A Recent article in The American Psychologist looks
at the efficacy of psychodynamic psychotherapy:
The article can be found here:
www.apa.org/pubs/journals/releases/amp-65-2-shedler.pdf
The Efficacy of Psychodynamic
Psychotherapy
Jonathan Shedler University of Colorado Denver School
of Medicine
Empirical evidence supports the efficacy of
psychodynamic
therapy. Effect sizes for psychodynamic therapy are
as
large as those reported for other therapies that have
been
actively promoted as “empirically supported” and
“evi-
dence based.” In addition, patients who receive
psychody-
namic therapy maintain therapeutic gains and appear
to
continue to improve after treatment ends. Finally,
nonpsy-
chodynamic therapies may be effective in part because
the
more skilled practitioners utilize techniques that
have long
been central to psychodynamic theory and practice.
The
perception that psychodynamic approaches lack
empirical
support does not accord with available scientific
evidence
and may reflect selective dissemination of research
find-
ings.
Keywords: psychotherapy outcome, psychotherapy
process, psychoanalysis, psychodynamic therapy, meta-
analysis
T
here is a belief in some quarters that psychodynamic
concepts and treatments lack empirical support or
that scientific evidence shows that other forms of
treatment are more effective. The belief appears to
have
taken on a life of its own. Academicians repeat it to
one
another, as do health care administrators, as do
health care
policymakers. With each repetition, its apparent
credibility
grows. At some point, there seems little need to
question or
revisit it because “everyone” knows it to be so.
The scientific evidence tells a different story:
Consid-
erable research supports the efficacy and
effectiveness of
psychodynamic therapy. The discrepancy between
percep-
tions and evidence may be due, in part, to biases in
the
dissemination of research findings. One potential
source of
bias is a lingering distaste in the mental health
professions
for past psychoanalytic arrogance and authority. In
decades
past, American psychoanalysis was dominated by a
hierar-
chical medical establishment that denied training to
non-
MDs and adopted a dismissive stance toward research.
This
stance did not win friends in academic circles. When
em-
pirical findings emerged that supported
nonpsychodynamic
treatments, many academicians greeted them
enthusiasti-
cally and were eager to discuss and disseminate them.
When empirical evidence supported psychodynamic con-
cepts and treatments, it was often overlooked.
This article brings together findings from several
em-
pirical literatures that bear on the efficacy of
psychody-
namic treatment. I first outline the distinctive
features of
psychodynamic therapy. I next review empirical
evidence
for the efficacy of psychodynamic treatment,
including
evidence that patients who receive psychodynamic
therapy
not only maintain therapeutic gains but continue to
improve
over time. Finally, I consider evidence that
nonpsychody-
namic therapies may be effective in part because the
more
skilled practitioners utilize interventions that have
long
been central to psychodynamic theory and practice.
Distinctive Features of
Psychodynamic Technique
Psychodynamic or psychoanalytic psychotherapy1 re-
fers to a range of treatments based on psychoanalytic
concepts and methods that involve less frequent
meetings
and may be considerably briefer than psychoanalysis
proper. Session frequency is typically once or twice
per
week, and the treatment may be either time limited or
open
ended. The essence of psychodynamic therapy is
exploring
those aspects of self that are not fully known,
especially as
they are manifested and potentially influenced in the
ther-
apy relationship.
Undergraduate textbooks too often equate psychoan-
alytic or psychodynamic therapies with some of the
more
outlandish and inaccessible speculations made by
Sigmund
Freud roughly a century ago, rarely presenting
mainstream
psychodynamic concepts as understood and practiced
to-
day. Such presentations, along with caricatured
depictions
in the popular media, have contributed to widespread
mis-
understanding of psychodynamic treatment (for
discussion
of how clinical psychoanalysis is represented and
misrep-
resented in undergraduate curricula, see Bornstein,
1988,
1995; Hansell, 2005; Redmond & Shulman, 2008). To
help
dispel possible myths and facilitate greater
understanding
of psychodynamic practice, in this section I review
core
features of contemporary psychodynamic technique.
Blagys and Hilsenroth (2000) conducted a search of
the PsycLit database to identify empirical studies
that com-
pared the process and technique of manualized
psychody-
namic therapy with that of manualized cognitive
behavioral
therapy (CBT). Seven features reliably distinguished
psy-
chodynamic therapy from other therapies, as
determined by
empirical examination of actual session recordings
and
I thank Mark Hilsenroth for his extensive
contributions to this article;
Marc Diener for providing some of the information
reported here; Robert
Feinstein, Glen Gabbard, Michael Karson, Kenneth
Levy, Nancy McWil-
liams, Robert Michels, George Stricker, and Robert
Wallerstein for their
comments on drafts of the article; and the 500-plus
members of the
Psychodynamic Research Listserv for their collective
wisdom and sup-
port.
Correspondence concerning this article should be
addressed
to Jonathan Shedler, Department of Psychiatry,
University of Colo-
rado Denver School of Medicine, Mail Stop A011-04,
13001 East 17th
Place, Aurora, CO 80045. E-mail: jonathan@shedler.com
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
transcripts (note that the features listed below
concern
process and technique only, not underlying principles
that
inform these techniques; for a discussion of concepts
and
principles, see Gabbard, 2004; McWilliams, 2004;
Shedler,
2006a):
1. Focus on affect and expression of emo-
tion. Psychodynamic therapy encourages exploration
and discussion of the full range of a patient’s
emotions. The
therapist helps the patient describe and put words to
feel-
ings, including contradictory feelings, feelings that
are
troubling or threatening, and feelings that the
patient may
not initially be able to recognize or acknowledge
(this
stands in contrast to a cognitive focus, where the
greater
emphasis is on thoughts and beliefs; Blagys &
Hilsenroth,
2002; Burum & Goldfried, 2007). There is also a
recogni-
tion that intellectual insight is not the same as
emotional
insight, which resonates at a deep level and leads to
change
(this is one reason why many intelligent and
psychologi-
cally minded people can explain the reasons for their
dif-
ficulties, yet their understanding does not help them
over-
come those difficulties).
