Article on the effectiveness of Psychodynamic Psychotherapy Scientific American
Getting to Know Me
By Jonathan Shedler
Jeffrey (not his real name) came to treatment complaining of depression, anxiety and trouble getting along with others. Colleagues in the engineer- ing department where he worked complained he was “not a team player,” and his wife saw him as distant and hypercritical. Beyond this, he carried
with him a constant feeling of dread, no matter how well things were going. I agreed with Jeffrey that his dread seemed out of proportion to anything that was
Psychodynamic therapy has been caricatured as navel-gazing, but studies show powerful benefits
￼actually happening in his life and suggested it might be in proportion to something that was not imme- diately obvious to either of us. I asked him to tell me about himself. Among other things, I learned that his father had been an alcoholic who would attack without warning, driving Jeffrey to leave home at an early age.
It was one thing for Jeffrey to tell me of his unhap- py past, but soon this old relationship pattern came to life, as Jeffrey began responding to me as if I were an unpredictable, angry adversary. Consciously, he saw me as an ally with his welfare at heart. Yet he seemed constantly poised to “protect” himself by fending me off, as though he expected I would use what he said against him. His responses were so ingrained that he did not recognize them as out of the ordinary.
I did not regard Jeffrey’s attitude as an obstacle. On the contrary, reliving this relationship pattern with me was central to his recovery. I would fre- quently point out that Jeffrey was responding as if I were an enemy, and he gradually began to notice, too. In those moments, his thoughts and feelings of- ten ran to his father. I helped him connect the dots:
“When you turned to your father for help, he humil- iated you. Perhaps a part of you expects the same treatment from me.” Jeffrey began to connect with old emotions, speaking of the terror he had felt dur- ing his father’s outbursts. His sense of dread began to make sense—and then slowly dissipated. Jeffrey gradually recognized—not just intellectually but in a way that truly sank in emotionally—that the beat- ings were over. The world began to feel less danger- ous, and he started letting others “in” in ways he nev- er had before. His work relationships improved, and he and his wife became closer than either had previ- ously thought possible. He began to enjoy his life.
The treatment that helped Jeffrey, known as psychoanalytic or psychodynamic therapy, traces its heritage to psychoanalysis in the famous drap- ery-hung study of Sigmund Freud in Vienna. But psychodynamic therapy as practiced today bears little resemblance to the world of Oedipal conflict, penis envy and castration anxiety that has been so lampooned in New Yorker cartoons and Woody Al- len films. Patients do not lie on a couch free-associ- ating as an inscrutable therapist silently looks on,
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The term “psycho- analysis” conjures images of Freud’s couch (top left), but contemporary psy- chodynamic therapy (top right) is not the psychoanalysis of yesteryear. It has evolved new meth- ods and may be the best way to tackle recurring problems.
nor must they commit to four or five sessions a week for years on end.
Freud’s legacy is not a specific theory but rather a sensibility: an appreciation of the depth and com- plexity of mental life and a recognition that we do not fully know ourselves. It is also an acknowledg- ment that what we do not know is nonetheless man- ifested in our relationships and can cause suffer- ing— or, in a therapy relationship, can be examined and potentially reworked.
But the modernization of psychodynamic ther- apy has gone largely unnoticed. For years psycho- analysts did little to disseminate ideas outside their own circles, and this self-imposed exile from aca- demic research left a void, into which was born an alternative: cognitive-behavior therapy (CBT). In this newer approach, therapists focused on specific problems and readily observable thoughts and be- haviors, rather than embracing the messy, emotion- al complexity of people’s mental lives.
Over the past decades psychologists have con- ducted thousands of studies that showed the effec- tiveness of cognitive-behavior therapy. The ap- proach initially seemed to promise quick cures—a promise that dovetailed with the interests of health insurers, who wanted to pay as little as possible for mental health care. CBT was portrayed as the gold standard, and many practitioners wrote off psycho- dynamic therapy as antiquated and unscientific. But as I recently showed in a research review published in American Psychologist, the prestigious flagship journal of the American Psychological Association, psychodynamic therapy has been not only misun- derstood but vastly underestimated.
