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Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054
Psychodynamic psychotherapy: article
developing the evidence base
Jessica Yakeley
In this article I will outline recent develop ments Jessica Yakeley is a consultant
SUMMARY in the field of psychodynamic psychotherapy psychiatrist in forensic psycho
Psychodynamic psychotherapy has been research that go some way in refuting these therapy at the Portman Clinic, and
criticised as being based on outdated principles of Director of Medical Education
psychoanalysis and lacking an adequate evidence criticisms. Contrary to the beliefs of some and Associate Medical Director
base to convincingly demonstrate its efficacy. detractors of psychodynamic psychotherapy, there at the Tavistock and Portman NHS
This article summarises the recent evidence is now a convincing body of empirical evidence Foundation Trust. She is currently
from welldesigned outcome studies to support the Lead on Meaningful Evaluation
from high-quality outcome studies to show that of Psychotherapy Services for the
psychodynamic psychotherapy is as effective in its efficacy. Moreover, process–outcome research Medical Psychotherapy Faculty of
the treatment of a range of mental disorders as linking specific psychodynamic interventions the Royal College of Psychiatrists
other psychological treatment modalities such to therapeutic outcomes within a theoretical and Chair of the Research and
as cognitive–behavioural therapy, as well as framework based on attachment has facilitated Evidence Task Group of the British
reviewing process–outcome research aiming Psychoanalytic Council.
better understanding of the processes of change Correspondence Dr Jessica
to elucidate mechanisms of therapeutic change. and enabled therapeutic technique to be adapted Yakeley, Portman Clinic, 8 Fitzjohns
A paradigm for psychodynamic psychotherapy and refined, with the development of tailored Avenue, London NW3 5NA, UK.
research based on attachment theory is psycho dynamic psychotherapies for specific Email: jyakeley@taviport.nhs.uk
introduced, which may inform the development of conditions.
psychodynamic therapeutic modalities tailored for
specific conditions. What is psychodynamic psychotherapy?
LEARNING OBJECTIVES Psychodynamic psychotherapy has its historical
• Understand the basic principles and techniques origins in Freud’s work and is based on the
of psychodynamic psychotherapy. fundamental principles of psychoanalysis. These
• Be able to summarise the recent evidence base include the dynamic unconscious, transference,
for the efficacy of psychodynamic psychotherapy. countertransference, resistance, defence, psychic
• Appreciate process–outcome research that determinism (the notion that our thoughts and
elucidates therapeutic mechanisms underpinning actions are determined by unconscious forces and
psychodynamic psychotherapy. have symbolic meaning), and a developmental
DECLARATION OF INTEREST perspective, in which childhood experiences are
None. seen as critical in shaping the adult personality.
Although the terms ‘psychoanalytic psychotherapy’
and ‘psychodynamic psychotherapy’ are often used
Psychodynamic psychotherapy has been belea interchangeably, psychodynamic psychotherapy
guered in recent times. Accusations that it is may be viewed as encompassing a broader
based on outdated principles of psychoanalysis, perspective which includes the ‘relational’, i.e.
that it lacks an empirical research base and the interpersonal, intersubjective and embodied
that its emphasis on longerterm treatments by experience of both the social world and the
highly trained pro fessionals makes it less cost internal world, in which representations are built
effective than other psychological treatments have up over time and reflect dispositions that arise
contributed to the dismantling of psychodynamic from innate vulnerability and early childhood
psychotherapy services within the National Health experience. It also refers to the dynamic nature
Service (NHS) in favour of more ‘evidencebased’ of both the internal and external worlds in that
interventions. Although the economic recession has they shift and change in the context of social
been a challenge to all mental health services forced relationships and group settings experienced over
to make financial savings, reports suggest that a lifetime (Yakeley 2013).
psycho dynamic psycho therapy provision within Free association
the public health sector has been disproportionately
reduced compared with other treatment modalities Traditional psychodynamic psychotherapy
(British Psychoanalytic Council 2013). utilises techniques derived from psychoanalysis,
269
https://doi.org/10.1192/apt.bp.113.012054 Published online by Cambridge University Press
Yakeley
but sessions are less frequent, provided once BOx 1 Seven features that distinguish
or twice a week over a shorter time span, and psycho dynamic psychotherapy from
‘face to face’, with the patient sitting up rather other therapies
than lying on the couch as in psychoanalysis.
