The research suggests that benefits of this therapy increase with time.

Cognitive behavioral therapy (CBT) has emerged, both in the research literature and in the media, as a "first among equals" in psychotherapy — most often studied and most frequently cited in news reports. CBT seeks to change conscious thoughts and observable behaviors by making patients more aware of them. But considerable research also supports the efficacy of other types of psychotherapy, in particular psychodynamic therapy. In fact, a review in American Psychologist cited evidence that psychodynamic therapy is just as effective as CBT, and that the benefits may increase over time.

Psychodynamic therapy has its roots in psychoanalysis, the long-term "talking cure." Like psychoanalysis, psychodynamic therapy recognizes that the relationships and circumstances of early life continue to affect people as adults, that human behavior results from unconscious as well as conscious or rational motives, and that the act of talking about problems can help people find ways to solve them or at least to bear them.

Both psychoanalysis and psychodynamic therapy rely on the therapeutic alliance in order to work. The therapeutic alliance is the personal connection between therapist and patient that enables them to work in tandem so that the patient can gain insight into aspects of experience that may be difficult to talk and think about. As the therapeutic alliance deepens, a therapist helps patients to understand themselves in new ways, and to become more mindful of a greater range of their thoughts, feelings, perceptions, and experiences. Dr. Glen Gabbard, professor of psychiatry and psychoanalysis at Baylor College of Medicine, has called the therapeutic alliance the "envelope" within which psychodynamic therapy takes place.

Although modern therapists frequently question the distinction, it is useful to note that psychodynamic therapy and psychoanalysis differ in some ways. During psychoanalysis, patients generally attend meetings three to five days a week, whereas in psychodynamic therapy, a patient typically sees a therapist once or twice a week. Thus the intensity of the therapeutic relationship is greater in psychoanalysis. Both psychoanalysis and the long-term form of psychodynamic therapy may be conducted in an open-ended manner, over many years, with the patient and therapist/analyst taking as much time as they need to decide about the duration of treatment. Short-term treatment with psychodynamic therapy, in contrast, is time-limited and usually lasts less than six months.

Psychodynamic therapy is an option for patients with a variety of mental health disorders and personality disorders. Paragraph 9 0 Gwendolyn Orme Apr 8 Gwendolyn Orme Gwendolyn Orme Gwendolyn Orme (Apr 08 2019 2:12PM) : I will need to ensure that this type of therapy can be used to treat phobias. It is the second most used therapy, but I need to ensure that phobias can be treated using it. Edit Reply Reply with AI Comment Options ▼ Edit Comment Delete Comment Archive Comment Show Comment URL New Conversation Paragraph 9, Sentence 1 0 No sentence-level conversations. Start one. Although it is similar in some ways to psychoanalysis, psychodynamic therapy may be shorter in duration or intensity. Paragraph 10 0 Gwendolyn Orme Apr 8 Gwendolyn Orme Gwendolyn Orme Gwendolyn Orme (Apr 08 2019 2:13PM) : The length of psychoanalysis is one of the biggest issues with it, so the shorter time frame of psychodynamic therapy is a big plus. Edit Reply Reply with AI Comment Options ▼ Edit Comment Delete Comment Archive Comment Show Comment URL New Conversation Paragraph 10, Sentence 1 0 No sentence-level conversations. Start one. Several reviews suggest that psychodynamic therapy is as effective as cognitive behavioral therapy. Paragraph 11 0 No paragraph-level conversations. Start one. Paragraph 11, Sentence 1 0 No sentence-level conversations. Start one.

Gaining self-knowledge

A paper compared psychodynamic therapy to CBT. It highlighted notable differences between these two forms of therapy.

Acknowledging emotion. Whereas CBT focuses on thoughts and beliefs, psychodynamic therapy encourages a patient to explore and talk about emotions as well — including those that are contradictory, threatening, or not immediately apparent. The focus is on using therapy to gain emotional, as well as intellectual, insight. Ideally, insight enables a patient to reconsider life patterns that once seemed inevitable or uncontrollable, and leads to the identification of new choices and options. The insight may lead a patient to feel more ready to make changes.

Understanding avoidance. Psychodynamic therapy helps patients to recognize and overcome ingrained and often automatic ways in which they avoid distressing thoughts and feelings. Therapy may bring avoidance into high relief — such as when patients cancel therapy appointments, arrive late, or tiptoe around emotionally charged topics. Psychodynamic therapists point out that such psychological maneuvers often involve painful compromises between the wish to attend sessions in order to get help, and the fear of what may emerge during therapy. Psychodynamic therapy can help a patient become more aware of these maneuvers, which are likely to manifest outside of therapy as well, with the aim of nurturing more flexible and adaptive ways of coping.

