Psychodynamic therapy can help people improve their quality of life by helping them gain a better understanding of the way they think and feel. The idea is that this will improve their ability to make choices, relate to others, and forge the kind of life they would like to live.
When most people think of therapy, the thoughts and images that come to mind tend to be those related to psychodynamic therapy. This is because psychodynamic therapy is based on the work of Sigmund Freud, who many people know as the “father of psychoanalysis.”
Although the American Psychological Association identify five general categories of therapy — with many more subtypes — most types have roots that are traceable to Freud’s groundbreaking work.
Keep reading to learn more about psychodynamic therapy, including its origins, how it works, and its potential benefits.
What is it?
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Psychodynamic therapy is a talking therapy. This means that it is based on the concept that talking about problems can help people learn and develop the skills they need to address them.
It is an approach that embraces the multifaceted aspects of an individual’s life. It strives to help people understand the sometimes unknown or unconscious motivations behind difficult feelings and behaviors.
Having this insight can lead to symptom relief, help people feel better, and allow them to make better choices.
How does it work?
Psychodynamic therapy is based on the following key principles:
- Unconscious motivations — such as social pressure, biology, and psychology — can affect behavior.
- Experience shapes personality, which can, in return, affect an individual’s response to that experience.
- Past experiences affect the present.
- Developing insight and emotional understanding can help individuals with psychological issues.
- Expanding the range of choices and improving personal relationships can help people address their problems.
- Freeing themselves from their pasts can help people live better in the future.
Transference and countertransference are also important. With this approach, the client will transfer their feelings toward someone onto the therapist, and the therapist will redirect these feelings back toward the client. It can take place without the client’s awareness, and many therapists have varying approaches to this concept.
In psychodynamic therapy, the relationship between the therapist and the client is very important. It provides a container in which people can gain insights into themselves, their pasts, and their feelings. They can develop a better understanding of how they see the world and the ways in which all these factors affect their experiences.
With the help of a therapist, people undergoing psychodynamic therapy will work to understand their feelings, beliefs, and childhood experiences. The goal is to help people recognize self-defeating patterns, explore new ways of being in the world, and help people feel better.
A psychodynamic approach to therapy can work with individuals, couples, families, and in group therapy situations.
Because its focus tends to be on relationships and understanding thoughts and feelings, which people may have avoided confronting, psychodynamic therapy can be time consuming.
Short-term psychodynamic therapy generally lasts for 25–30 sessions over a period of 6–8 months, while long-term psychodynamic therapy — according to one study — may last for longer than a year or span more than 50 sessions.
History and origins
Psychodynamic therapy grew out of the theories of Sigmund Freud. However, it has evolved considerably from the 19th-century model.
Early leaders in the field who contributed to the development of this approach include Carl Jung, Melanie Klein, and Anna Freud.
In its earlier stages, therapy could last for years, with a person even having several therapy sessions per week.
Practitioners typically had a medical background and a paternalistic approach.
Is it effective?
Measuring the impact of treatment for psychological issues can be complicated. That said, there is evidence to suggest that psychodynamic therapy works for the following conditions:
- Depression: Studies indicate that it can help people address recurring life patterns that play a part in their depression.
- Social anxiety, social phobia, and panic disorder: Studies have found promising results and improved remission.
- Anorexia nervosa: Strong evidence suggests that it promotes recovery from anorexia nervosa.
- Pain: Unexplained chronic and abdominal pain respond well to this therapy, data suggest.
- Borderline personality disorder: Studies have found structured, integrated, and supervised treatment to be effective.
- Psychopathological issues in children and adolescents: Researchers have found psychodynamic treatment to be effective overall in reducing symptoms of psychopathological issues in children aged 6–18 years.
Experts report that psychodynamic therapy can also improve people’s lives by helping them:
- strengthen their self-understanding to break self-defeating cycles
- address issues with avoidance
- improve their understanding of relationship dynamics
One of the most intriguing benefits of psychodynamic therapy, according to multiple studies, is that they keep on coming.
What this means is that individuals who undergo this kind of treatment continue to show improvement months after they complete it.
Vs. other forms of therapy
Although there is variety in the results, most studies have found psychodynamic therapy to be roughly as effective as two of the most common other forms of therapy: cognitive behavioral therapy (CBT) and medication.
CBT
CBT is a popular form of therapy that focuses on helping people adopt healthier ways of thinking and acting by enhancing their awareness of their choices.
Medication
Antidepressants and other medications have proven effective in treating depression and other mental health conditions.
Anyone who thinks that they may be experiencing a mental health condition should speak to a doctor to determine which type of antidepressant is most suitable for them.