In contrast to therapies where the therapist sets • Focus on affect and expression of emotion
an agenda or actively structures the session, the • Exploring attempts to avoid distressing thoughts and
patient is encouraged to say whatever is in their feelings (defence and resistance)
mind, following the psychoanalytic technique of • Identifying recurring themes and patterns
‘free association’. The psychotherapist’s task is
to discover the unconscious themes that underlie • Discussion of past experience (developmental process)
the patient’s discourse via the patient’s slips of • Focus on interpersonal relations
the tongue, associative links and resistances to • Focus on the therapy relationship (including
speaking about certain topics that the patient is transference)
unaware of. The psychotherapist intervenes in • Exploration of wishes and fantasies
the form of verbal communications, which can (Blagys 2000)
be categorised along a spectrum from the more
supportive or empathic, to more challenging and
interpretative as the therapy progresses. identify empirical studies comparing manualised
Interpretative and supportive interventions psychotherapy technique with that of manualised
CBT. From empirical examination of recordings
Interpretative interventions enhance the patient’s and transcripts of actual sessions they identified
insight about repetitive conflicts sustaining their seven distinctive features concerning process and
problems (Gabbard 2004), and offer a new formu technique that reliably distinguished psycho
lation of unconscious meaning and motivation for dynamic psychotherapy from other therapies
the patient. ‘Transference interpretations’, focusing determined (Box 1).
on the relationship between therapist and patient
in the ‘here and now’ or affective interchange of Specific psychodynamic therapeutic
the session, are often viewed by contemporary modalities
therapists as the most mutative interventions. In A number of distinct psychodynamic psycho
practice, the therapist adopts a flexible approach therapies or modalities have evolved which
so that any session may include a combination combine elements from other approaches, including
of supportive and interpretative interventions the interpersonal, humanistic and cognitive
according to the patient’s need and mental state traditions. These therapies have usually been
at the time. developed and tailored for a specific disorder, such
The countertransference as depression or borderline personality disorder,
but subsequently generalised to treat a wider range
Psychodynamic psychotherapists also pay special of conditions. They tend to be timelimited, have a
attention to the therapist’s countertransference, clear theoretical basis and promote modifications
that is, the feelings and emotional reactions that of specific techniques, which are defined and
the therapist has towards the patient. These illustrated in manuals. Such manualisation is
can be a source of useful information about the helpful in communicating and disseminating what
patient and their internal object relations, which exactly occurs in the therapy under question, but
determine their pattern of relating to others. is also necessary to ensure consistent training,
Core features of contemporary psychodynamic interrater reliability and adherence to the model in
psychotherapy outcome studies of treatment efficacy. Such studies
have significantly contributed to the evidence base
Although the concepts and techniques of psycho for psychodynamic psychotherapy in general (see
dynamic psychotherapy have evolved considerably below).
since Freud and have led to the development of Table 1 lists the main modalities of modified
a range of specific psychodynamic therapeutic psychodynamic therapies that have been developed
modalities for different conditions, core features and are available to at least some extent within the
of contemporary psychodynamic psychotherapy NHS and public health sector in the UK. Most of
may be distinguished that differentiate it from these therapies are only available in specialised
other therapies such as cognitive–behavioural mental health or psychological services, but
therapy (CBT). Blagys & Hilsenroth (2000) dynamic interpersonal therapy is available as one
conducted a comprehensive literature search to of the brief psychotherapies provided nationally
270 Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054
https://doi.org/10.1192/apt.bp.113.012054 Published online by Cambridge University Press
Psychodynamic psychotherapy: developing the evidence base
as part of the Increasing Access to Psychological TABLE 1 Main psychodynamic therapies available in the UK’s National Health Service
Therapies (IAPT) programme introduced by the
Department of Health in 2007 (Department of Therapy & Clinical
Health 2007). studies Core features indications
Interpersonal Brief, focused, structured therapy emphasising current Depression
The research challenges for therapy (IPT) interpersonal relations. Four focuses: grief, disputes,
psychodynamic psychotherapy (Klerman 1996) deficits and role transition
Psychodynamic Psychodynamic therapy with humanistic and Depression,
The limitations of the empirical base for psycho interpersonal interpersonal elements, consisting of seven somatisation
dynamic psychotherapy have been well rehearsed. therapy (PIT) integrated components: explanatory rationale, shared
First, the psychoanalytic community as a whole (Hobson 1985; understanding, staying with feelings, focus on difficult
Guthrie 1991, feelings, gaining insight, sequencing interventions and
has been historically disinterested or resistant to 1999) making changes
the value of research, which has resulted in the Dynamic Brief focused therapy based on distillation of evidence Depression,
critical scientific evaluation of psychodynamic interpersonal based manualised psychodynamic approaches, anxiety disorders
treatments lagging behind the evaluation of other therapy (DIT) incorporating object relations, attachment and
