The Efficacy of Psychodynamic Psychotherapy

1 The Efficacy of Psychodynamic PsychotherapyJonathan ShedlerUniversity of Colorado Denver School of MedicineEmpirical evidence supports the Efficacy of psychodynamictherapy. Effect sizes for Psychodynamic therapy are aslarge as those reported for other therapies that have beenactively promoted as empirically supported and evi-dence based. In addition, patients who receive psychody-namic therapy maintain therapeutic gains and appear tocontinue to improve after treatment ends. Finally, nonpsy-chodynamic therapies may be effective in part because themore skilled practitioners utilize techniques that have longbeen central to Psychodynamic theory and practice. Theperception that Psychodynamic approaches lack empiricalsupport does not accord with available scientific evidenceand may reflect selective dissemination of research : Psychotherapy outcome, psychotherapyprocess, psychoanalysis, Psychodynamic therapy, meta-analysisThere is a belief in some quarters that psychodynamicconcepts and treatments lack empirical support orthat scientific evidence shows that other forms oftreatment are more effective.

2 The belief appears to havetaken on a life of its own. Academicians repeat it to oneanother, as do health care administrators, as do health carepolicymakers. With each repetition, its apparent credibilitygrows. At some point, there seems little need to question orrevisit it because everyone knows it to be scientific evidence tells a different story: Consid-erable research supports the Efficacy and effectiveness ofpsychodynamic therapy. The discrepancy between percep-tions and evidence may be due, in part, to biases in thedissemination of research findings. One potential source ofbias is a lingering distaste in the mental health professionsfor past psychoanalytic arrogance and authority. In decadespast, American psychoanalysis was dominated by a hierar-chical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research. Thisstance did not win friends in academic circles. When em-pirical findings emerged that supported nonpsychodynamictreatments, many academicians greeted them enthusiasti-cally and were eager to discuss and disseminate empirical evidence supported Psychodynamic con-cepts and treatments, it was often article brings together findings from several em-pirical literatures that bear on the Efficacy of psychody-namic treatment.

3 I first outline the distinctive features ofpsychodynamic therapy. I next review empirical evidencefor the Efficacy of Psychodynamic treatment, includingevidence that patients who receive Psychodynamic therapynot only maintain therapeutic gains but continue to improveover time. Finally, I consider evidence that nonpsychody-namic therapies may be effective in part because the moreskilled practitioners utilize interventions that have longbeen central to Psychodynamic theory and Features ofPsychodynamic TechniquePsychodynamicorpsychoanalytic psychotherapy1re-fers to a range of treatments based on psychoanalyticconcepts and methods that involve less frequent meetingsand may be considerably briefer than psychoanalysisproper. Session frequency is typically once or twice perweek, and the treatment may be either time limited or openended. The essence of Psychodynamic therapy is exploringthose aspects of self that are not fully known, especially asthey are manifested and potentially influenced in the ther-apy textbooks too often equate psychoan-alytic or Psychodynamic therapies with some of the moreoutlandish and inaccessible speculations made by SigmundFreud roughly a century ago, rarely presenting mainstreampsychodynamic concepts as understood and practiced to-day.

4 Such presentations, along with caricatured depictionsin the popular media, have contributed to widespread mis-understanding of Psychodynamic treatment (for discussionof how clinical psychoanalysis is represented and misrep-resented in undergraduate curricula, see Bornstein, 1988,1995; Hansell, 2005; Redmond & Shulman, 2008). To helpdispel possible myths and facilitate greater understandingof Psychodynamic practice, in this section I review corefeatures of contemporary Psychodynamic and Hilsenroth (2000) conducted a search ofthe PsycLit database to identify empirical studies that com-pared the process and technique of manualized psychody-namic therapy with that of manualized cognitive behavioraltherapy (CBT). Seven features reliably distinguished psy-chodynamic therapy from other therapies, as determined byempirical examination of actual session recordings andI thank Mark Hilsenroth for his extensive contributions to this article;Marc Diener for providing some of the information reported here; RobertFeinstein, Glen Gabbard, Michael Karson, Kenneth Levy, Nancy McWil-liams, Robert Michels, George Stricker, and Robert Wallerstein for theircomments on drafts of the article; and the 500-plus members of thePsychodynamic Research Listserv for their collective wisdom and concerning this article should be addressedto Jonathan Shedler, Department of Psychiatry, University of Colo-rado Denver School of Medicine, Mail Stop A011-04, 13001 East 17thPlace, Aurora, CO 80045.

5 E-mail: use the March 2010 American Psychologist 2010 American Psychological Association 0003-066X/10/$ 65, No. 2, 98 109 DOI: (note that the features listed below concernprocess and technique only, not underlying principles thatinform these techniques; for a discussion of concepts andprinciples, see Gabbard, 2004; McWilliams, 2004; Shedler,2006a):1. Focus on affect and expression of therapy encourages explorationand discussion of the full range of a patient s emotions. Thetherapist helps the patient describe and put words to feel-ings, including contradictory feelings, feelings that aretroubling or threatening, and feelings that the patient maynot initially be able to recognize or acknowledge (thisstands in contrast to a cognitive focus, where the greateremphasis is on thoughts and beliefs; Blagys & Hilsenroth,2002; Burum & Goldfried, 2007). There is also a recogni-tion that intellectual insight is not the same as emotionalinsight, which resonates at a deep level and leads to change(this is one reason why many intelligent and psychologi-cally minded people can explain the reasons for their dif-ficulties, yet their understanding does not help them over-come those difficulties).