Limitations
Although psychodynamic therapy can be an effective form of treatment for many mental health conditions, the researchers behind one report found that it may be less effective for the following conditions:
- post-traumatic stress disorder (PTSD)
- obsessive-compulsive disorder
- drug addiction
- psychosis
Psychodynamic therapy can still be effective for PTSD in some cases, though there is no strong evidence for this.
That said, this same report points out that results from many of the studies into various treatments for mental health conditions tend to lean toward the author’s “theoretical orientation,” or to coincide with the author’s affiliation.
Therefore, the researchers call for more systematic evidence around these treatments. They also highlight the fact that the effectiveness of psychodynamic treatment can greatly depend on the psychiatrist themselves.
Overall, it is clear that more studies into various forms of psychotherapy are necessary. This will help determine which type might be best suited for which individuals and which psychiatric conditions.
Summary
Psychodynamic therapy is a form of talking therapy that has proven effective in helping people dealing with depression, anxiety, pain, and relationship issues.
This treatment approach helps people see what is behind their problems by giving them a better understanding of their unconscious feelings, thoughts, and past experiences.
Developing these psychological skills helps people make better choices and feel better in the long-term.
Psychodynamic psychotherapy has been beleaguered in recent times. Accusations that it is based on outdated principles of psychoanalysis, that it lacks an empirical research base and that its emphasis on longer-term treatments by highly trained professionals makes it less cost-effective than other psychological treatments have contributed to the dismantling of psychodynamic psychotherapy services within the National Health Service (NHS) in favour of more ‘evidence-based’ interventions. Although the economic recession has been a challenge to all mental health services forced to make financial savings, reports suggest that psychodynamic psychotherapy provision within the public health sector has been disproportionately reduced compared with other treatment modalities (British Psychoanalytic Council 2013).
In this article I will outline recent developments in the field of psychodynamic psychotherapy research that go some way in refuting these criticisms. Contrary to the beliefs of some detractors of psychodynamic psychotherapy, there is now a convincing body of empirical evidence from well-designed outcome studies to support its efficacy. Moreover, process–outcome research linking specific psychodynamic interventions to therapeutic outcomes within a theoretical framework based on attachment has facilitated better understanding of the processes of change and enabled therapeutic technique to be adapted and refined, with the development of tailored psychodynamic psychotherapies for specific conditions.
What is psychodynamic psychotherapy?
Psychodynamic psychotherapy has its historical origins in Freud’s work and is based on the fundamental principles of psychoanalysis. These include the dynamic unconscious, transference, countertransference, resistance, defence, psychic determinism (the notion that our thoughts and actions are determined by unconscious forces and have symbolic meaning), and a developmental perspective, in which childhood experiences are seen as critical in shaping the adult personality. Although the terms ‘psychoanalytic psychotherapy’ and ‘psychodynamic psychotherapy’ are often used interchangeably, psychodynamic psychotherapy may be viewed as encompassing a broader perspective which includes the ‘relational’, i.e. the interpersonal, intersubjective and embodied experience of both the social world and the internal world, in which representations are built up over time and reflect dispositions that arise from innate vulnerability and early childhood experience. It also refers to the dynamic nature of both the internal and external worlds in that they shift and change in the context of social relationships and group settings experienced over a lifetime (Reference Yakeley and AdsheadYakeley 2013).
Free association
Traditional psychodynamic psychotherapy utilises techniques derived from psychoanalysis, but sessions are less frequent, provided once or twice a week over a shorter time span, and ‘face to face’, with the patient sitting up rather than lying on the couch as in psychoanalysis. In contrast to therapies where the therapist sets an agenda or actively structures the session, the patient is encouraged to say whatever is in their mind, following the psychoanalytic technique of ‘free association’. The psychotherapist’s task is to discover the unconscious themes that underlie the patient’s discourse via the patient’s slips of the tongue, associative links and resistances to speaking about certain topics that the patient is unaware of. The psychotherapist intervenes in the form of verbal communications, which can be categorised along a spectrum from the more supportive or empathic, to more challenging and interpretative as the therapy progresses.
Interpretative and supportive interventions
Interpretative interventions enhance the patient’s insight about repetitive conflicts sustaining their problems (Reference GabbardGabbard 2004), and offer a new formulation of unconscious meaning and motivation for the patient. ‘Transference interpretations’, focusing on the relationship between therapist and patient in the ‘here and now’ or affective interchange of the session, are often viewed by contemporary therapists as the most mutative interventions. In practice, the therapist adopts a flexible approach so that any session may include a combination of supportive and interpretative interventions according to the patient’s need and mental state at the time.
