Gordon, R.M. (2010), The Scientific Renaissance of Psychodynamic Therapy (PDT), Pennsylvania Psychologist Quarterly, March, 70,3, 22-23.
The Scientific Renaissance of Psychodynamic Therapy (PDT)
Robert M. Gordon, Ph.D. ABPP
John Simmons (2009) in his “The Scientific 100” ranked the top six scientists of all time: Newton, Einstein, Bohr, Darwin, Pasteur and Freud. Although most of Freud’s ideas have strong empirical support (Bornstein & Masling, 1998; Westen, 1998) as does the psychodynamic formulation of psychopathology (PDM Task Force, 2006), and psychoanalytic treatment (de Maat et al. 2009; Leichsenring & Rabung, 2008), despite this, there is still a great deal of resistance to a psychodynamic psychology.
Empirical research in psychoanalysis began early on. Otto Fenichel in 1930 studied the results of 721 patients in psychoanalysis at the Berlin Institute. He found that psychoanalysis was very effective for the neurotic patients, but not so effective for the psychotic patients. Psychoanalytic researchers continued publishing empirical effectiveness and process studies with refinements in theory and treatment over the years. Although this research has been largely ignored by academic psychologists.
Effectiveness research in naturalistic settings fell out of favor to the randomized controlled trials (RCTs). This methodology greatly favored behavioral and cognitive treatments that were very short-term and single symptom focused that could be easily studied under stricter laboratory conditions. In the early 1990s the division of Clinical Psychology considered RCTs the “gold standard” and they advocated only those treatments supported by RCT research. Psychodynamic researchers had problems with this sort of research on ethical grounds (for example offering only a long-term control group to people in need of treatment) and theoretical grounds. For example, the value of trying to understand personality piecemeal in a laboratory setting when it is a complex, dynamic, adaptive system and then validly generalizing the results to naturalistic settings.
Psychodynamic researchers wanted to study complex syndromes that involved affects, memories, cognitions, behaviors, preconscious fantasies, temperament, attachment and object internalizations and defenses in a dynamic interaction. They were interested in studying polysymptomatic patients with underlying personality disorders that are common to actual practice, as well assessing increasing mental capacities such as ego resiliency. For example, I (Gordon, 2008) found a powerful effect size increase of .80 in the MMPI Ego Strength scale after about 3 years of psychoanalytic psychotherapy with 55 polysymptomatic borderline level patients.
Cogan & Porcerelli, (2005) using the Shedler-Westen Assessment Procedure (SWAP) as an outcome measure, found that patients who completed psychoanalysis as compared to those in the beginning stage of psychoanalysis, not only had significantly lower scores in symptoms such as depression, anxiety, guilt, shame, feelings of inadequacy, and fears of rejection, but also significantly higher scores in inner strengths and capacities. These included an increased capacity for pleasure, ability to achieve, empathy for others, interpersonal effectiveness, and increased resiliency.
Eventually, a new generation of psychoanalytic researchers began to do ethically sound, high quality, short-term and long-term effectiveness (field) and efficacy (RCT) research. They still had trouble getting published. In an insightful move, relabeling “psychoanalytic” as “psychodynamic” circumvented much of the prejudice (I use the terms interchangeably), and funding and publication outlets slowly opened up.
Psychodynamic therapy (PDT) is now the more favored term with researchers for referring to all the forms of psychoanalytic treatment. Blagys & Hilsenroth (2000) found seven features that reliably distinguished PDT from other therapies: 1. focus on affect and expression of emotion, 2. exploration of attempts to avoid distressing thoughts and feelings, 3. identification of recurring themes and patterns, 4. discussion of past experience (developmental focus), 5. focus on interpersonal relations, 6. focus on the therapy relationship, and 7. exploration of wishes and fantasies.
Jonathan Shedler (2010) recently summarized the efficacy research on psychodynamic therapy in the American Psychologist. The publication in this journal marks a historic turn in events for psychoanalytic science. He reported that RCT studies supported the efficacy of PDT for depression, anxiety, panic, somatoform disorders, eating disorders, substance related disorders, and personality disorders. He compared the meta-analytic studies of PDT with the meta-analytic studies of CBT and related therapies. The psychodynamic outcome studies tended to have similar or larger effect sizes as the “empirically supported” non-psychodynamic treatments. This should not be surprising since PDT targets more personality constructs at a deeper level with more intensive treatment than the non-psychodynamic treatments.
Further, while the benefits of the non-psychodynamic empirically supported therapies tend to decay over time (Westen, Novotny, & Thompson-Brenner, 2004), PDT has enduring benefits. For example, Bateman & Fonagy, (2008) found that five years after treatment completion (and eight years after treatment initiation), 87% of patients who received “treatment as usual” continued to meet diagnostic criteria for borderline personality disorder, compared to 13% of patients who received PDT. No other treatment for personality pathology has shown such enduring benefits.
Shedler presented five independent meta-analyses showing that the benefits of PDT not only endure but also increased with time. That is, the patients not only had significant symptom reduction that held up over time, but also acquired increased mental capacities that allowed them to continue in their maturation over the years. Additionally, Shedler presented several studies that showed that it is the psychodynamic process that predicted successful outcome in cognitive therapy rather than the pure cognitive aspects of the treatment.
Now, more than 100 years since Freud’s ideas of a dynamic unconscious rattled American psychologists, there is more than enough evidence to require graduate schools to teach psychodynamic theory and treatment as scientifically valid and essential to our understanding of psychology.
Bateman, A. & Fonagy, P. (2008). 8-Year follow-up of patients Treated tor borderline personality disorder: Mentalization-Based Treatment versus Treatment as Usual. American Journal of Psychiatry, 165, 631-638.
Bornstein, R. F., & Masling, J. M. (Eds.) (1998). Empirical Studies of Psychoanalytic Theories, Volume 7: Empirical Perspectives on the Psychoanalytic Unconscious. Washington, DC: American Psychological Association.
Blagys, M.D. & Hilsenroth, M.J. (2000). Distinctive activities of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7, 167-188.
Cogan R. & Porcerelli, J.H. (2005). Clinician reports of personality pathology of patients beginning and patients ending psychoanalysis. Psychology and Psychotherapy: Theory, Research, and Practice, 78(2), 235-248.
de Maat, S., de Jonghe, F., Schoevers, R. and Dekker, J. (2009). The Effectiveness of Long-Term Psychoanalytic Therapy: A Systematic Review of Empirical Studies, Harvard Review of Psychiatry,17:1,1 — 23
Gordon, R.M. (2008). Addendum To MMPI/MMPI–2 Changes In Long Term Psychoanalytic Psychotherapy. Issues in Psychoanalytic Psychology, Issues In Psychoanalytic Psychology Vol. 30, No. 2, p.159.
Leichsenring, F., Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. Journal of the American Medical Association, 300, 1551-1565.
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Simmons, J.G (2009). The Scientific 100: A Ranking of the Most Influential Scientists, Past and Present. Fall River Press, N.Y., N.Y.
Westen, D. (1998). The scientific legacy of Sigmund Freud: Toward a psychodynamically informed psychological science. Psychological Bulletin, 124, 333-371.
Westen, D., Novotny, C.M., & Thompson-Brenner, H. (2004). The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials. Psychological Bulletin, 130, 631–663.