A team from the Justus-Liebig University Giessen in Germany has conducted a systematic search for evidence for the effectiveness of psychodynamic psychotherapy. They concluded that this form of therapy was effective for a range of common mental disorders including major depressive disorder, social anxiety disorder, some personality disorders, somatoform pain disorder and anorexia nervosa. They also found some evidence for effectiveness in treating dysthymia, complicated grief, panic disorder, generalized anxiety disorder and substance abuse/dependence. Read more The effectiveness of psychodynamic psychotherapy ›

I’ve just caught up with a 2008 article in the Journal of the American Medical Association reviewing a meta-analysis of studies looking at the effectiveness of long-term psychodynamic psychotherapy. The meta-analysis looked at 23 studies, including 11 randomised controlled trials and involving 1,053 patients. The meta-analysis concluded that long-term psychodynamic psychotherapy led to significantly better outcomes than shorter forms of psychotherapy, especially for individuals who were experiencing more complex mental disorders. Thanks to Mike Langlois who pointed out this article to me.

The meta-analysis looked at studies, published over the past 50 years, of individual psychodynamic psychotherapies that lasted for at least one year. Studies were only included if they had reliable outcome data and had a prospective design, that is, they included before and after assessments of the patient. Patients treated in the studies had a range of mental disorders including ‘personality disorders, chronic mental disorders (defined as mental disorders lasting ≥1 year), multiple mental disorders (defined as 2 or more diagnoses of mental disorders), and complex depressive or anxiety disorders’.

The two authors independently rated the reported treatment outcomes in terms of overall effectiveness, the presenting problems, general psychiatric symptoms, personality functioning and social functioning. The studies were then analysed to compare the outcomes achieved by long-term psychodynamic psychotherapy, with those of other forms of therapy, including ‘CBT, cognitive-analytic therapy, dialectical-behavioral therapy, family therapy, supportive therapy, short-term psychodynamic therapy, and psychiatric treatment’.

The article describes the detailed statistical analysis that was carried out on these 23 studies. This analysis came to the following conclusion:

In this meta-analysis, (long-term psychodynamic psychotherapy) was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning. Long-term psychodynamic psychotherapy yielded large and stable effect sizes in the treatment of patients with personality disorders, multiple mental disorders, and chronic mental disorders. The effect sizes for overall outcome increased significantly between end of therapy and follow-up.

Interestingly, the number of therapy sessions seemed more significant in these positive outcomes, than the number of weeks that the therapy lasted.

There are growing pressures, at least within the UK, for psychotherapy to be offered in its shorter, and therefore less costly forms. It’s certainly correct for a range of help to be available to people in distress. It is also true that many individuals may only need, or be prepared to contemplate, a relatively brief therapy. However, the studies looked at in this analysis suggest that more complex or chronic problems are best helped by longer-term work.

As a society and as individuals we face difficult economic realities. In both cases we need to decide how much we want to invest in our mental wellbeing.

One of the criticisms levelled at psychoanalytic psychotherapy is the absence of evidence for its effectiveness and, especially, the absence of randomised controlled trials (RCTs). By comparing outcomes for randomly selected groups of individuals who receive different treatments or none, these trials set out to prove the effectiveness or not of treatments. RCT is often described as the gold standard of research. In the past, psychoanalytic psychotherapists have been reluctant generally to undertake research and especially research that uses RCTs. This attitude towards research seems to be changing with an increasing number of research studies that demonstrate the effectiveness of psychoanalytic psychotherapy. See, for example, my blog post ‘Psychodynamic psychotherapy brings lasting benefits through self-knowledge’ – http://goo.gl/40fiy.

More research into the efficacy of psychoanalytic psychotherapy is certainly desirable and as practitioners we should be self-critical enough to welcome external validation of our methods. However, it’s worth also being aware that much medical research, including RCTs, is less scientifically sound than is often thought.

A recent article in the Atlantic describes the work of John Ioannidis and his team at the University of Ioannina. See http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/

The team is investigating the credibility of published biomedical research, including looking at studies that were originally thought to be conclusive, but have later proved to be incorrect. In one of their papers they looked at 49 of the most highly regarded and frequently cited medical papers published in the last 13 years. Of these papers, 45 contained claims for effective interventions, but only 34 of these had been retested, leaving 11 without independent verification. Of those studies that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. So two fifths of these key papers, when retested, were shown to be misleading, papers that were widely cited and referred to by physicians for guidance.

Also worrying was the persistent influence of these misleading studies. The article mentions ‘three prominent health studies from the 1980s and 1990s that were each later soundly refuted…(where) researchers continued to cite the original results as correct more often than as flawed—in one case for at least 12 years after the results were discredited’.

The Atlantic article describes several factors that Ioannidis claims can distort research outcomes and influence the likelihood of publication. These include the pressures of competition for funding and academic success, and plain wish fulfilment on the part of the researchers.

Research into all forms of therapy is to be welcomed. However, the efficacy of some approaches is more easily investigated with RCTs and these forms of therapy are often held up as having a more secure evidence base. These are claims that should be challenged. The work of Ioannidis and his team shows that RCTs do not necessarily provide a trustworthy and scientific proof of efficacy.

A recent study published by the American Psychological Association provides strong evidence for the effectiveness of psychoanalytic psychotherapy. As practitioners we know the power and effectiveness of our work. However I, for one, can feel disarmed when I’m in meetings with other, sceptical professionals who dismiss psychoanalytic work for not having an evidence base. Unfortunately, in some of my roles I’m often in such meetings.

For this reason I was pleased to read about this APA study which reviewed eight meta-analyses, comprising 160 studies of psychodynamic therapy, plus nine meta-analyses of other psychological treatments and antidepressant medications. Read more Psychodynamic Psychotherapy Brings Lasting Benefits through Self-Knowledge ›