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The Effectiveness of psychodynamic psychotherapy: A systematic review of recent international and Australian research

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Dr Cadeyrn Gaskin, Gaskin Research, Melbourne, Australia

Introduction

In Australia (Pelling, 2005; Schofield, 2008), as well as internationally (Aldridge & Pollard, 2005), it is common for counsellors and psychotherapists to use psychodynamic approaches in their work with clients. The findings from a survey of professional and clinical members of the 41 Psychotherapy and Counselling Federation of Australia member associations, for example, showed that 30% of respondents regarded psychodynamic approaches as being their primary theoretical orientation (Schofield, 2008). With the significant use of psychodynamic approaches, it is necessary to keep psychotherapists up to date with current evidence of the efficacy of these approaches.

Psychodynamic psychotherapy focuses on those aspects of self that may be unknown (i.e., unconscious processes), especially as they manifest in therapeutic relationships (Shedler, 2010). Distinguishing techniques and processes of psychodynamic psychotherapy include: (1) focusing on affect and the expression of the clients’ emotions; (2) exploring clients’ attempts to avoid topics or engage in activities that the obstruct therapeutic progress; (3) identifying patterns in actions, thoughts, feelings, experiences, and relationships; (4) emphasising past experiences; (5) focusing on interpersonal experiences; (6) placing an emphasis on the therapeutic relationship; and (7) exploring dreams, wishes, or fantasies (Blagys & Hilsenroth, 2000).

Psychodynamic psychotherapy refers to a range of treatments with similar theoretical underpinnings and methods. Specific treatments that have attracted the attention of researchers in recent years include: short-term psychodynamic psychotherapy (STPP; Malan, 1976; Malan & Osimo, 1992), long-term psychodynamic psychotherapy (LTPP; Gabbard, 2004), intensive short-term dynamic psychotherapy (Davanloo, 1990, 2000), short-term psychodynamic supportive psychotherapy (de Jonghe, 2005), and supportive-expressive psychotherapy (Barber & Crits-Christoph, 1995; Luborsky, 1984). In Australia, researchers have been especially interested in investigating the effectiveness of the conversational model (CM; Hobson, 1985; Meares, 2000, 2004) in the treatment of borderline personality disorder.

The purpose of this paper is to present the findings of a systematic review of recent and Australian research into the effectiveness of psychodynamic psychotherapy. With respect to each of the two bodies of literature (i.e., recent studies and Australian studies), the specific aims of this review were to determine:

(a)   the effectiveness of psychodynamic psychotherapy,

(b)   whether the effects of psychodynamic psychotherapy endure following the termination of treatment, and

(c)    the effectiveness of psychodynamic psychotherapy in comparison to other treatments.

Method

The structure and contents of this paper is consistent with current guidance for reporting systematic reviews of studies that evaluate healthcare interventions (Liberati et al., 2009).

Information Sources

Studies were identified through searching the following electronic databases: MEDLINE Complete (1857-) and PsycINFO (1800-). The review of recent research focused on papers published in the last five years (i.e., 2007 onwards), whereas the review of Australian literature was concentrated on studies published during the last 10 years (i.e., 2002 onwards). Limits were applied to language (English only) and publication type (periodicals, peer reviewed). The terms used in the search for recent studies were psychodynamic, insight-oriented therapy, self-psychology, conversational model, intersubjectivity, study, studies, and trial*. The terms used in the search for Australian studies were those used in the search for recent studies with the addition of the term Australia. These search strategies are presented in Appendix 7. The search was current as at 8 August 2012.

Eligibility Criteria

Inclusion criteria

Studies were included in this review if they reported the effect of psychodynamic psychotherapy on affective, behavioural, or cognitive outcome measures. Systematic reviews, meta-analyses, randomised controlled trials, quasi-experimental studies, and descriptive studies were eligible for inclusion in this review. No restrictions were placed on studies with respect to the ages of participants.