The countertransference
Psychodynamic psychotherapists also pay special attention to the therapist’s countertransference, that is, the feelings and emotional reactions that the therapist has towards the patient. These can be a source of useful information about the patient and their internal object relations, which determine their pattern of relating to others.
Core features of contemporary psychodynamic psychotherapy
Although the concepts and techniques of psychodynamic psychotherapy have evolved considerably since Freud and have led to the development of a range of specific psychodynamic therapeutic modalities for different conditions, core features of contemporary psychodynamic psychotherapy may be distinguished that differentiate it from other therapies such as cognitive–behavioural therapy (CBT). Reference Blagys and HilsenrothBlagys & Hilsenroth (2000) conducted a comprehensive literature search to identify empirical studies comparing manualised psychotherapy technique with that of manualised CBT. From empirical examination of recordings and transcripts of actual sessions they identified seven distinctive features concerning process and technique that reliably distinguished psychodynamic psychotherapy from other therapies determined (Box 1).
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• Focus on affect and expression of emotion
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• Exploring attempts to avoid distressing thoughts and feelings (defence and resistance)
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• Identifying recurring themes and patterns
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• Discussion of past experience (developmental process)
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• Focus on interpersonal relations
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• Focus on the therapy relationship (including transference)
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• Exploration of wishes and fantasies
(Reference Blagys and HilsenrothBlagys 2000)
Specific psychodynamic therapeutic modalities
A number of distinct psychodynamic psychotherapies or modalities have evolved which combine elements from other approaches, including the interpersonal, humanistic and cognitive traditions. These therapies have usually been developed and tailored for a specific disorder, such as depression or borderline personality disorder, but subsequently generalised to treat a wider range of conditions. They tend to be time-limited, have a clear theoretical basis and promote modifications of specific techniques, which are defined and illustrated in manuals. Such manualisation is helpful in communicating and disseminating what exactly occurs in the therapy under question, but is also necessary to ensure consistent training, interrater reliability and adherence to the model in outcome studies of treatment efficacy. Such studies have significantly contributed to the evidence base for psychodynamic psychotherapy in general (see below).
Table 1 lists the main modalities of modified psychodynamic therapies that have been developed and are available to at least some extent within the NHS and public health sector in the UK. Most of these therapies are only available in specialised mental health or psychological services, but dynamic interpersonal therapy is available as one of the brief psychotherapies provided nationally as part of the Increasing Access to Psychological Therapies (IAPT) programme introduced by the Department of Health in 2007 (Department of Health 2007).
The research challenges for psychodynamic psychotherapy
The limitations of the empirical base for psychodynamic psychotherapy have been well rehearsed. First, the psychoanalytic community as a whole has been historically disinterested or resistant to the value of research, which has resulted in the critical scientific evaluation of psychodynamic treatments lagging behind the evaluation of other forms of psychiatric and psychological interventions (Reference Gerber, Kocsis and MilordGerber 2010). This resistance may be due to a variety of reasons, including suspicion of research methods such as manualisation of treatments, randomisation of patients or recording of sessions; viewing narrowly defined trial criteria and research conditions as non-representative of clinical practice (i.e. the gap between clinical efficacy and effectiveness); and a reluctance to give up cherished beliefs about theory and technique based on individual experience and clinical lore rather than a willingness to take on board empirical findings which may challenge established practice.
Second, many of the trials of psychodynamic psychotherapy that have been conducted have lacked sufficient methodological rigour, for example, in unclear definitions of patient characteristics or treatment methods, inadequate sample sizes, poor monitoring of adherence to the treatment model and interrater reliability, and less than optimal control conditions in which treatment as usual is used instead of an alternative potential active treatment. The number of randomised controlled trials (RCTs) of psychodynamic psychotherapy is small compared with those that have been carried out in the evaluation of other forms of psychotherapy, particularly CBT.
Third, many of these studies have focused on brief psychodynamic treatments, whereas many psychodynamic clinicians are interested in elucidating the mechanisms of change of longer-term treatments which aim at deeper structural changes in the patient’s personality organisation rather than solely symptom improvement.
Outcome studies of psychodynamic psychotherapy
Meta-analyses and effect sizes
Despite these challenges in conducting methodologically robust research in the field, in the past two decades there has been an increasing number of high-quality RCTs in psychodynamic psychotherapy. Reference ShedlerShedler (2010) has highlighted the importance of several key meta-analyses published in high-impact journals, which pool the results of these studies and demonstrate that effect sizes (Box 2) for psychodynamic psychotherapies are as large as those reported for other treatments that have been actively promoted as ‘evidence-based’, such as CBT.