The reality is that psychodynamic therapy has proved its effectiveness in rigorous controlled stud- ies. Not only that, but research shows that people who receive psychodynamic therapy actually con- tinue to improve after therapy ends—presumably be- cause the understanding they gain is global, not tar- geted to encapsulated, one-time problems. Thanks to misinformation and entrenched interests, howev- er, much of this research has been overlooked.
There is no end of cartoons spoofing psycho- analysis: Santa Claus on the couch confessing, “I don’t believe in myself anymore,” or a house on a couch telling the dispassionate analyst, “My bubble burst!” But cartoons are not reality. Psychodynamic therapy is practical, and it helps free people from suffering. So what is it that makes psychodynamic therapy so powerful? By analyzing tapes from hun- dreds of hours of actual therapy sessions, research- ers have identified seven distinctive features.
Exploring emotions. Psychodynamic therapists encourage patients to explore their full emotional range—including contradictory feelings, feelings that
The Value of Self-Examination
Psychodynamic therapy is not the psychoanalysis of Freud’s 1>>day: patients sit on a chair instead of lying on a couch, have sessions once or twice—not four or five times—a week, and may
finish in months as opposed to years.
Though often dismissed as too open-ended to solve spe- 2>>cific problems, psychodynamic therapy alleviates symp-
toms as effectively as newer, more targeted therapies.
People who undergo psychodynamic therapy continue 3>>to make gains after the therapy ends, perhaps because it addresses underlying psychological patterns that affect many
areas of life.
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￼￼￼￼￼￼PETER APRAHAMIAN Corbis (left); JON BRADLEY Getty Images (right)
￼￼I kept encountering patients who had been shunted from
one “quick fix” treatment to another, with little lasting benefit.
are troubling or threatening, and feelings they may ini- tially be unable to express. A CBT practitioner might respond to emotional difficulty with homework as- signments and worksheets or seek to persuade pa- tients that irrational thinking has skewed their feel- ings. Psychodynamic therapists, in contrast, are like- ly to invite patients to explore their feelings further.
Examining avoidances. Efforts to avoid dis- tressing or threatening thoughts and feelings can be obvious, as when patients miss sessions or fall si- lent. They can also be subtle, as when people focus on facts and events to the exclusion of emotions or emphasize external circumstances instead of their own role in shaping events. Psychodynamic thera- pists encourage patients to examine why and how they avoid what is distressing.
Identifying recurring patterns. Sometimes peo- ple are acutely aware of painful or self-defeating patterns—like choosing romantic partners who are unavailable or sabotaging themselves when success is at hand—but feel unable to escape them. Some- times they need help to recognize the patterns.
Discussing past experience. Related to identi- fying recurring patterns is the recognition that past experiences affect our experience of the present. By exploring how early experiences color present-day perceptions, psychodynamic therapists help pa- tients free themselves from the bonds of the past and live more fully in the present.
Focusing on relationships. Psychodynamic ther- apists recognize that mental health problems tend to be rooted in problematic relationship patterns. For example, some people do not express their emotion- al needs for fear of rejection and consequently cannot get them met—a recipe for depression vulnerability.
Examining the patient/therapist relationship.
In other therapies, patients’ emotional reactions to the therapist may be seen as distractions. In psycho- dynamic therapy, they are the heart of the work. This is because a person’s habitual way of being in relationships inevitably emerges in the therapy rela- tionship as well—psychodynamic therapists call this phenomenon “transference.” For example, a person who has trouble with intimacy may struggle to open up to the therapist, and one who fears rejec- tion may strive to be an especially “good” patient. Recognizing transference offers patients a unique opportunity to rework old patterns.
Valuing fantasy life. In contrast to CBT, in which therapists may follow a predetermined agen-
da, psychodynamic therapists encourage patients to speak freely about whatever is on their minds. Fan- tasies, dreams and daydreams provide a rich source of information about their hopes, desires and fears.
