Efficacy of Psychodynamic Psychotherapy: Statistics and Growth

All research has limitations. Still, there are many studies that use math to say that therapy works, and why. What changes do we want to make in our lives?

What’s the most effective kind of psychotherapy? We could look at treatment results: cleared symptoms, manageable emotions, and enriched relationships; or more broadly, joy in life, better self-esteem, and greater creativity to apply our strengths and talents.

We would want our investment of emotional labor, time, and finances to ensure lasting change that doesn’t evaporate when treatment ends. Otherwise, we could just lean on our own resources, like willpower and exercise, supportive friends, the right podcast or the best self-help books (which can all be helpful!).

What’s the scientific evidence that psychodynamic psychotherapy, in particular, actually works?

Therapy and the historical context of psychoanalysis

Psychodynamic psychotherapy is an in-depth treatment based on psychoanalysis, albeit less intensive with fewer meetings per week. Over a century ago, Sigmund Freud introduced controversial ideas about the human mind. It didn’t take long, though, before his followers divided up to pursue their own understandings of the psyche. The different schools fought for superiority and the final claim to truth. In this fight, psychoanalysis became arrogant, while popular culture and the art world shrunk such profound theories into ridiculous simplifications and caricatures. Unconscious conflict gave way to the singular triad of thoughts–feelings–behavior as the cause of human suffering. CBT rose as the most evidence-based treatment, while psychoanalysis receded into the realm of quasi-quackery.

We will find, however, an abundance of rigorous medical literature that establishes significant evidence for the efficacy of psychodynamic psychotherapy.

What is psychodynamic psychotherapy?

Psychodynamic psychotherapy develops self-understanding as the road to healing and fulfillment. The therapeutic relationship builds psychological safety to open awareness to the mind’s range of thoughts, feelings, wishes, and perceptions. Dialogue translates inner life into words that find meaning in what we’ve been through. We discover aspects of ourselves that we didn’t use to know. Difficult, familiar feelings become reworked in real time. Intellectual insight transforms into deep emotional understanding as a powerful force that leads to real change.

Psychodynamic psychotherapy uses this collaborative work between patient and therapist:

• Focusing on emotions: Emotions may be difficult to articulate, especially if overwhelming, intense, or conflicting. We enter into the experience of our feelings when we penetrate the surface-level rendering of facts and external events. We inevitably find strong feelings about ourselves.
• Noticing avoidance: Fear, shame, guilt, or disgust can understandably divert us from pain. This rerouting takes many forms: showing up late, changing the subject, talking about events without any feeling. Hesitation probably means we’re on to something important.
• Uncovering themes and patterns: We may not realize when we repeat the same ways of thinking and feeling, or relating to ourselves and others. Life events may share similarities for a reason.
• Metabolizing the past: The past often impacts our lives right now. Early relationships with important people may be contributing to problems today.
• Focusing on relationships: Connections with other humans affect our inner life, self-concept, and ability to self-soothe. Interpersonal problems cause deep psychological pain as our emotional needs go unmet. How do we learn to be more present in relationships?
• Understanding the therapeutic relationship itself: Habitual ways of relating to others will spontaneously play out with the therapist. The therapist, in turn, maintains curiosity and compassion as these problematic patterns are experienced, understood, and changed in real time.
• Exploring wishes and fantasies: The therapist encourages the client to speak freely. Setting aside reality to momentarily play with possibility, we travel to ideas, images, or metaphors that speak to what we really want in life; we may glimpse new ways to feel about ourselves, too.

So how well does psychotherapy generally work?

To evaluate the effectiveness of a treatment, we turn to medical literature’s highest form of research evidence: the meta-analysis. This type of review summarizes findings from all studies on a given question, and uses statistics to pool data into one, average combined result of a treatment. This result is the effect size, categorized as large, moderate, or small (0.8, 0.5, 0.2 respectively).

More than forty years ago, the first major meta-analysis on psychotherapy analyzed data from 457 independent studies. Therapy resulted in a large effect size (0.85). A subsequent review of 18 different meta-analyses further determined a large effect size (0.75).

As a reference point, a common antidepressant fluoxetine or Prozac shows a small effect size at 0.26. We can’t definitively say that therapy is more effective than medication, though, because studies use different methodologies.

How well does psychodynamic psychotherapy work?

These studies also support the clinical finding that therapy starts a process of growth, or development, that continues to drive future change even after therapy has ended.

Considerations

Studies on psychodynamic psychotherapy assess complex outcomes, as meaningful life goals are difficult to capture on symptom scales for anxiety and depression. Participants need similar problems, at the exclusion of other problems, in order to measure the change after treatment. Studies take longer because of the nature of in-depth work. Finally, patients seeking this treatment usually suffer from long-standing difficulties; their results may not generalize to the general population.

Studies on CBT use manualized treatment to ensure that everyone in the experimental group receives the same, standardized interventions; shorter timelines require less research funding and limit patient drop-out. Shorter treatments also imply faster relief, without the commitment and investment in a long term process.