Efficacy measures how well an intervention or treatment works in clinical trials designed to show internal validity so that causal inferences may be made.
Clinical effectiveness is the extent to which an intervention or treatment improves the outcome for patients in everyday clinical practice. There is often a gap between efficacy and effectiveness.
Meta-analysis is a widely accepted method used in medicine and psychology to strengthen the evidence about treatment efficacy. It refers to the statistical analysis of a collection of results for the purpose of summarising and integrating the findings of independent studies of a specific treatment, that in themselves are too small or limited in scope, to come to a conclusion about treatment efficacy.
Effect size refers to the difference between treatment and control groups, expressed in standard deviation units. An effect size of 1.0 indicates that the average patient receiving the treatment under consideration is one standard deviation healthier on the normal distribution than the average patient receiving no treatment. An effect size of 0.8 is considered a large effect, 0.5 is considered moderate, 0.2 is small.
For example, a meta-analysis published by the Cochrane Library (Reference Abbass, Hancock and HendersonAbbass 2006) reviewed 23 RCTs comparing short-term psychodynamic psychotherapy for common mental disorders against minimal treatment and non-treatment control interventions, yielding an overall effect size of 0.97 for general symptom improvement, which increased to 1.51 when the patients were assessed at 9-month follow-up. Another meta-analysis, reported in Archives of General Psychiatry, of 17 high-quality RCTs reported an effect size of 1.17 for short-term psychodynamic psychotherapy compared with control interventions (Reference Leichsenring, Rabung and LeibingLeichsenring 2004). Two more recent meta-analyses, published in the JAMA (Reference Leichsenring and RabungLeichsenring 2008, Reference Leichsenring and Rabung2009) and the Harvard Review of Psychiatry (Reference de Maat, de Jonghe and Schoeversde Maat 2009), have examined the efficacy of long-term psychodynamic psychotherapy (1 year or more) for a range of DSM diagnoses and complex mental disorders. These found that the effect sizes for longer-term psychodynamic psychotherapy were not only significantly higher than those for the shorter-term therapies, but that they continued to increase from termination of treatment to long-term follow-up, especially for patients with severe personality pathology.
Outcomes for specific disorders
Many of the studies in these meta-analyses, however, included patients with a range of symptoms and conditions, rather than focusing on specific diagnostic categories. Other recent meta-analyses have focused on the evidence base for psychodynamic psychotherapy for specific disorders.
Thus, Reference Abbass, Kisely and KroenkeAbbass et al (2009), in a meta-analysis of 23 studies examining the efficacy of short-term psychodynamic psychotherapy for somatic disorders, reported an effect size of 0.69 for improvement in general psychiatric symptoms and 0.59 for improvement in somatic symptoms.
A meta-analysis looking at the efficacy of both psychodynamic psychotherapy and CBT for personality disorder published in the American Journal of Psychiatry (Reference Leichsenring and LeibingLeichsenring 2003) showed pre- to post-treatment effect sizes of 1.46 for psychodynamic psychotherapy and 1.0 for CBT.
In a very recent publication, Reference Leichsenring and KleinLeichsenring & Klein (2014) review the empirical evidence for psychodynamic therapy for specific mental disorders in adults. They conducted a computerised search of MEDLINE, PsycINFO and Current Contents, as well as manual searches of articles and textbooks, and communication with authors and experts in the field. The search criteria identified all RCTs published between January 1970 and September 2013 that examined the efficacy of psychodynamic psychotherapy for specific mental disorders using treatment manuals and reliable and valid measures for diagnosis and outcome. Meta-analysis of the 47 RCTs that met these rigorous criteria showed that psychodynamic therapy is efficacious for a range of common mental disorders, including depressive disorders, anxiety disorders, somatoform disorders, personality disorders, eating disorders, complicated grief, post-traumatic stress disorder and substance-related disorders.
The Dodo verdict
This accumulation of empirical evidence convincingly demonstrates that psychodynamic psychotherapy is not inferior in efficacy to other psychological treatments. Moreover, it shows that the benefits of psychodynamic psychotherapy may be long lasting and extend beyond symptom remission. However, perhaps paradoxically, the methodological superiority of more recent trials, which have included active treatments as controls, has highlighted the well-known ‘Dodo verdict’ (Reference RosenzweigRosenzweig 1936; Reference Luborsky, Singer and LuborskyLuborsky 1975), based on the conclusion of the dodo in Alice in Wonderland that ‘Everybody has won and all must have prizes’. This refers to the consistent finding in psychotherapy research of the outcome equivalence of different therapies, in that no specific therapy is shown to have greater efficacy than any other.