2. Exploration of attempts to avoid dis-
tressing thoughts and feelings. People do a great
many things, knowingly and unknowingly, to avoid
aspects
of experience that are troubling. This avoidance (in
theo-
retical terms, defense and resistance) may take
coarse
forms, such as missing sessions, arriving late, or
being
evasive. It may take subtle forms that are difficult
to
recognize in ordinary social discourse, such as
subtle shifts
of topic when certain ideas arise, focusing on
incidental
aspects of an experience rather than on what is
psycholog-
ically meaningful, attending to facts and events to
the
exclusion of affect, focusing on external
circumstances
rather than one’s own role in shaping events, and so
on.
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
when success 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
relation between past and present, and the ways in
which
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
experience in order to live more fully in the
present.
5. Focus on interpersonal relations. Psy-
chodynamic therapy places heavy emphasis on patients’
relationships and interpersonal experience (in
theoretical
terms, object relations and attachment). Both
adaptive and
nonadaptive aspects of personality and self-concept
are
forged in the context of attachment relationships,
and psy-
chological difficulties often arise when problematic
inter-
personal patterns interfere with a person’s ability
to meet
emotional needs.
6. Focus on the therapy relationship. The
relationship between therapist and patient is itself
an im-
portant interpersonal relationship, one that can
become
deeply meaningful and emotionally charged. To the
extent
that there are repetitive themes in a person’s
relationships
and manner of interacting, these themes tend to
emerge in
some form in the therapy relationship. For example, a
person prone to distrust others may view the
therapist with
suspicion; a person who fears disapproval, rejection,
or
abandonment may fear rejection by the therapist,
whether
knowingly or unknowingly; a person who struggles with
anger and hostility may struggle with anger toward
the
therapist; and so on (these are relatively crude
examples;
the repetition of interpersonal themes in the therapy
rela-
tionship is often more complex and subtle than these
ex-
amples suggest). The recurrence of interpersonal
themes in
the therapy relationship (in theoretical terms,
transference
and countertransference) provides a unique
opportunity to
explore and rework them in vivo. The goal is greater
flexibility in interpersonal relationships and an
enhanced
capacity to meet interpersonal needs.
7. Exploration of fantasy life. In contrast to
other therapies in which the therapist may actively
structure
sessions or follow a predetermined agenda,
psychodynamic
Jonathan
Shedler
99February–March 2010
● American Psychologist
therapy encourages patients to speak freely about
whatever
is on their minds. When patients do this (and most
patients
require considerable help from the therapist before
they can
truly speak freely), their thoughts naturally range
over
many areas of mental life, including desires, fears,
fanta-
sies, dreams, and daydreams (which in many cases the
patient has not previously attempted to put into
words). All
of this material is a rich source of information
about how
the person views self and others, interprets and
makes
sense of experience, avoids aspects of experience, or
inter-
feres with a potential capacity to find greater
enjoyment
and meaning in life.
The last sentence hints at a larger goal that is
implicit
in all of the others: The goals of psychodynamic
therapy
include, but extend beyond, symptom remission.
Success-
ful treatment should not only relieve symptoms (i.e.,
get rid
of something) but also foster the positive presence
of
psychological capacities and resources. Depending on
the
person and the circumstances, these might include the
capacity to have more fulfilling relationships, make
more
effective use of one’s talents and abilities,
maintain a
realistically based sense of self-esteem, tolerate a
wider
range of affect, have more satisfying sexual
experiences,
understand self and others in more nuanced and
sophisti-
cated ways, and face life’s challenges with greater
freedom
and flexibility. Such ends are pursued through a
process of
self-reflection, self-exploration, and self-discovery
that
takes place in the context of a safe and deeply
authentic
relationship between therapist and patient. (For a
jargon-
free introduction to contemporary psychodynamic
thought,
see That Was Then, This Is Now: Psychoanalytic
Psycho-
therapy for the Rest of Us [Shedler, 2006a, which is
freely
available for download at
http://psychsystems.net/shedler.
html]).
How Effective Is Psychotherapy in
General?
In psychology and in medicine more generally,
meta-anal-
ysis is a widely accepted method for summarizing and
synthesizing the findings of independent studies
(Lipsey &
Wilson, 2001; Rosenthal, 1991; Rosenthal &
DiMatteo,
2001). Meta-analysis makes the results of different
studies
comparable by converting findings into a common
metric,
allowing findings to be aggregated or pooled across
studies.
A widely used metric is effect size, which is the
difference
between treatment and control groups, expressed in
stan-
dard deviation units.2 An effect size of 1.0 means
that the
average treated patient is one standard deviation
healthier
on the normal distribution or bell curve than the
average
untreated patient. An effect size of 0.8 is
considered a large
effect in psychological and medical research, an
effect size
of 0.5 is considered a moderate effect, and an effect
size of
0.2 is considered a small effect (Cohen, 1988).
The first major meta-analysis of psychotherapy out-
come studies included 475 studies and yielded an
overall
effect size (various diagnoses and treatments) of
0.85 for
patients who received psychotherapy compared with un-
treated controls (Smith, Glass, & Miller, 1980).
Subsequent
meta-analyses have similarly supported the efficacy
of psy-
chotherapy. The influential review by Lipsey and
Wilson
(1993) tabulated results for 18 meta-analyses
concerned
with general psychotherapy outcomes, which had a
median
effect size of 0.75. It also tabulated results for 23
meta-
analyses concerned with outcomes in CBT and behavior
modification, which had a median effect size of 0.62.
A
meta-analysis by Robinson, Berman, and Neimeyer
(1990)
summarized the findings of 37 psychotherapy studies
con-
cerned specifically with outcomes in the treatment of
de-
pression, which had an overall effect size of 0.73.
These are
relatively large effects. (For a review of
psychotherapy
efficacy and effectiveness research, see Lambert
& Ogles,
2004).