Exclusion criteria

Psychoanalysis and therapies described as being psychoanalytically-oriented were excluded from the review. Studies, or findings within studies, were also excluded if psychodynamic psychotherapy was initiated at the same time as other treatments (e.g., medications, other psychotherapeutic approaches). Papers in which findings pertinent to this review were duplicated from other publications included in the review were excluded. Narrative reviews and case studies were excluded from the review.

Study Selection and Data Extraction

The author performed the eligibility assessment of the studies in an unblinded, standardised manner. The following data were extracted from papers that met the eligibility criteria: study authors, year of publication, study design, intervention name, intervention duration, intervention characteristics, number of participants, participant characteristics, outcome measures, comparison conditions, intervention effectiveness, intervention effectiveness relative to comparison conditions, follow up length of time, number of participants at follow up, intervention effectiveness at follow up, intervention effectiveness relative to comparison conditions at follow up.

Data Analysis

Descriptive statistics pertaining to (where possible) the primary outcome measures of each study were extracted. In studies with more than one follow up point, the statistics for the final follow up point have been reported. Effect sizes for the differences between treatments and differences between time points are reported (e.g., Cohen’s d, η2). When these statistics were not reported in the original papers, they were calculated using the statistics available (e.g., M, SD, t, n). With respect to differences between time points, it is preferable to adjust Cohen’s d values for the potentially large correlations between repeated measures (Dunlap, Cortina, Vaslow, & Burke, 1996). Given that researchers rarely report these correlations, however, an acceptable alternative is to use means and standard deviations provided to estimate effect sizes. In the social sciences, guidelines for small, medium, and large effect sizes for d are 0.2, 0.5, and 0.8, and for η2 are .01, .06, and .14, respectively (Cohen, 1988). Whenever possible, levels of statistical significance were also extracted from the papers.

Findings

The findings from the reviews of recent and Australian literature are presented separately.

Review of Recent Literature

Of the 1,343 records retrieved from the two databases, 59 papers met the eligibility criteria to be included in this review (see Figure 1).

Systematic reviews and meta-analyses

During the search, four combined systematic reviews and meta-analyses, nine meta-analyses, and eight systematic reviews were found. Summaries of the papers with meta-analyses are presented separately (see Table 1) from those in which only systematic reviews are reported (see Table 2). Collectively, the findings from these reviews demonstrate that psychodynamic psychotherapy, in various forms, is effective in the treatment of mood disorders (mainly depressive disorders), some anxiety disorders (mainly generalised anxiety disorder), somatic symptoms and somatoform disorders, and some personality disorders (mainly borderline and Cluster C personality disorders). Cluster C includes obsessive-compulsive, avoidant, and dependent personality disorders (American Psychiatric Association, 2000). There is also evidence from a limited number of studies that psychodynamic psychotherapy can be effective in the treatment of eating disorders, post traumatic stress disorder, and some substance-related disorders (alcohol dependence, opiate dependence). Longer forms of psychodynamic psychotherapy may be more effective than short forms for the treatment of depression, anxiety, and general psychiatric symptoms.

The evidence suggests that the effects of psychodynamic psychotherapy may endure after the termination of treatment. When follow up measurements have been included in studies, there have generally been minimal changes in depression, mood, general psychopathy, and interpersonal functioning scores between the conclusion of treatment and follow up.

Psychodynamic psychotherapy is superior to treatment as usual (TAU) and of equivalent effectiveness to other psychotherapies in the treatment of several conditions (depressive disorders, in particular). Some evidence, however, suggests that cognitive behavioural therapy (CBT) may be slightly more effective than psychodynamic psychotherapy for various conditions.

