The effectiveness of Psychodynamic Therapy: Latest evidence

Peter Fonagy, head of the department of Clinical, Educational and Health Psychology at University College London and co-originator of Mentalization-based Therapy for Borderline Personality Disorder (BPD), recently published a report on the most current evidence for Psychodynamic Therapy in World Psychiatry. The 14-page article cites more than 200 recent studies and reviews the most current evidence for Psychodynamic Therapy for treating depression, anxiety, eating disorders, somatic (body) issues, drug dependence, psychosis, and personality disorders. Fonagy focused his review on individual studies (with a preference for randomized controlled trials when possible) over meta-analyses (although some meta-analyses were considered). While the review looked at all recent studies that claimed to use psychodynamic treatments, a broad definition of what Fonagy considers to be key aspects of psychodynamic theory and treatment was included:

"This review uses a broad definition of psychodynamic treatment as a stance taken to human subjectivity that is inclusive and aimed at comprehensive understanding of the interplay between aspects of the individual's relationship with his/her environment, whether external or internal. It refers to the extraordinary potential for dynamic self-alteration and self-correction...(incorporating) a developmental perspective,...limitations on conscious influence, ubiquity of conflict, internal representation of relationships, mental defences, and that complex meanings can be attached to experience (pg 138)."

Here is a summary of his findings:There are several key disorders for which Fonagy was simply not able to find good research on Psychodynamic Therapy. It is important to note that absence of evidence does not constitute evidence of absence. In other words, the lack of strong research studies assessing the effectiveness of Psychodynamic Therapy for some conditions does not indicate that Psychodynamic Therapy is ineffective for those issues. It merely shows that more research needs to be done.Overall:

• Psychodynamic Therapies appear to benefit individuals with depression, some forms of anxiety, eating disorders, somatic problems, and personality disorder.

• Long-term Psychodynamic Therapies appear to benefit individuals with complex disorders. A strength of long-term Psychodynamic Therapies includes prolonged contact between patient and therapist.

• As has long been the case, there is little evidence to suggest that Psychodynamic Therapies are superior to other approaches in general. Note: This does not mean that they are inferior. Assessing superiority of one treatment over another is a very complicated endeavor. CBT and Psychodynamic approaches continue to show comparable effectiveness across multiple domains. It is more a matter of individual fit.

Depression:

• Overall, Fonagy found support for the use of Psychodynamic Therapy for the treatment of depression. Effect sizes over placebo and other inactive controls were moderate rather than large. Evidence shows that benefits are maintained long-term.

• There is no reliable evidence that CBT is superior to Psychodynamic treatment approaches. However, there are too few studies to establish equivalence. Evidence suggests that long-term Psychodynamic Therapy is effective for complex and chronic cases of depression.

Anxiety:

• Evidence supports effectiveness of Psychodynamic Therapy for Social Anxiety.

• While CBT showed larger remission rates for phobia at termination, the differences between the two treatment approaches disappeared between 6-month and 2-year follow ups.

• A lack of studies made it impossible to assess Psychodynamic Therapy for Generalized Anxiety Disorder.

• Limited studies show support for Psychodynamic Therapy over applied relaxation for Panic Disorder. This is an area that needs further research.

• There is some evidence for effectiveness in treating Post-traumatic Stress Disorder (PTSD).

• No evidence was found to support effectiveness of Psychodynamic Therapy for Obsessive Compulsive Disorder (OCD).

Eating Disorders:

• Fonagy found strong evidence for effectiveness of Psychodynamic Therapy in the treatment of anorexia nervosa.

• Evidence for the treatment of bulimia nervosa was inconclusive and warrants further study.

Somatic Disorders (e.g. chronic pain symptoms):

• Fonagy found robust support for the effectiveness of Psychodynamic Therapy in the treatment of somatoform disorders compared to controls.

• In particular, Interpersonal Therapy approaches (a type of Psychodynamic Therapy) showed substantial and long-term effects.

Drug Dependence:

• Fonagy did not find strong support for Psychodynamic Therapy or CBT over individual drug counseling.

• In this area of treatment, it appears that group and individual treatment approaches that are specific to substance abuse issues may be superior.

Psychosis:Since psychotic disorders are often chronic and complex, treatment has increasingly focused on medication management.

• Current evidence suggests that Psychodynamic Therapies provide short-term benefits, but that these benefits are not generally sustained long-term.

• It should be noted that there is also limited evidence for the use of CBT to treat psychosis. This is another area where more research needs to be done.

Personality Disorders:This is an area where Psychodynamic Therapies continue to shine.

• Evidence shows superiority over controls across suicidality, global and interpersonal functioning, and comorbid issues.

• Fonagy notes that several Psychodynamic Therapies are officially endorsed by the American Psychological Association (Division 12) as empirically-supported for the treatment of personality disorders.

It is clear from Fonagy's report that much research remains to be done assessing which treatment approaches yield benefits for specific issues and concerns. Overall, the evidence appears to support the continued use of Psychodynamic Therapies for chronic and complex issues. Here is a link to Fonagy's report. I invite you to check it out for yourself.

*For more on the evidence supporting psychodynamic therapy, Dr. Ian Pritchard, a clinical psychologist in Reno, NV, has assembled a list of evidence-based psychodynamic psychotherapy research articles on his website.

Works Cited:Fonagy, P. (2015), The effectiveness of psychodynamic psychotherapies: An update. World Psychiatry, 14: 137–150.