To provide some points of reference, it is
instructive
to consider effect sizes for antidepressant
medications. An
analysis of U.S. Food and Drug Adminstration (FDA)
databases (published and unpublished studies)
reported in
the New England Journal of Medicine found effect
sizes of
0.26 for fluoxetine (Prozac), 0.26 for sertraline
(Zoloft),
0.24 for citalopram (Celexa), 0.31 for escitalopram
(Lexa-
pro), and 0.30 for duloxetine (Cymbalta). The overall
mean
effect size for antidepressant medications approved
by the
FDA between 1987 and 2004 was 0.31 (Turner, Matthews,
Linardatos, Tell, & Rosenthal, 2008).3 A
meta-analysis
reported in the prestigious Cochrane Library
(Moncrieff,
Wessely, & Hardy, 2004) found an effect size of
0.17 for
tricyclic antidepressants compared with active
placebo (an
active placebo mimics the side effects of an
antidepressant
drug but is not itself an antidepressant).4 These are
rela-
tively small effects. Methodological differences
between
medication trials and psychotherapy trials are
sufficiently
great that effect sizes may not be directly
comparable, and
the findings should not be interpreted as conclusive
evi-
dence that psychotherapy is more effective. Effect
sizes for
antidepressant medications are reported to provide
refer-
ence points that will be familiar to many readers
(for more
comprehensive listings of effect size reference
points, see,
e.g., Lipsey & Wilson, 1993; Meyer et al., 2001).
2
This score, known as the standardized mean
difference, is used to
summarize the findings of randomized control trials.
More broadly, the
concept effect size may refer to any measure that
expresses the magnitude
of a research finding (Rosenthal & Rosnow, 2008).
3
The measure of effect size in this study was Hedges’
g (Hedges,
1982) rather than Cohen’s d (Cohen, 1988), which is
more commonly
reported. The two measures are based on slightly
different computa-
tional formulas, but in this case the choice of
formula would have
made no difference: “Because of the large sample size
(over 12,000),
there is no change in going from g to d; both values
are .31 to two
decimal places” (R. Rosenthal, personal communication
to Marc Die-
ner, January 2008).
4
Although antidepressant trials are intended to be
double-blind, the
blind is easily penetrated because the adverse side
effects of antidepres-
sant medications are physically discernible and
widely known. Study
participants and their doctors can therefore figure
out whether they are
receiving medication or placebo, and effects
attributed to medication may
be inflated by expectancy and demand effects. Use of
“active” placebos
better protects the blind, and the resulting effect
sizes are approximately
half as large as those otherwise reported.
100 February–March 2010
● American Psychologist
How Effective Is Psychodynamic
Therapy?
A recent and especially methodologically rigorous
meta-
analysis of psychodynamic therapy, published by the
Cochrane Library,5 included 23 randomized controlled
trials of 1,431 patients (Abbass, Hancock, Henderson,
&
Kisely, 2006). The studies compared patients with a
range of common mental disorders6 who received short-
term ( 40 hours) psychodynamic therapy with controls
(wait list, minimal treatment, or “treatment as
usual”)
and yielded an overall effect size of 0.97 for
general
symptom improvement. The effect size increased to
1.51
when the patients were assessed at long-term
follow-up
( 9 months posttreatment). In addition to change in
general symptoms, the meta-analysis reported an
effect
size of 0.81 for change in somatic symptoms, which
increased to 2.21 at long-term follow-up; an effect
size
of 1.08 for change in anxiety ratings, which
increased to
1.35 at follow-up; and an effect size of 0.59 for
change
in depressive symptoms, which increased to 0.98 at
follow-up.7 The consistent trend toward larger effect
sizes at follow-up suggests that psychodynamic
therapy
sets in motion psychological processes that lead to
on-
going change, even after therapy has ended.
A meta-analysis published in Archives of General Psy-
chiatry included 17 high-quality randomized
controlled trials
of short-term (average of 21 sessions) psychodynamic
therapy
and reported an effect size of 1.17 for psychodynamic
therapy
compared with controls (Leichsenring, Rabung, &
Leibing,
2004). The pretreatment to posttreatment effect size
was 1.39,
which increased to 1.57 at long-term follow-up, which
oc-
curred an average of 13 months posttreatment.
Translating
these effect sizes into percentage terms, the authors
noted that
patients treated with psychodynamic therapy were
“better off
with regard to their target problems than 92% of the
patients
before therapy” (Leichsenring et al., 2004, p. 1213).
A newly released meta-analysis examined the efficacy
of short-term psychodynamic therapy for somatic
disorders
(Abbass, Kisely, & Kroenke, 2009). It included 23
studies
involving 1,870 patients who suffered from a wide
range of
somatic conditions (e.g., dermatological,
neurological, car-
diovascular, respiratory, gastrointestinal,
musculoskeletal,
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.
Among studies that reported data on health care
utilization,
77.8% reported reductions in health care utilization
that
were due to psychodynamic therapy—a finding with po-
tentially enormous implications for health care
reform.
A meta-analysis reported in the American Journal of
Psychiatry examined the efficacy of both
psychodynamic
psychotherapy (14 studies) and CBT (11 studies) for
person-
ality disorders (Leichsenring & Leibing, 2003).
The meta-
analysis reported pretreatment to posttreatment
effect sizes
using the longest term follow-up available. For
psychody-
namic therapy (mean length of treatment was 37
weeks), the
mean follow-up period was 1.5 years and the
pretreatment to
posttreatment effect size was 1.46. For CBT (mean
length of
treatment was 16 weeks), the mean follow-up period
was 13
weeks and the effect size was 1.0. The authors
concluded that
both treatments demonstrated effectiveness. A more
recent
review of short-term (average of 30.7 sessions)
psychody-
namic therapy for personality disorders included data
from
seven randomized controlled trials (Messer &
Abbass, in
press). The study assessed outcome at the longest
follow-up
period available (an average of 18.9 months
posttreatment)
and reported effect sizes of 0.91 for general symptom
im-
provement (N 7 studies) and 0.97 for improvement in
interpersonal functioning (N 4 studies).
Two recent studies examined the efficacy of long-
term psychodynamic treatment. A meta-analysis re-
ported in the Journal of the American Medical Associ-
ation (Leichsenring & Rabung, 2008) compared
long-
term psychodynamic therapy ( 1 year or 50 sessions)
with shorter term therapies for the treatment of
complex
mental disorders (defined as multiple or chronic
mental
disorders, or personality disorders) and yielded an
effect
size of 1.8 for overall outcome.8 The pretreatment to
posttreatment effect size was 1.03 for overall
outcome,
which increased to 1.25 at long-term follow-up (p
.01), an average of 23 months posttreatment. Effect
sizes
increased from treatment completion to follow-up for
all
five outcome domains assessed in the study (overall
effectiveness, target problems, psychiatric symptoms,
personality functioning, and social functioning). A
sec-
ond meta-analysis, reported in the Harvard Review of
Psychiatry (de Maat, de Jonghe, Schoevers, &
Dekker,
2009), examined the effectiveness of long-term psy-
chodynamic therapy (average of 150 sessions) for
adult
outpatients with a range of diagnoses. For patients
with
mixed/moderate pathology, the pretreatment to
posttreat-
ment effect was 0.78 for general symptom improvement,
which increased to 0.94 at long-term follow-up, an
average of
3.2 years posttreatment. For patients with severe
personality
pathology, the pretreatment to posttreatment effect
was 0.94,
which increased to 1.02 at long-term follow-up, an
average of
5.2 years posttreatment.