forms of psychiatric and psychological interven (Lemma 2010) mentalisation theory. Focuses on patient’s interpersonal
and affective functioning in ‘here and now’ of session
tions (Gerber 2010). This resistance may be Cognitive Brief therapy integrating psychoanalytic and cognitive Neurotic
due to a variety of reasons, including suspicion analytic therapy techniques, emphasising patient’s relationships. disorders,
of research methods such as manualisation of (CAT) Constructs reformulation of difficulties with patient borderline
treatments, randomisation of patients or recording (Ryle 1982, defining ‘reciprocal role procedures’ based on early personality
1990) relationships, and defensive mechanisms maintaining disorder
of sessions; viewing narrowly defined trial criteria them (‘traps’, ‘dilemmas’ and ‘snags’)
and research conditions as nonrepresentative Mentalisation Group and individual therapy based on attachment Borderline
of clinical practice (i.e. the gap between clinical based therapy theory integrating psychodynamic, cognitive and personality
efficacy and effectiveness); and a reluctance (MBT) relational components. Focuses on enhancing disorder, eating
to give up cherished beliefs about theory and (Bateman 2004, mentalisation (the ability to reflect on one’s own and disorders,
2006) others’ states of mind and link these to actions and depression,
technique based on individual experience and behaviours) substance
clinical lore rather than a willingness to take on misuse, parenting
board empirical findings which may challenge difficulties
established practice. Transference Individual therapy two or three times a week, based on Borderline and
focused psycho psychoanalytic object relations theory using modified other severe
Second, many of the trials of psychodynamic therapy (TFT) psychoanalytic techniques. Focuses on the reactivation personality
psychotherapy that have been conducted have (Clarkin 2006; and interpretation of the patient’s splitoff internalised disorders
lacked sufficient methodological rigour, for exam Kernberg 2008) object relations in the transference
ple, in unclear definitions of patient characteristics
or treatment methods, inadequate sample sizes, past two decades there has been an increasing
poor monitoring of adherence to the treatment number of highquality RCTs in psychodynamic
model and interrater reliability, and less than opti psychotherapy. Shedler (2010) has highlighted the
mal control conditions in which treatment as usual importance of several key metaanalyses published
is used instead of an alternative potential active in highimpact journals, which pool the results of
treatment. The number of randomised controlled these studies and demonstrate that effect sizes
trials (RCTs) of psychodynamic psychotherapy is (Box 2) for psychodynamic psychotherapies are as
small compared with those that have been carried large as those reported for other treatments that
out in the evaluation of other forms of psycho have been actively promoted as ‘evidencebased’,
therapy, particularly CBT. such as CBT.
Third, many of these studies have focused on For example, a metaanalysis published by the
brief psychodynamic treatments, whereas many Cochrane Library (Abbass 2006) reviewed 23 RCTs
psychodynamic clinicians are interested in comparing shortterm psycho dynamic psycho
elucidating the mechanisms of change of longer therapy for common mental disorders against
term treatments which aim at deeper structural minimal treatment and nontreatment control
changes in the patient’s personality organisation interventions, yielding an overall effect size of 0.97
rather than solely symptom improvement. for general symptom improvement, which increased
to 1.51 when the patients were assessed at 9month
Outcome studies of psychodynamic followup. Another metaanalysis, reported in
psychotherapy Archives of General Psychiatry, of 17 highquality
Meta-analyses and effect sizes RCTs reported an effect size of 1.17 for shortterm
psychodynamic psychotherapy compared with
Despite these challenges in conducting methodo control interventions (Leichsenring 2004). Two
logically robust research in the field, in the more recent metaanalyses, published in the JAMA
Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 271
https://doi.org/10.1192/apt.bp.113.012054 Published online by Cambridge University Press
Yakeley
BOx 2 Research terminology well as manual searches of articles and textbooks,
and communication with authors and experts in
Efficacy measures how well an intervention summarising and integrating the findings of the field. The search criteria identified all RCTs
or treatment works in clinical trials designed independent studies of a specific treatment, published between January 1970 and September
to show internal validity so that causal that in themselves are too small or limited 2013 that examined the efficacy of psychodynamic
inferences may be made. in scope, to come to a conclusion about psychotherapy for specific mental disorders using
Clinical effectiveness is the extent to treatment efficacy. treatment manuals and reliable and valid measures
which an intervention or treatment improves Effect size refers to the difference between for diagnosis and outcome. Metaanalysis of the 47
the outcome for patients in everyday clinical treatment and control groups, expressed RCTs that met these rigorous criteria showed that
practice. There is often a gap between in standard deviation units. An effect size psychodynamic therapy is efficacious for a range
efficacy and effectiveness. of 1.0 indicates that the average patient of common mental disorders, including depressive
receiving the treatment under consideration disorders, anxiety dis orders, somatoform disorders,
Meta-analysis is a widely accepted is one standard deviation healthier on the personality disorders, eating disorders, complicated
method used in medicine and psychology normal distribution than the average patient grief, posttraumatic stress disorder and substance
to strengthen the evidence about treatment receiving no treatment. An effect size related disorders.