All successful therapies must relieve symptoms such as anxiety or depression. But psychodynamic treatment aims for more: it focuses on building core psychological strengths—such as the capacity to have more fulfilling relationships, to make more ef- fective use of one’s abilities, and to face life’s chal- lenges with greater freedom and flexibility.
I delved into the research supporting psychody- namic therapy because I kept encountering patients who had been shunted from one “quick fix” treat- ment to another, with little or no lasting benefit. In my experience, the brief therapies promoted as “em- pirically supported” were often failing, despite claims that their benefits are scientifically proven.
Cognitive-behavior therapists may also incor- porate some of the seven features described above, but not to the same extent as psychodynamic thera- pists. Instead of encouraging patients to speak free- ly, they may teach exercises or skills. Instead of ex- ploring feelings in depth, they are more likely to fo- cus on thoughts. Instead of examining how past
￼￼￼Different Ways to Feel Better
Psychodynamic therapy may be more effective than other treatments promoted as “evidence based.” One major study found an “effect size”—a measure of treatment benefit—of 0.97. For CBT, 0.68 is a typical effect size. For antidepressant medication, the average effect size is 0.31.
Anti- Cognitive- Psychodynamic depressants behavior therapy
JONATHAN SHEDLER is an associate professor of psychiatry at the Univer- sity of Colorado School of Medicine and director of psychology at the Uni- versity of Colorado Hospital Outpatient Psychiatry Service.
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and 0.8 large, so the benefit Abbass found is huge. Seven other meta-analyses, collectively including 160 studies and a wide range of mental health conditions, also showed substantial benefits for psychodynamic therapy. These studies included both randomized controlled trials—in which groups of patients who receive treatment are compared with groups who do not—as well as studies that evaluated the same pa- tients before and after treatment.
In contrast, a recent (and fairly representative) meta-analysis of 33 rigorously conducted studies of cognitive-behavior therapy for depression and anx- iety showed an effect size of 0.68.
Even more intriguing, Abbass’s meta-analysis also looked at patient assessments conducted nine months or more after therapy ended. The effect size grew from 0.97 to 1.51. Now, this is astonishing. In fact, six sep- arate meta-analyses reported data from follow-up as- sessments, and all showed benefits that kept growing after treatment ended. This continued improvement suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change.
Therapy is not a pill you swallow to feel better; it is a delicate and complex process that reflects the patient’s and therapist’s unique personal qualities
￼More Than Just Talk
How the two major kinds of therapy differ
The Therapist’s Own Therapy
What Happens in Treatment
Exploratory: The therapist facilitates self-examination and self-awareness
￼Educational: The therapist provides information, teaches skills, assigns homework
￼The therapist treats the whole person
￼The therapist treats the symptoms or diagnosis
￼Therapy emphasizes the examined life
￼￼Therapy emphasizes measurable results
￼“Success” means not only symptom improvement but a richer, freer life
￼“Success” is often defined in terms of measurable outcomes such as questionnaire scores or frequency of behaviors
￼￼￼￼Essential to deepen understanding of mental life and avoid playing out the therapist’s own emotional issues with patients
￼Irrelevant unless the therapist has a mental illness
￼￼The assumption is that negative feelings have their own origins, independent of logic; feelings are accepted and worked with on their own terms
￼The assumption is that negative feelings are caused by “irrational” thoughts or beliefs; therapy aims at changing beliefs
￼The patient is encouraged to follow thoughts and feelings where they lead
￼The therapist may direct the session or follow a preset agenda
￼Considers the relationship between past and present
￼￼Emphasizes present-day situations
￼The patient’s emotional reactions to the therapist are viewed as opportunities to rework problematic relationship patterns
￼The patient’s emotional reactions to the therapist may be viewed as distractions or interferences
￼￼￼and present are interrelated, they are more likely to focus on current events. These approaches often do not address root problems, so patients may feel bet- ter temporarily, then continue replaying patterns that cause suffering.