6 2. Exploration of attempts to avoid dis-tressing thoughts and do a greatmany things, knowingly and unknowingly, to avoid aspectsof experience that are troubling. This avoidance (in theo-retical terms, defense and resistance) may take coarseforms, such as missing sessions, arriving late, or beingevasive. It may take subtle forms that are difficult torecognize in ordinary social discourse, such as subtle shiftsof topic when certain ideas arise, focusing on incidentalaspects of an experience rather than on what is psycholog-ically meaningful, attending to facts and events to theexclusion of affect, focusing on external circumstancesrather than one s own role in shaping events, and so therapists actively focus on and Identification of recurring themes therapists work to identifyand explore recurring themes and patterns in patients thoughts, feelings, self-concept, relationships, and life ex-periences. In some cases, a patient may be acutely aware ofrecurring patterns that are painful or self-defeating but feelunable to escape them ( , a man who repeatedly findshimself drawn to romantic partners who are emotionallyunavailable; a woman who regularly sabotages herselfwhen success is at hand).

7 In other cases, the patient may beunaware of the patterns until the therapist helps him or herrecognize and understand Discussion of past experience (develop-mental focus).Related to the identification of recur-ring themes and patterns is the recognition that past expe -rience, especially early experiences of attachment figures,affects our relation to, and experience of, the therapists explore early experiences, therelation between past and present, and the ways in whichthe past tends to live on in the present. The focus is noton the past for its own sake, but rather on how the pastsheds light on current psychological difficulties. The goal isto help patients free themselves from the bonds of pastexperience in order to live more fully in the Focus on interpersonal therapy places heavy emphasis on patients relationships and interpersonal experience (in theoreticalterms, object relations and attachment). Both adaptive andnonadaptive aspects of personality and self-concept areforged in the context of attachment relationships, and psy-chological difficulties often arise when problematic inter-personal patterns interfere with a person s ability to meetemotional Focus on the therapy between therapist and patient is itself an im-portant interpersonal relationship, one that can becomedeeply meaningful and emotionally charged.

8 To the extentthat there are repetitive themes in a person s relationshipsand manner of interacting, these themes tend to emerge insome form in the therapy relationship. For example, aperson prone to distrust others may view the therapist withsuspicion; a person who fears disapproval, rejection, orabandonment may fear rejection by the therapist, whetherknowingly or unknowingly; a person who struggles withanger and hostility may struggle with anger toward thetherapist; and so on (these are relatively crude examples;the repetition of interpersonal themes in the therapy rela-tionship is often more complex and subtle than these ex-amples suggest). The recurrence of interpersonal themes inthe therapy relationship (in theoretical terms, transferenceand countertransference) provides a unique opportunity toexplore and rework them in vivo. The goal is greaterflexibility in interpersonal relationships and an enhancedcapacity to meet interpersonal Exploration of fantasy contrast toother therapies in which the therapist may actively structuresessions or follow a predetermined agenda, psychodynamicJonathanShedler99 February March 2010 American Psychologisttherapy encourages patients to speak freely about whateveris on their minds.

9 When patients do this (and most patientsrequire considerable help from the therapist before they cantruly speak freely), their thoughts naturally range overmany areas of mental life, including desires, fears, fanta-sies, dreams, and daydreams (which in many cases thepatient has not previously attempted to put into words). Allof this material is a rich source of information about howthe person views self and others, interprets and makessense of experience , avoids aspects of experience , or inter-feres with a potential capacity to find greater enjoymentand meaning in last sentence hints at a larger goal that is implicitin all of the others: The goals of Psychodynamic therapyinclude, but extend beyond, symptom remission. Success-ful treatment should not only relieve symptoms ( , get ridof something) but also foster the positive presence ofpsychological capacities and resources. Depending on theperson and the circumstances, these might include thecapacity to have more fulfilling relationships, make moreeffective use of one s talents and abilities, maintain arealistically based sense of self-esteem, tolerate a widerrange of affect, have more satisfying sexual experiences,understand self and others in more nuanced and sophisti-cated ways, and face life s challenges with greater freedomand flexibility.

10 Such ends are pursued through a process ofself-reflection, self-exploration, and self-discovery thattakes place in the context of a safe and deeply authenticrelationship between therapist and patient. (For a jargon-free introduction to contemporary Psychodynamic thought,seeThat Was Then, This Is Now: Psychoanalytic Psycho-therapy for the Rest of Us[Shedler, 2006a, which is freelyavailable for download at ]).How Effective Is Psychotherapy inGeneral?In psychology and in medicine more generally, meta-anal-ysis is a widely accepted method for summarizing andsynthesizing the findings of independent studies (Lipsey &Wilson, 2001; Rosenthal, 1991; Rosenthal & DiMatteo,2001). Meta-analysis makes the results of different studiescomparable by converting findings into a common metric,allowing findings to be aggregated or pooled across widely used metric iseffect size, which is the differencebetween treatment and control groups, expressed in stan-dard deviation effect size of means that theaverage treated patient is one standard deviation healthieron the normal distribution or bell curve than the averageuntreated patient.