efficacy. It refers to the statistical analysis of 0.8 is considered a large effect, 0.5 is
of a collection of results for the purpose of considered moderate, 0.2 is small. The Dodo verdict
This accumulation of empirical evidence
convincingly demonstrates that psychodynamic
(Leichsenring 2008, 2009) and the Harvard Review psychotherapy is not inferior in efficacy to other
of Psychiatry (de Maat 2009), have examined the psychological treatments. Moreover, it shows that
efficacy of longterm psychodynamic psychotherapy the benefits of psychodynamic psychotherapy
(1 year or more) for a range of DSM diagnoses may be long lasting and extend beyond symptom
and complex mental disorders. These found that remission. However, perhaps para doxically, the
the effect sizes for longerterm psychodynamic methodological superiority of more recent trials,
psychotherapy were not only significantly higher which have included active treatments as controls,
than those for the shorterterm therapies, but that has highlighted the wellknown ‘Dodo verdict’
they continued to increase from termination of (Rosenzweig 1936; Luborsky 1975), based on the
treatment to longterm followup, especially for conclusion of the dodo in Alice in Wonderland that
patients with severe personality pathology. ‘Everybody has won and all must have prizes’. This
refers to the consistent finding in psychotherapy
Outcomes for specific disorders research of the outcome equivalence of different
Many of the studies in these metaanalyses, therapies, in that no specific therapy is shown to
however, included patients with a range of symp have greater efficacy than any other.
toms and conditions, rather than focusing on This finding is usually interpreted as being
specific diagnostic categories. Other recent due to ‘common factors’, i.e. techniques and
metaanalyses have focused on the evidence mechanisms common to different therapies which
base for psychodynamic psychotherapy for constitute the agents of change and are frequently
specific disorders. subsumed under the umbrella of the ‘therapeutic
Thus, Abbass et al (2009), in a metaanalysis alliance’. How ever, the dodo verdict here might
of 23 studies examining the efficacy of short also be due to a failure to measure real differences
term psychodynamic psychotherapy for somatic that exist between different therapies but have
disorders, reported an effect size of 0.69 for eluded detection because our measures are
improvement in general psychiatric symptoms and inadequate. In the case of psychodynamic psycho
0.59 for improvement in somatic symptoms. therapy, there may be a fun damental mismatch
A metaanalysis looking at the efficacy of both between what outcome studies tend to measure in
psycho dynamic psychotherapy and CBT for improvement or alleviation of symptoms and what
personality disorder published in the American psychodynamic psychotherapy aims to achieve in
Journal of Psychiatry (Leichsenring 2003) showed going beyond symptom remission to change deeper
pre to posttreatment effect sizes of 1.46 for personality structures and capacities, enabling the
psycho dynamic psychotherapy and 1.0 for CBT. patient to live with greater freedom and possibility
In a very recent publication, Leichsenring & (Shedler 2010).
Klein (2014) review the empirical evidence for What works and how?
psychodynamic therapy for specific mental disorders
in adults. They conducted a computerised search Such questions have prompted a shift in
of MEDLINE, PsycINFO and Current Contents, as psycho therapy research from outcome to
272 Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054
https://doi.org/10.1192/apt.bp.113.012054 Published online by Cambridge University Press
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