These meta-analyses represent the most recent and
methodologically rigorous evaluations of psychody-
namic therapy. Especially noteworthy is the recurring
finding that the benefits of psychodynamic therapy
not only
5
More widely known in medicine than in psychology, the
Cochrane
Library was created to promote evidence based
practice and is considered
a leader in methodological rigor for meta-analysis.
6
These included nonpsychotic symptom and behavior
disorders
commonly seen in primary care and psychiatric
services, for example,
nonbipolar depressive disorders, anxiety disorders,
and somatoform dis-
orders, often mixed with interpersonal or personality
disorders (Abbass et
al., 2006).
7
The meta-analysis computed effect sizes in a variety
of ways. The
findings reported here are based on the single method
that seemed most
conceptually and statistically meaningful (in this
case, a random effects
model, with a single outlier excluded). See the
original source for more
fine-grained analyses (Abbass et al., 2006).
8
The atypical method used to compute this effect size
may provide
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,
Bassel, & Jewett, 2009).
101February–March 2010
● American Psychologist
endure but increase with time, a finding that has now
emerged from at least five independent meta-analyses
(Ab-
bass et al., 2006; Anderson & Lambert, 1995; de
Maat et
al., 2009; Leichsenring & Rabung, 2008;
Leichsenring et
al., 2004). In contrast, the benefits of other
(nonpsychody-
namic) empirically supported therapies tend to decay
over
time for the most common disorders (e.g., depression,
generalized anxiety; de Maat, Dekker, Schoevers,
& de
Jonghe, 2006; Gloaguen, Cottraux, Cucharet, &
Blackburn,
1998; Hollon et al., 2005; Westen, Novotny, &
Thompson-
Brenner, 2004).9
Table 1 summarizes the meta-analytic findings de-
scribed above and adds additional findings to provide
fur-
ther points of reference. Except as noted, effect
sizes listed
in the table are based on comparisons of treatment
and
control groups and reflect response at the completion
of
treatment (not long-term follow-up).
Studies supporting the efficacy of psychodynamic
ther-
apy span a range of conditions and populations.
Randomized
controlled trials support the efficacy of
psychodynamic ther-
apy for depression, anxiety, panic, somatoform
disorders,
eating disorders, substance-related disorders, and
personality
disorders (Leichsenring, 2005; Milrod et al., 2007).
Findings concerning personality disorders are partic-
ularly intriguing. A recent study of patients with
borderline
personality disorder (Clarkin, Levy, Lenzenweger,
& Kern-
berg, 2007) not only demonstrated treatment benefits
that
equaled or exceeded those of another evidence-based
treat-
ment, dialectical behavior therapy (Linehan, 1993),
but
9
The exceptions to this pattern are specific anxiety
conditions such as
panic disorder and simple phobia, for which
short-term, manualized treat-
ments do appear to have lasting benefits (Westen et
al., 2004).
Table 1
Illustrative Effect Sizes From Meta-Analyses of
Treatment Outcome Studies
Treatment type and reference Description Effect size
N of studies ormeta-analyses
General psychotherapy
Smith et al. (1980) Various therapies and disorders
0.85 475 studies
Lipsey & Wilson (1993) Various therapies and
disorders 0.75a 18 meta-analyses
Robinson et al. (1990) Various therapies for
depression 0.73 37 studies
CBT and related therapies
Lipsey & Wilson (1993) CBT and behavior therapy,
various disorders 0.62b 23 meta-analyses
Haby et al. (2006) CBT for depression, panic, and
generalized
anxiety 0.68 33 studies
Churchill et al. (2001) CBT for depression 1.0 20
studies
Cuijpers et al. (2007) Behavioral activation for
depression 0.87 16 studies
Öst (2008) Dialectical behavior therapy, primarily
for
borderline personality disorder 0.58 13 studies
Antidepressant medication
Turner et al. (2008) FDA-registered studies of
antidepressants
approved between 1987 and 2004 0.31 74 studies
Moncrieff et al. (2004) Tricyclic antidepressants
versus active placebo 0.17 9 studies
Psychodynamic therapy
Abbass et al. (2006) Various disorders, general
symptom improvement 0.97 12 studies
Leichsenring et al. (2004) Various disorders, change
in target problems 1.17 7 studies
Anderson & Lambert (1995) Various disorders and
outcomes 0.85 9 studies
Abbass et al. (2009) Somatic disorders, change in
general psychiatric
symptoms 0.69 8 studies
Messer & Abbass (in press) Personality disorders,
general symptom
improvement 0.91 7 studies
Leichsenring & Leibing (2003) Personality
disorders, pretreatment to
posttreatment 1.46
c
14 studies
Leichsenring & Rabung (2008) Long-term
psychodynamic therapy vs. shorter term
therapies for complex mental disorders, overall
outcome
1.8 7 studies
de Maat et al. (2009) Long-term psychoanalytic
therapy, pretreatment to
posttreatment 0.78
c
10 studies
a
Median effect size across 18 meta-analyses (from
Lipsey & Wilson, 1993, Table 1.1). b Median
effect size across 23 meta-analyses (from Lipsey
& Wilson, 1993,
Table 1.2). c Pretreatment to posttreatment
(within-group) comparison.
102 February–March 2010
● American Psychologist
also showed changes in underlying psychological
mecha-
nisms (intrapsychic processes) believed to mediate
symp-
tom change in borderline patients (specifically,
changes in
reflective function and attachment organization; Levy
et al.,
2006). These intrapsychic changes occurred in
patients
who received psychodynamic therapy but not in
patients
who received dialectical behavior therapy.
