8 for overall outcome. The pretreatment to
              in depressive symptoms, which increased to 0.98 at                   posttreatment effect size was 1.03 for overall outcome,
                          7
              follow-up.     The consistent trend toward larger effect             which increased to 1.25 at long-term follow-up (p 
              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
                    Ameta-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,
                    Anewlyreleased 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            5.2 years posttreatment.
              (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,         findingthat the benefits of psychodynamic therapy not only
              genitourinary, immunological). The study reported effect
              sizes 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
              Amongstudies 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                al., 2006).
                                                                                       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               8 The atypical method used to compute this effect size may provide
              mean follow-up period was 1.5 years and the pretreatment to          an inflated estimate of efficacy, and the effect size may not be comparable
                                                                                   to other effect sizes reported in this review (for discussion, see Thombs,
              posttreatment effect size was 1.46. For CBT (mean length of          Bassel, & Jewett, 2009).
              February–March 2010 ● American Psychologist                                                                                     101
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...The efficacy of psychodynamic psychotherapy jonathan shedler university colorado denver school medicine empirical evidence supports efcacy over time finally i consider that nonpsychody therapy effect sizes for are as namic therapies may be effective in part because more large those reported other have been skilled practitioners utilize interventions long actively promoted empirically supported and evi central to theory practice dence based addition patients who receive psychody distinctive features maintain therapeutic gains appear continue improve after treatment ends nonpsy technique chodynamic techniques or psychoanalytic re fers a range treatments on perception approaches lack concepts methods involve less frequent meetings support does not accord with available scientic considerably briefer than psychoanalysis reect selective dissemination research nd proper session frequency is typically once twice per ings week either limited open keywords outcome ended essence exploring process...

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