Short-term treatment, average 30 sessions

The Cochrane Library published a meta-analysis of 23 randomized controlled trials (RCTs) with 1431 patients treated for anxiety, depression, somatic/physical symptoms, and interpersonal and personality issues. Treatment yielded a very large effect size (0.97). Stated as a percentage, participants reported 84% symptom improvement over the control group. After 9 months, symptoms were 93% better than those who did not get treatment.

In Archives of General Psychiatry, a meta-analysis examined 17 RCTs: target problems improved 92% for patients after treatment (1.39). Progress on goals, symptoms, and social functioning continued to improve at 1 year follow-up.

For somatic disorders, or persistent physical symptoms, a meta-analysis of 23 studies and 1870 patients showed moderate effect size (0.59). Effect size on general psychiatric symptoms was moderate to large (0.69). Healthcare utilization also decreased by 78%.

For personality disorders, a meta-analysis in the American Journal of Psychiatry reviewed 14 studies to determine how results fare with time. At 1.5 years follow-up, pretreatment to posttreatment effect size was exceedingly large (1.46). Another study of 7 RCTs found that at 19 months follow-up, symptoms and interpersonal functioning improved with a large effect size (0.91 and 0.97 respectively).

Long-term treatment, average 100 sessions

A meta-analysis in Journal of the American Medical Association found an exceedingly large effect after treatment (1.08). After 2 years, benefits increased to an exceedingly large effect (1.25). Improvements continued to accumulate in treatment targets, psychiatric symptoms, as well as personality and interpersonal functioning.

A subsequent meta-analysis in the Harvard Review of Psychiatry found a large effect size for general symptom improvement in a range of disorders (0.78). At 3 years follow-up, benefits became exceedingly large (0.94). Even in severe personality disorders, effects were large at the end of treatment and even greater at 5 year follow-up (0.94 and 1.02, respectively).

What makes a good outcome for therapy?

Studies have found that no one therapy is superior; investigator bias favored findings typically in support of their preferred modality. Both psychodynamic and cognitive behavioral therapy are empirically validated.

However, studies still have limitations in how and what they measure as successful results. Outcomes determined by symptom scales fail to capture the human need to keep growing and developing. How can researchers capture this?

One scale does try to define mental health, the Shedler-Westen Assessment Procedure (SWAP), via ratings on psychological health and inner capacities.

Highlights of the SWAP evaluate growth in the following areas:

• Empathy, compassion
• Mentalization, or thinking about another person’s perspectives, thoughts, feelings, and needs
• Expressing oneself
• More realistic perceptions and appraisals of other people and situations
• Appreciation of humor
• Ability to process, find meaning, come to terms with, and grow from past painful experiences
• More satisfying sex life
• Using one’s talents and abilities, with pleasure in challenges and accomplishments
• Creativity
• Happiness in life itself, and life’s activities
• More outgoing; comfort in social situations
• Sense of belonging and community
• Assertiveness and interpersonal effectiveness
• Capacity to hear difficult or emotionally threatening information, and benefit from this
• Self-understanding
• More thoughtful, conscientious, and responsible
• Nurturing others
• Close and lasting friendships and relationships, mutually supportive

Common elements between silos

Therapy brings about change, but not simply from theory or techniques alone. What are the mechanisms, then, that relieve suffering and reactivate development?

To answer this question, experts rated hundreds of hours of session recordings on a research scale, the Psychotherapy Process Q-Sort (PQS). This instrument lists 100 variables to examine therapist technique, process, and behavior.

Experts found that therapists in both modalities used techniques from outside of their theoretical orientation, but therapist use of psychodynamic techniques actually predicted successful outcomes in both modalities. Effective therapists prioritized these factors with the following results:

• The strength of the therapeutic alliance and working relationship predicted improvement on all outcomes. Vulnerability can be intolerable. The therapist collaborates as an authentic person with warmth, empathy, and understanding. The therapist helps the client take risks that gradually build trust. The therapist is with the patient when feelings get messy; this may be the patient’s first experience of not feeling alone.
• The patient’s capacity to experience the work on an emotional level predicted improvement on all outcome measures.
• Treatment that incorporated exploration of past relationships and attachments with early caregivers predicted successful outcomes.
• Therapist adherence to a strictly cognitive model of change predicted worse outcomes.

But this is not to say that focus on cognitive techniques is harmful or bad. It’s dogmatic adherence compromising therapist attunement and sensitivity that leads to worse outcomes.

There are limitations in all research on psychotherapy. Psychotherapy changes into new forms with every generation who trains for clinical work. Psychoanalysis is no longer the archaic concepts of Freud, even though his ideas are foundational and meaningful to this day.

Many people come to in-depth therapy because they have emotional pain and feel alone. Relationships, performance at school or work, and, especially, the capacity to just be with ourselves– all hard things. It takes time and work. The fundamental laws of physics understand that all of energy expands into chaos, not a perfectly planned, permanent universe.

What heals and changes the brain is being able to make sense of our experiences. If the experiences in us are overwhelming, deeply troubling, or so upsetting that the feelings don’t make any sense– then we need another person with us for this pain to get better. We need empathy and the feeling of being understood in another person’s mind. We need important people to understand us and reflect back to us how our experiences make sense.

That is the common denominator of effective therapy.