Such intrapsychic changes may account for long-term
treatment benefits. A newly released study showed
endur-
ing benefits of psychodynamic therapy five years
after
treatment completion (and eight years after treatment
ini-
tiation). At five-year follow-up, 87% of patients who
re-
ceived “treatment as usual” continued to meet
diagnostic
criteria for borderline personality disorder,
compared with
13% of patients who received psychodynamic therapy
(Bateman & Fonagy, 2008). No other treatment for
person-
ality pathology has shown such enduring benefits.
These last findings must be tempered with the caveat
that they rest on two studies and therefore cannot
carry as
much evidential weight as findings replicated in
multiple
studies conducted by independent research teams. More
generally, it must be acknowledged that there are far
more
empirical outcome studies of other treatments,
notably
CBT, than of psychodynamic treatments. The
discrepancy
in sheer numbers of studies is traceable, in part, to
the
indifference to empirical research of earlier
generations of
psychoanalysts, a failing that continues to haunt the
field
and that contemporary investigators labor to address.
A second caveat is that many psychodynamic outcome
studies have included patients with a range of
symptoms
and conditions rather than focusing on specific
diagnostic
categories (e.g., those defined by diagnostic
criteria speci-
fied in the Diagnostic and Statistical Manual of
Mental
Disorders [4th edition, DSM-IV; American Psychiatric
As-
sociation, 1994]). The extent to which this is a
limitation is
open to debate. A concern often raised about
psychother-
apy efficacy studies is that they use highly selected
and
unrepresentative patient samples and, consequently,
that
their findings do not generalize to real-world
clinical prac-
tice (e.g., Westen et al., 2004). Nor is there
universal
agreement that DSM–IV diagnostic categories define
dis-
crete or homogeneous patient groups (given that
psychiat-
ric comorbidity is the norm and that diagnosable com-
plaints are often embedded in personality syndromes;
Blatt
& Zuroff, 2005; Westen, Gabbard, & Blagov,
2006). Be
that as it may, an increasing number of studies of
psy-
chodynamic treatments do focus on specific diagnoses
(e.g., Bateman & Fonagy, 2008; Clarkin et al.,
2007; Cui-
jpers, van Straten, Andersson, & van Oppen, 2008;
Leich-
senring, 2001, 2005; Milrod et al., 2007).
A Rose by Another Name:
Psychodynamic Process in Other
Therapies
The “active ingredients” of therapy are not
necessarily
those presumed by the theory or treatment model. For
this
reason, randomized controlled trials that evaluate a
therapy
as a “package” do not necessarily provide support for
its
theoretical premises or the specific interventions
that derive
from them. For example, the available evidence
indicates
that the mechanisms of change in cognitive therapy
(CT)
are not those presumed by the theory. Kazdin (2007),
reviewing the empirical literature on mediators and
mech-
anisms of change in psychotherapy, concluded,
“Perhaps
we can state more confidently now than before that
what-
ever may be the basis of changes with CT, it does not
seem
to be the cognitions as originally proposed” (p. 8).
There are also profound differences in the way ther-
apists practice, even therapists ostensibly providing
the
same treatment. What takes place in the clinical
consulting
room reflects the qualities and style of the
individual ther-
apist, the individual patient, and the unique
patterns of
interaction that develop between them. Even in
controlled
studies designed to compare manualized treatments,
thera-
pists interact with patients in different ways,
implement
interventions differently, and introduce processes
not spec-
ified by the treatment manuals (Elkin et al., 1989).
In some
cases, investigators have had difficulty determining
from
verbatim session transcripts which manualized
treatment
was being provided (Ablon & Jones, 2002).
For these reasons, studies of therapy “brand names”
can be highly misleading. Studies that look beyond
brand
names by examining session videotapes or transcripts
may
reveal more about what is helpful to patients
(Goldfried &
Wolfe, 1996; Kazdin, 2007, 2008). Such studies
indicate
that the active ingredients of other therapies
include unac-
knowledged psychodynamic elements.
One method of studying what actually happens in
therapy sessions makes use of the Psychotherapy
Process
Q-Sort (PQS; Jones, 2000). This instrument consists
of 100
variables that assess therapist technique and other
aspects
of the therapy process based on specific actions,
behaviors,
and statements made during sessions. In a series of
studies,
blind raters scored the 100 PQS variables from
archival,
verbatim session transcripts for hundreds of therapy
hours
from outcome studies of both brief psychodynamic
therapy
and CBT (Ablon & Jones, 1998; Jones & Pulos,
1993).10
In one study, the investigators asked panels of
inter-
nationally recognized experts in psychoanalytic
therapy
and CBT to use the PQS to describe “ideally”
conducted
treatments (Ablon & Jones, 1998). On the basis of
the
expert ratings, the investigators constructed
prototypes of
ideally conducted psychodynamic therapy and CBT. The
two prototypes differed considerably.
The psychodynamic prototype emphasized unstruc-
tured, open-ended dialogue (e.g., discussion of
fantasies
and dreams); identifying recurring themes in the
patient’s
experience; linking the patient’s feelings and
perceptions to
past experiences; drawing attention to feelings
regarded by
the patient as unacceptable (e.g., anger, envy,
excitement);
pointing out defensive maneuvers; interpreting
warded-off
10
The cognitive therapy study was a randomized
controlled trial for
depression; the psychodynamic therapy studies were
panel studies for
mixed disorders and for posttraumatic stress
disorder, respectively. See
the original source for more detailed descriptions
(Ablon & Jones, 1998;
Jones & Pulos, 1993).
103February–March 2010
● American Psychologist
or unconscious wishes, feelings, or ideas; focusing
on the
therapy relationship as a topic of discussion; and
drawing
connections between the therapy relationship and
other
relationships.
The CBT prototype emphasized dialogue with a more
specific focus, with the therapist structuring the
interaction
and introducing topics; the therapist functioning in
a more
didactic or teacher-like manner; the therapist
offering ex-
plicit guidance or advice; discussion of the
patient’s treat-
ment goals; explanation of the rationale behind the
treat-
ment and techniques; focusing on the patient’s
current life
situation; focusing on cognitive themes such as
thoughts
and belief systems; and discussion of tasks or
activities
(“homework”) for the patient to attempt outside of
therapy
sessions.11
In three sets of archival treatment records (one from
a
study of cognitive therapy and two from studies of
brief
psychodynamic therapy), the researchers measured
thera-
pists’ adherence to each therapy prototype without
regard
to the treatment model the therapists believed they
were
applying (Ablon & Jones, 1998). Therapist
adherence to
the psychodynamic prototype predicted successful out-
come in both psychodynamic and cognitive therapy.