Randomised controlled trials

From the search, 20 papers reporting on 18 randomised controlled trials (RCTs) that met the eligibility criteria were retrieved (see Tables 3 and 4). In 17 of these studies, the efficacy of individual psychodynamic psychotherapy was investigated, with group therapy evaluated in the remaining study (Sandahl et al., 2011). Collectively, these studies included 1,845 participants in treatment and comparison conditions. STPP was the most common form of psychodynamic psychotherapy investigated, being included in six studies.

Over half the studies (n = 11) included participants with anxiety or depressive disorders, with the findings suggesting that psychodynamic psychotherapy is effective in reducing the symptoms related to these conditions. A small number of studies have demonstrated that psychodynamic psychotherapy is beneficial in the treatment of hypochondriasis, borderline and other personality disorders, and alcohol-related disorders.

The effects of psychodynamic psychotherapy beyond the termination of treatment are equivocal. The findings of most studies suggest that the effects are at least maintained at follow up.

The evidence for the effectiveness of psychodynamic psychotherapy in comparison with other treatments is equivocal. Psychodynamic psychotherapy appears to be superior to TAU for anxiety and depressive disorders, and equivalent to TAU for borderline personality disorder and hypochondriasis. Psychodynamic psychotherapy seems equivalent to antidepressant medications and CBT in the treatment of depression.

Quasi-experimental studies

During the search of recent literature, 18 papers on 17 quasi-experimental studies were found (see Tables 5 and 6). These designs used in these studies were: non-randomised controlled trials (n = 4), non-equivalent groups controlled trials (n = 3), a time series design (n = 1), and single condition, pre-treatment/post-treatment (n = 9).

Most of the studies (n = 13) included participants with broad ranges of disorders or psychosocial issues. In general, psychodynamic psychotherapy appeared effective in the treatment of the problems presented in therapy. For those studies in which people with specific disorders were treated, psychodynamic psychotherapy was associated with the reduction of symptoms relating to depressive disorders, anxiety disorders, and borderline personality disorder.

Review of Australian Literature

Of the 75 records retrieved from the databases, four met the eligibility criteria for this review (see Figure 2).

Systematic reviews and meta-analyses

No systematic reviews or meta-analyses of Australian literature were found.

Randomised controlled trials

No randomised controlled trials were found.

Quasi-experimental studies

Four papers were found, each describing different aspects of the same study (Gerull, Meares, Stevenson, Korner, & Newman, 2008; Korner, Gerull, Meares, & Stevenson, 2006; Meares, Gerull, Stevenson, & Korner, 2011; Stevenson, Meares, & D’Angelo, 2005). The participants in this study were 60 patients (the number of patients differed slightly between some of the papers) with borderline personality disorder. Patients received psychotherapy based on the CM, which was provided twice weekly over 12 months. Patients on a waiting list for psychotherapy received TAU and served as the control condition. CM was superior to TAU in facilitating changes in self (η2 = .14, p = .004) and affect deregulation (η2 = .10, p = .02), but equivalent to TAU in terms of impulse changes (η2 = .05, p = .11; Meares et al., 2011). With regard to social adjustment, CM was superior to TAU with respect to partners (η2 = .26, p = .001) and children (η2 = .18, p = .004), but the two conditions were equivalent in terms of the family unit (η2 = .07, p = .06; Gerull et al., 2008). CM was superior to TAU in producing changes in global function (η2 = .10, p = .001), but the conditions were equivalent using an alternative measure of symptom severity (η2 = .01, p = .57; Korner et al., 2006). Between post-treatment and five year follow up, there were significant reductions in time off work (p = .03), time as inpatients (p = .04), and symptoms (p = .01; Stevenson et al., 2005).

Discussion

The reviewed evidence suggests that psychodynamic psychotherapy is effective in treating a broad range of mental health conditions, particularly depressive disorders, some anxiety disorders (especially generalised anxiety disorder), somatic symptoms and some somatoform disorders (e.g., hypochondriasis), and some personality disorders (primarily borderline and Cluster C personality disorders). In a limited number of studies, psychodynamic psychotherapy has also been effective in the treatment of eating disorders, post traumatic stress disorder, and some substance-related disorders (alcohol dependence, opiate dependence). In reviews and studies on the effectiveness of psychodynamic psychotherapy, meta-analysts and researchers have routinely reported medium, large, and very large (exceeding two standard deviations) effect sizes for improvement on primary outcome measures. Such improvements are typically retained beyond the termination of therapy.

