Thursday, September 20, 2012

Jonathan Shedler - Robust Empirical Support for Psychodynamic Treatment

Abstract: "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 "evidence based." In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic 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 findings." (p. 98)

Discussion: "One intent of this article was to provide an overview of some basic principles of psychodynamic therapy for readers 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 psychodynamic treatments does, however, have important limitations. First, the number of randomized controlled trials for other forms of psychotherapy, notably CBT, is considerably larger than that for psychodynamic therapy, perhaps by an order of magnitude. Many of these trials—specifically, the newer and better-designed trials—are more methodologically rigorous (although some of the newest psychodynamic 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 literature 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 underappreciated.

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 experimental 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 psychodynamic approaches lack scientific support (e.g., Barlow & Durand, 2005; Crews, 1996; Kihlstrom, 1999) are no longer defensible. Presentations that equate psychoanalysis with dated concepts that last held currency in the psychoanalytic community in the early 20th century are similarly misleading; they are at best uninformed and at worst disingenuous.

A second irony is that relatively few clinical practitioners, including psychodynamic practitioners, are familiar with the research reviewed in this article. Many psychodynamic 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 supporting psychodynamic concepts and treatments. Just as antipsychoanalytic sentiment may have impeded dissemination of this research in academic circles, distrust of academic research methods may have impeded dissemination in psychoanalytic 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 consumers of clinical research (e.g., Task Force on Promotion
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 research 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 methods, clinically unrepresentative samples, investigator allegiance effects, inconsistent methods of reporting results, and inconsistent findings across multiple outcome variables of uncertain clinical relevance. If clinical practitioners are indeed the intended "consumers" of psychotherapy research, then psychotherapy research needs to be more consumer relevant (Westen, Novotny, & 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 unacknowledged) "active ingredients" of other therapies include techniques and processes that have long been core, centrally defining features of psychodynamic treatment. Finally, the evidence indicates that the benefits of psychodynamic treatment are lasting and not just transitory and appear to extend well beyond symptom remission. For many people, psychodynamic therapy may foster inner resources and capacities that allow richer, freer, and more fulfilling lives."
 (pp. 106-107)

Jonathan Shedler (2010) The Efficacy of Psychodynamic Psychotherapy, American Psychologist, Vol. 65, No. 2, pp. 98–109

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