Ther-
apist adherence to the CBT prototype showed little or
no
relation to outcome in either form of therapy. The
findings
replicated those of an earlier study that employed a
differ-
ent methodology and also found that psychodynamic
inter-
ventions, not CBT interventions, predicted successful
out-
come in both cognitive and psychodynamic treatments
(Jones & Pulos, 1993).
An independent team of investigators using different
research methods also found that psychodynamic
methods
predicted successful outcome in cognitive therapy
(Caston-
guay, Goldfried, Wiser, Raue, & Hayes, 1996). The
study
assessed outcomes in cognitive therapy conducted
accord-
ing to Beck’s treatment model (Beck, Rush, Shaw,
&
Emery, 1979), and the findings had been reported as
evi-
dence for the efficacy of cognitive therapy for
depression
(Hollon et al., 1992).12
Investigators measured three variables from verbatim
transcripts of randomly selected therapy sessions in
a sam-
ple of 64 outpatients. One variable assessed quality
of the
working alliance (the concept working alliance, or
thera-
peutic alliance, is now widely recognized and often
con-
sidered a nonspecific or “common” factor in many
forms of
therapy; many do not realize that the concept comes
di-
rectly from psychoanalysis and has played a central
role in
psychoanalytic theory and practice for over four
decades;
see Greenson, 1967; Horvath & Luborsky, 1993).
The
second variable assessed therapist implementation of
the
cognitive treatment model (i.e., addressing distorted
cog-
nitions believed to cause depressive affect). The
third vari-
able, labeled experiencing, beautifully captures the
essence
of psychoanalytic process:
At the lower stages of [experiencing], the client
talks about
events, ideas, or others (Stage 1); refers to self
but without
expressing emotions (Stage 2); or expresses emotions
but only as
they relate to external circumstances (Stage 3). At
higher stages,
the client focuses directly on emotions and thoughts
about self
(Stage 4), engages in an exploration of his or her
inner experience
(Stage 5), and gains awareness of previously implicit
feelings and
meanings [emphasis added] (Stage 6). The highest
stage (7) refers
to an ongoing process of in-depth self-understanding.
(Caston-
guay et al., 1996, p. 499)
Especially noteworthy is the phrase “gains awareness
of previously implicit feelings and meanings.” The
term
implicit refers, of course, to aspects of mental life
that are
not initially conscious. The construct measured by
the scale
hearkens back to the earliest days of psychoanalysis
and its
central goal of making the unconscious conscious
(Freud,
1896/1962).13
In this study of manualized cognitive therapy for
depression, the following findings emerged: (a)
Working
alliance predicted patient improvement on all outcome
measures; (b) psychodynamic process (“experiencing”)
predicted patient improvement on all outcome
measures;
and (c) therapist adherence to the cognitive
treatment
model (i.e., focusing on distorted cognitions)
predicted
poorer outcome. A subsequent study using different
meth-
odology replicated the finding that interventions
aimed at
cognitive change predicted poorer outcome (Hayes,
Cas-
tonguay, & Goldfried, 1996). However, discussion
of in-
terpersonal relations and exploration of past
experiences
with early caregivers— both core features of
psychody-
namic technique—predicted successful outcome.
These findings should not be interpreted as
indicating
that cognitive techniques are harmful, and other
studies
have reported positive relations between CBT
technique
and outcome (Feeley, DeRubeis, & Gelfand, 1999;
Strunk,
DeRubeis, Chiu, & Alvarez, 2007; Tang &
DeRubeis,
1999). Qualitative analysis of the verbatim session
tran-
scripts suggested that the poorer outcomes associated
with
cognitive interventions were due to implementation of
the
cognitive treatment model in dogmatic, rigidly
insensitive
ways by certain of the therapists (Castonguay et al.,
1996).
(No school of therapy appears to have a monopoly on
dogmatism or therapeutic insensitivity. Certainly,
the his-
tory of psychoanalysis is replete with examples of
dog-
matic excesses.) On the other hand, the findings do
indicate
that the more effective therapists facilitated
therapeutic
processes that have long been core, centrally
defining fea-
tures of psychoanalytic theory and practice.
Other empirical studies have also demonstrated links
between psychodynamic methods and successful outcome,
whether or not the investigators explicitly
identified the
methods as “psychodynamic” (e.g., Barber,
Crits-Chris-
toph, & Luborsky, 1996; Diener, Hilsenroth, &
Wein-
berger, 2007; Gaston, Thompson, Gallagher, Cournoyer,
&
11
See the original source for more complete
descriptions of the two
therapy prototypes (Ablon & Jones, 1998).
12
The study is one of the archival studies analyzed by
Jones and his
associates (Ablon & Jones, 1998; Jones &
Pulos, 1993).
13
Although the term “experiencing” derives from the
humanistic
therapy tradition, the phenomenon assessed by the
scale—a trajectory of
deepening self-exploration, leading to increased
awareness of implicit or
unconscious mental life—is the core defining feature
of psychoanalysis
and psychoanalytic therapy.
104 February–March 2010
● American Psychologist
Gagnon, 1998; Hayes & Strauss, 1998; Hilsenroth,
Acker-
man, Blagys, Baity, & Mooney, 2003; Høglend et
al., 2008;
Norcross, 2002; Pos, Greenberg, Goldman, &
Korman,
2003; Vocisano et al., 2004).
The Flight of the Dodo
The heading of this section is an allusion to what
has come
to be known in the psychotherapy research literature
as the
Dodo bird verdict. After reviewing the psychotherapy
out-
come literatures of the time, Rosenzweig (1936), and
sub-
sequently Luborsky, Singer, and Luborsky (1975),
reached
the conclusion of the Dodo bird in Alice in
Wonderland:
“Everybody has won, and all must have prizes.”
Outcomes
for different therapies were surprisingly equivalent,
and no
form of psychotherapy proved superior to any other.
In the
rare instances when studies found differences between
ac-
tive treatments, the findings virtually always
favored the
preferred treatment of the investigators (the
investigator
allegiance effect; Luborsky et al., 1999).