When I was preparing my American Psycholo- gist paper, I was amazed by how strong the scientific evidence was in support of psychodynamic therapy. One of the most rigorous studies I described in my paper was led by psychologist Allan Abbass of Dal- housie University in Nova Scotia and published in 2006 in the prestigious Cochrane Library. Abbass examined the effectiveness of psychodynamic treat- ments that lasted for fewer than 40 sessions. His team compiled the results of 23 randomized con- trolled trials—the kind of carefully orchestrated, rig- orous study that medical researchers use to test new drugs. These trials involved 1,431 patients who suf- fered from depression, anxiety, stress-related physi- cal ailments and other psychological problems.
This kind of investigation is called a meta-anal- ysis because it compiles the findings of numerous other studies. Abbass’s meta-analysis found an “ef- fect size” of 0.97 for overall psychiatric improve- ment. What does that mean? Effect size measures the amount of treatment benefit. In this type of study, an effect size of 0.2 is considered small, 0.5 moderate
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CORBIS (left); AGE FOTOSTOCK (right)
Psychodynamic thera- pists identify recurring relationship themes and patterns. For example, a woman who felt ignored as
a child (far left) may find herself having similar feelings in adulthood (left). Psy- chodynamic therapy can help free her from old patterns.
and interactions. The relationship between thera- pist and patient—what therapists call the “working alliance”—is critical to success.
In several 1996 studies Pennsylvania State Uni- versity psychologist Louis Castonguay and his asso- ciates found that depressed patients improved more when the working alliance was strong and when therapy put patients on a trajectory of deepening self-examination that led to awareness of previously unconscious feelings and meanings—a core princi- ple of psychodynamic therapy.
In contrast, attempting to change negative thoughts—a foundational feature of CBT—actually predicted worse results.
And in a study that at this writing was in press in the journal Psychotherapy: Research, Theory, Prac- tice, and Training, leading psychotherapists and re- searchers teamed up to ask: What happens in thera- py that helps or hinders progress? Over an 18-month period, patients and therapists separately filled out cards after each session, describing memorable inter- actions. According to therapists and patients alike, the most helpful interventions were those that yield- ed emotional, not just intellectual, insight.
Of particular note—given the field’s knee-jerk approbation of cognitive-behavior therapy—is re- search conducted in the 1990s by the late psycholo- gist Enrico Jones of the University of California, Berkeley. His team analyzed recordings of hundreds of therapy sessions, both psychodynamic and CBT. They found that the more the therapists drew on
key psychodynamic principles such as addressing patients’ avoidances or defenses, exploring emo- tions and fantasies, identifying recurring themes, and discussing the therapy relationship, the better patients fared— in both psychodynamic and cogni- tive-behavior therapy. In contrast, the use of bed- rock CBT methods such as teaching skills and strat- egies or assigning homework showed no benefits.
In other words, when CBT was successful, it was largely because therapists departed from their official playbook and did the kinds of things psy- chodynamic therapists do.
Ultimately, there are basic truths of human psy- chology that most people understand intuitively. We do not fully know ourselves; the things we do not know can cause suffering; and there is benefit in self-awareness.
Psychodynamic therapy is based on these truths and has demonstrated its benefits scientifically. It’s time for academic researchers to examine their re- sistance to the truth. M
◆ Schopenhauer’s Porcupines: Intimacy and Its Dilemmas. Deborah Luepnitz. Basic Books, 2002.
◆ Psychoanalytic Psychotherapy: A Practitioner’s Guide. Nancy McWil- liams. Guilford Press, 2004.
◆ The Efficacy of Psychodynamic Psychotherapy. J. Shedler in American Psychologist, Vol. 65, No. 2, pages 98–109; February/March 2010.
◆ That Was Then, This Is Now: An Introduction to Contemporary Psycho- dynamic Therapy. Jonathan Shedler. http://psychsystems.net/ shedler.html
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