This finding is usually interpreted as being due to ‘common factors’, i.e. techniques and mechanisms common to different therapies which constitute the agents of change and are frequently subsumed under the umbrella of the ‘therapeutic alliance’. However, the dodo verdict here might also be due to a failure to measure real differences that exist between different therapies but have eluded detection because our measures are inadequate. In the case of psychodynamic psychotherapy, there may be a fundamental mismatch between what outcome studies tend to measure in improvement or alleviation of symptoms and what psychodynamic psychotherapy aims to achieve in going beyond symptom remission to change deeper personality structures and capacities, enabling the patient to live with greater freedom and possibility (Reference ShedlerShedler 2010).
Implications for practice
Psychodynamic psychotherapists themselves, in their failure to fully embrace an evidence-based approach and be open to adaptation of their concepts and techniques in the light of empirical findings, must bear some responsibility for the perception that the therapy they practise is ineffective. Moreover, the expanding array of different therapeutic modalities risks being satirised as a collection of competing brands promoted by their charismatic inventors, which may obscure more serious and collaborative efforts to find common therapeutic techniques and factors, as well as factors more specific to particular psychic processes or pathological conditions.
Nevertheless, the scientific evidence summarised here should dismantle the myth that psychodynamic approaches lack empirical support, a myth that may reflect selective dissemination of robust research findings (Reference ShedlerShedler 2010). These findings provide evidence to show that psychodynamic treatments are effective for a wide range of mental disorders, and challenge the current trend for a psychodynamic approach to be solely located in specialised personality disorder services rather than available in generic mental health or psychological services treating more common mental disorders such as anxiety and depression. This evidence also underscores the importance of experience in psychodynamic psychotherapy as part of the training of all psychiatrists.
It is therefore encouraging that dynamic interpersonal therapy (DIT) (Reference Lemma, Target and FonagyLemma 2012), a simple short-term individual psychodynamic therapy for mood disorders, has been rolled out nationally within IAPT services as the brief psychodynamic model for the treatment of depression. The DIT treatment protocol emerged from the work of an expert reference group on clinical competencies which identified and distilled the key therapeutic components drawn from manualised psychoanalytic/dynamic therapies with the strongest empirical evidence for efficacy, and is therefore an excellent example of an evidence-based, collaboratively designed and tested psychodynamic intervention.
However, the provision of longer-term psychodynamic therapies is becoming increasingly scarce within the public sector, despite evidence that they may provide enduring positive outcomes in both symptom reduction and personality change. It remains our responsibility to ensure that such evidence is fairly and openly communicated to commissioners and policy makers so that psychodynamic psychotherapies retain a legitimate place within the choice of evidence-based treatments available for our patients.
MCQs
Select the single best option for each question stem
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1Which of the following features is not characteristic of contemporary psychodynamic psychotherapy technique?
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a focus on emotion and affect
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b exploration of significant events in childhood
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c transference interpretations
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d setting goals
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e use of countertransference.
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2Which of the following is not true regarding outcome studies of psychodynamic psychotherapy?
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a effect sizes for psychodynamic psychotherapy are as large as those reported for cognitive–behavioural therapy
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b better designed studies include manualisation of the treatment intervention
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c process–outcome studies show that the efficacy of psychodynamic psychotherapy is most likely due to ‘common factors’
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d the number of RCTs of psychodynamic psychotherapy is much smaller than that for cognitive–behavioural therapy
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e effect sizes for longer-term psychodynamic psychotherapy are higher than those for the shorter-term therapies.
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3Which therapist techniques are associated with positive outcome?
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a early repair of negative transference experiences
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b high rate of transference interpretations
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c early interpretation of unconscious fantasies
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d self-disclosure
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e early fostering of positive therapeutic alliance.
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4Which of the following is not true of attachment theory?
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a attachment theory explicitly underpins cognitive analytic therapy
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b the patients of therapists who are measured as having secure attachments on the AAI tend to have better outcomes
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c attachment research has provided empirical evidence validating the concept of transference
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d therapeutic outcome can be measured by observing changes in the patient’s attachment status
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e attachment theory may provide a framework for non-psychodynamic treatments.
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5Available evidence suggests that best therapeutic practice involves:
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a proliferation of new therapeutic modalities
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b cutting traditional psychodynamic psychotherapy services
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c receiving treatment from a warm and empathic therapist
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d shorter-term therapies
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e the therapist’s self-disclosure.
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