Subsequent research has done little to alter the Dodo
bird verdict (Lambert & Ogles, 2004; Wampold,
Minami,
Baskin, & Callen Tierney, 2002). For example,
studies that
have directly compared CBT with short-term psychody-
namic therapy for depression have failed to show
greater
efficacy for CBT over psychodynamic therapy or vice
versa
(Cuijpers et al., 2008; Leichsenring, 2001).
Leichsenring
(2001) noted that both treatments appeared to qualify
as
empirically supported therapies according to the
criteria
specified by the American Psychological Association’s
Di-
vision 12 Task Force on Promotion and Dissemination
of
Psychological Procedures (1995; Chambless et al.,
1998).
Some of the studies compared psychodynamic treatments
of only eight sessions’ duration, which most
practitioners
would consider inadequate, with 16-session CBT treat-
ments. Even in these studies, outcomes were
comparable
(Barkham et al., 1996; Shapiro et al., 1994).
There are many reasons why outcome studies may fail
to
show differences between treatments even if important
differ-
ences really exist. Others have discussed the
limitations and
unexamined assumptions of current research methods
(Gold-
fried & Wolfe, 1996; Norcross, Beutler, &
Levant, 2005;
Westen et al., 2004). Here I focus on one salient
limitation: the
mismatch between what psychodynamic therapy aims to
ac-
complish and what outcome studies typically measure.
As noted earlier, the goals of psychodynamic therapy
include, but extend beyond, alleviation of acute
symptoms.
Psychological health is not merely the absence of
symp-
toms; it is the positive presence of inner capacities
and
resources that allow people to live life with a
greater sense
of freedom and possibility. Symptom-oriented outcome
measures commonly used in outcome studies (e.g., the
Beck Depression Inventory [Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961] or the Hamilton Rating
Scale for
Depression [Hamilton, 1960]) do not attempt to assess
such
inner capacities (Blatt & Auerbach, 2003; Kazdin,
2008).
Possibly, the Dodo bird verdict reflects a failure of
re-
searchers, psychodynamic and nonpsychodynamic alike,
to
adequately assess the range of phenomena that can
change
in psychotherapy.
The Shedler–Westen Assessment Procedure (SWAP;
Shedler & Westen, 2007; Westen & Shedler,
1999a,
1999b) represents one method of assessing the kinds
of
inner capacities and resources that psychotherapy may
de-
velop. The SWAP is a clinician-report (not-self
report)
instrument that assesses a broad range of personality
pro-
cesses, both healthy and pathological. The instrument
can
be scored by clinicians of any theoretical
orientation and
has demonstrated high reliability and validity
relative to a
wide range of criterion measures (Shedler &
Westen, 2007;
Westen & Shedler, 2007). The SWAP includes an
empir-
ically derived Healthy Functioning Index comprising
the
items listed in Table 2, which define and
operationalize
mental health as consensually understood by clinical
prac-
titioners across theoretical orientations (Westen
& Shedler,
1999a, 1999b). Many forms of treatment, including
medi-
cations, may be effective in alleviating acute
psychiatric
symptoms, at least in the short run. However, not all
therapies aim at changing underlying psychological
pro-
cesses such as those assessed by the SWAP. (A working
version of the SWAP, which generates and graphs T
scores
for a wide range of personality traits and disorders,
can be
previewed at www.SWAPassessment.org.)
Researchers, including psychodynamically oriented
researchers, have yet to conduct compelling outcome
stud-
ies that assess changes in inner capacities and
resources,
but two studies raise intriguing possibilities and
suggest
directions for future research. One is a single case
study of
a woman diagnosed with borderline personality
disorder
who was assessed with the SWAP by independent asses-
sors (not the treating clinician) at the beginning of
treat-
ment and again after two years of psychodynamic
therapy
(Lingiardi, Shedler, & Gazzillo, 2006). In
addition to
meaningful decreases in SWAP scales that measure psy-
chopathology, the patient’s SWAP scores showed an in-
creased capacity for empathy and greater sensitivity
to
others’ needs and feelings; increased ability to
recognize
alternative viewpoints, even when emotions ran high;
in-
creased ability to comfort and soothe herself;
increased
recognition and awareness of the consequences of her
actions; increased ability to express herself
verbally; more
accurate and balanced perceptions of people and
situations;
a greater capacity to appreciate humor; and, perhaps
most
important, she had come to terms with painful past
expe-
riences and had found meaning in them and grown from
them. The patient’s score on the SWAP Healthy
Function-
ing Index increased by approximately two standard
devia-
tions over the course of treatment.
A second study used the SWAP to compare 26 pa-
tients beginning psychoanalysis with 26 patients
complet-
ing psychoanalysis (Cogan & Porcerelli, 2005).
The latter
group not only had significantly lower scores for
SWAP
items assessing depression, anxiety, guilt, shame,
feelings
of inadequacy, and fears of rejection but
significantly
higher scores for SWAP items assessing inner
strengths
and capacities (see Table 2). These included greater
satis-
faction in pursuing long-term goals, enjoyment of
chal-
lenges and pleasure in accomplishments, ability to
utilize
talents and abilities, contentment in life’s
activities, empa-
105February–March 2010
● American Psychologist
thy for others, interpersonal assertiveness and
effective-
ness, ability to hear and benefit from emotionally
threaten-
ing information, and resolution of past painful
experiences.
For the group completing psychoanalysis, the mean
score
on the SWAP Healthy Functioning Index was one
standard
deviation higher.
Methodological limitations preclude drawing causal
conclusions from these studies, but they suggest that
psy-
chodynamic therapy may not only alleviate symptoms
but
also develop inner capacities and resources that
allow a
richer and more fulfilling life. Measures such as the
SWAP
could be incorporated in future randomized controlled
tri-
als, scored by independent assessors blind to
treatment
condition, and used to assess such outcomes. Whether
or
not all forms of therapy aim for such outcomes, or
re-
searchers study them, they are clearly the outcomes
desired
by many people who seek psychotherapy. Perhaps this
is
why psychotherapists, irrespective of their own
theoretical
orientations, tend to choose psychodynamic
psychotherapy
for themselves (Norcross, 2005).
Discussion
One intent of this article was to provide an overview
of
some basic principles of psychodynamic therapy for
read-
ers who have not been exposed to them or who have not
heard them presented by a contemporary practitioner
who
takes them seriously and uses them clinically.