The findings on the effectiveness of psychodynamic psychotherapy in comparison to other treatments are equivocal. Generally, psychodynamic psychotherapy has been found to be superior to TAU (e.g., Abbass, Town, & Driessen, 2012) and equivalent to other psychotherapies (e.g., Cuijpers, van Straten, Andersson, & van Oppen, 2008; Leichsenring & Leibing, 2007).  This finding replicates that of a recent quality-based review of RCTs of psychodynamic psychotherapy (Gerber et al., 2011). In this review, psychodynamic psychotherapy was found to be superior to inactive comparators (e.g., TAU, waiting list) in 18 of the 24 comparisons. Psychodynamic psychotherapy was also found to be equivalent to active treatments (e.g., CBT) in 28 of 39 comparisons (although studies were typically underpowered for equivalence), superior in six of 39 comparisons, and inferior in five of 39 comparisons. Although these results are sufficient to consider psychodynamic psychotherapy to be empirically validated (as per American Psychological Association Division 12 standards), more research needs to be conducted to replicate and extend these findings to specific disorders (Gerber et al., 2011). The collective findings from the present review should encourage researchers to conduct head-to-head trials to compare various therapies for specific disorders, which would enable more definitive conclusions to be drawn about the relative effectiveness of different psychotherapies for the treatment of specific conditions.

Although some meta-analysts have concluded that LTPP is superior to shorter forms of psychotherapy (Leichsenring & Rabung, 2008, 2011), these claims have been strongly disputed (e.g., Bhar et al., 2010; Pignotti & Albright, 2011). Among the criticisms of Leichsenring and Rabung’s (2008) meta-analysis were that (a) the effect sizes for key comparisons were miscalculated, (b) the meta-analysis was performed on a small number of underpowered studies that differed markedly with respect to the patients treated, comparison conditions, interventions used, and outcome measures; and (c) the studies included in the meta-analysis had poor internal validity (Bhar et al., 2010). Higher quality trials of long-term versus short-term psychodynamic psychotherapy need to be conducted before firmer conclusions can be drawn.

This review has highlighted the substantial work that has occurred to evaluate the effectiveness of psychodynamic psychotherapy, especially in adults with depressive disorders and some anxiety disorders. More research is clearly needed in areas where initial studies have yielded positive findings, such as somatoform disorders, eating disorders, substance-related disorders, and other anxiety disorders. In addition, more work is needed to investigate the efficacy of psychodynamic therapy with children and adolescents. One meta-analysis on children and adolescents who had been sexually abused, for example, produced mixed findings on the effectiveness of psychodynamic psychotherapy (Sánchez-Meca, Rosa-Alcázar, & López-Soler, 2011). These findings were based on only two studies, however. Clearly, a stronger evidence base for the use of psychodynamic psychotherapy in the treatment of some issues needs to be developed.

The findings of this review suggest that Australian researchers have not been particularly active in publishing the results of research on the effectiveness of psychodynamic psychotherapy, except at the level of case studies. Only four papers (representing one study) were sourced during the search for Australian literature. The limited work in this area highlights a possible avenue for research to support clinicians in Australia.

Conclusion

The conclusion reached in this review is that there is strong support for the use of psychodynamic psychotherapy in the treatment of a broad range of psychological conditions. Moreover, the improvements gained through psychodynamic psychotherapy are typically maintained beyond the termination of treatment. Psychodynamic psychotherapy appears to be as effective as other psychotherapies, but more comparative trials are needed before firmer conclusions can be drawn.

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Appendices

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