Another was
to show that psychodynamic treatments have
considerable
empirical support. The empirical literature on
psychody-
namic treatments does, however, have important
limita-
tions. First, the number of randomized controlled
trials for
other forms of psychotherapy, notably CBT, is
consider-
ably larger than that for psychodynamic therapy,
perhaps
by an order of magnitude. Many of these
trials—specifi-
cally, the newer and better-designed trials—are more
meth-
odologically rigorous (although some of the newest
psy-
chodynamic randomized controlled trials, e.g., that
of
Clarkin et al., 2007, also meet the highest standards
of
methodological rigor). In too many cases,
characteristics of
patient samples have been too loosely specified,
treatment
methods have been inadequately specified and
monitored,
and control conditions have not been optimal (e.g.,
using
wait-list controls or “treatment as usual” rather
than active
alternative treatments—a limitation that applies to
research
on empirically supported therapies more generally).
These
and other limitations of the psychodynamic research
liter-
ature must be addressed by future research. My intent
is not
to compare treatments or literatures but to review
the
existing empirical evidence supporting psychodynamic
treatments and therapy processes, which is often
underap-
preciated.
In writing this article, I could not help being
struck by
a number of ironies. One is that academicians who
dismiss
psychodynamic approaches, sometimes in vehement
tones,
often do so in the name of science. Some advocate a
science of psychology grounded exclusively in the
exper-
imental method. Yet the same experimental method
yields
findings that support both psychodynamic concepts
(e.g.,
Westen, 1998) and treatments. In light of the
accumulation
of empirical findings, blanket assertions that
psychody-
namic approaches lack scientific support (e.g.,
Barlow &
Durand, 2005; Crews, 1996; Kihlstrom, 1999) are no
longer defensible. Presentations that equate
psychoanal-
ysis with dated concepts that last held currency in
the
psychoanalytic community in the early 20th century
are
Table 2
Definition of Mental Health: Items From the Shedler–
Westen Assessment Procedure (SWAP–200; Shedler
& Westen, 2007)
● Is able to use his/her talents, abilities,
and energy
effectively and productively.
● Enjoys challenges; takes pleasure in
accomplishing things.
● Is capable of sustaining a meaningful love
relationship
characterized by genuine intimacy and caring.
● Finds meaning in belonging and contributing
to a larger
community (e.g., organization, church, neighborhood).
● Is able to find meaning and fulfillment in
guiding,
mentoring, or nurturing others.
● Is empathic; is sensitive and responsive to
other people’s
needs and feelings.
● Is able to assert him/herself effectively
and appropriately
when necessary.
● Appreciates and responds to humor.
● Is capable of hearing information that is
emotionally
threatening (i.e., that challenges cherished beliefs,
perceptions, and self-perceptions) and can use and
benefit from it.
● Appears to have come to terms with painful
experiences
from the past; has found meaning in and grown from
such experiences.
● Is articulate; can express self well in
words.
● Has an active and satisfying sex life.
● Appears comfortable and at ease in social
situations.
● Generally finds contentment and happiness in
life’s
activities.
● Tends to express affect appropriate in
quality and
intensity to the situation at hand.
● Has the capacity to recognize alternative
viewpoints,
even in matters that stir up strong feelings.
● Has moral and ethical standards and strives
to live up to
them.
● Is creative; is able to see things or
approach problems in
novel ways.
● Tends to be conscientious and responsible.
● Tends to be energetic and outgoing.
● Is psychologically insightful; is able to
understand self and
others in subtle and sophisticated ways.
● Is able to find meaning and satisfaction in
the pursuit of
long-term goals and ambitions.
● Is able to form close and lasting
friendships characterized
by mutual support and sharing of experiences.
106 February–March 2010
● American Psychologist
similarly misleading; they are at best uninformed and
at
worst disingenuous.
A second irony is that relatively few clinical
practi-
tioners, including psychodynamic practitioners, are
famil-
iar with the research reviewed in this article. Many
psy-
chodynamic clinicians and educators seem ill-prepared
to
respond to challenges from evidence-oriented
colleagues,
students, utilization reviewers, or policymakers,
despite the
accumulation of high-quality empirical evidence
support-
ing psychodynamic concepts and treatments. Just as
anti-
psychoanalytic sentiment may have impeded
dissemination
of this research in academic circles, distrust of
academic
research methods may have impeded dissemination in
psy-
choanalytic circles (see Bornstein, 2001). Such
attitudes are
changing, but they cannot change quickly enough.
Researchers also share responsibility for this state
of affairs (Shedler, 2006b). Many investigators take
for
granted that clinical practitioners are the intended
con-
sumers of clinical research (e.g., Task Force on
Promo-
tion and Dissemination of Psychological Procedures,
1995), but many of the psychotherapy outcome studies
and meta-analyses reviewed for this article are
clearly
not written for practitioners. On the contrary, they
are
densely complex and technical and often seem written
primarily for other psychotherapy researchers—a case
of
one hand writing for the other. As an experienced re-
search methodologist and psychometrician, I must
admit
that deciphering some of these articles required
hours of
study and more than a few consultations with
colleagues
who conduct and publish outcome research. I am unsure
how the average knowledgeable clinical practitioner
could navigate the thicket of specialized statistical
meth-
ods, clinically unrepresentative samples,
investigator al-
legiance effects, inconsistent methods of reporting
re-
sults, and inconsistent findings across multiple
outcome
variables of uncertain clinical relevance. If
clinical prac-
titioners are indeed the intended “consumers” of
psycho-
therapy research, then psychotherapy research needs
to
b e mo r e c o n s u me r r e l e v a n t ( We s t e
n , No v o t n y , &
Thompson-Brenner, 2005).
With the caveats noted above, the available evidence
indicates that effect sizes for psychodynamic
therapies are
as large as those reported for other treatments that
have
been actively promoted as “empirically supported” and
“evidence based.” It indicates that the (often
unacknowl-
edged) “active ingredients” of other therapies
include tech-
niques and processes that have long been core,
centrally
defining features of psychodynamic treatment.
Finally, the
evidence indicates that the benefits of psychodynamic
treat-
ment are lasting and not just transitory and appear
to extend
well beyond symptom remission. For many people, psy-
chodynamic therapy may foster inner resources and
capac-
ities that allow richer, freer, and more fulfilling
lives.