Identifying patterns. Psychodynamic therapy recognizes that in mental life, the past is often prologue. Early-life experiences, especially with parents, caregivers, and other authority figures, shape present-day outlook and relationships. The goal of psychodynamic therapy is not to dwell on the past but to explore how prior relationships and attachments may provide insight into current psychological problems. A psychodynamic therapist may work with a patient to identify recurring patterns in relationships, emotions, or behaviors (such as being drawn to a verbally abusive partner) to help the patient recognize them. At other times the patient may already be painfully aware of self-defeating patterns, but needs help to understand why they keep recurring and how to overcome psychological obstacles to making changes. The aim of this work is to give patients greater freedom to direct their lives.

Focusing on relationships. Interpersonal relationships — with loved ones, friends, and colleagues — are a core focus of psychodynamic therapy. A person's characteristic responses to other people often emerge in relation to the therapist, a phenomenon known as transference. For example, a patient who experienced hostility or dependency in an early important relationship may find the same feelings arise during a therapy session. Thus the therapeutic relationship provides a window into the dynamics of a patient's relationships outside the office, and offers an opportunity to recognize and change self-defeating patterns.

Psychodynamic therapy often addresses not just transference, but also the therapist's responses to the patient, often called "counter-transference." Such reactions may reflect the therapist's own formative relationships, but they often signify the "pull" the therapist feels to play out the patient's relationship patterns. Either way, the psychodynamic therapist tries to help patients understand how they contribute both to beneficial and painful relationship patterns, and how such reactions often originate within the self, yet foster the tendency to see the outside world (including relationships) as the exclusive source of disappointment or other painful emotion.

Encouraging free associations. In CBT and other structured therapies, the clinician tends to lead the discussion. In psychodynamic therapy, the clinician encourages a patient to speak as freely as possible about thoughts, desires, dreams, fears, and fantasies, as they come to mind. Psychodynamic therapists believe this unstructured, uncensored process of reporting provides access to thoughts and feelings that might otherwise remain outside of awareness. These thoughts and feelings might then become the raw material for helpful insight, or be reworked in ways that expand freedom and choice. However, it is not true that psychodynamic therapy is entirely "non-directive." For example, good dynamic therapists frequently direct the attention of their patients to issues that they are avoiding.

Benefits improve over time

Randomized controlled studies are the ideal way to evaluate treatments in medicine, but psychodynamic therapy, with its individualized technique and complex aims, has not lent itself readily to this type of study. It is not surprising that it has taken longer for researchers to develop and validate rigorous methods for studying this treatment. Nevertheless, randomized controlled studies support the use of psychodynamic therapy for anxiety, borderline personality disorder, depression, eating disorders, post-traumatic stress disorder, panic disorder, somatoform disorders, and substance-use disorders.

Meta-analyses are another way to judge efficacy of treatment. These reviews convert findings from multiple studies using different methods and populations into a common metric, most often an "effect size" that estimates overall treatment benefit.

Short-term therapy. A meta-analysis by the Cochrane Collaboration, an international group of experts, included 23 randomized controlled studies involving a total of 1,431 patients with varying diagnoses, most often depression and anxiety. All underwent short-term psychodynamic therapy (defined in this review as less than 40 hours in duration). When compared with controls (a waiting list, minimal treatment, or treatment as usual), short-term psychodynamic therapy significantly improved symptoms, with modest to moderate clinical benefits. When patients were assessed nine months or more after treatment ended, to determine long-term outcomes, the effect size of psychodynamic therapy had increased, suggesting that therapy led to lasting psychological changes that yielded more benefits as time went on.

A meta-analysis in Archives of General Psychiatry included 17 randomized controlled trials involving patients with a range of diagnoses. It concluded that short-term psychodynamic therapy was significantly more effective than a waiting list control or treatment as usual in the community, and that it was just as effective as other types of psychotherapy, such as CBT, supportive therapy, and interpersonal therapy.

Long-term therapy. A meta-analysis published in The Journal of the American Medical Association compared long-term psychodynamic therapy (defined in this paper as lasting at least a year or consisting of at least 50 sessions) with various short-term psychotherapies. It included 11 randomized controlled trials and 12 observational studies (included to provide results of psychodynamic therapy as practiced in real-world clinical settings). The studies enrolled 1,053 patients diagnosed with personality disorders or hard-to-treat mood or anxiety disorders. The analysis showed that long-term psychodynamic therapy significantly benefited patients with complex psychiatric disorders, and that patients continued improving after therapy ended.

Another meta-analysis, published in the Harvard Review of Psychiatry, included 27 studies of long-term psychoanalytic therapy (most often psychodynamic therapy), enrolling more than 5,063 patients and lasting an average of 150 sessions. Only one of the studies was a randomized controlled study; five were surveys and 21 were epidemiologic studies (most of them prospective). Diagnoses included anxiety, depression, and personality disorders, but often were unspecified. Based on a comparison of effect sizes, this meta-analysis concluded that long-term psychoanalytic therapy may be particularly useful for patients with severe personality disorders, who benefited more from treatment than patients with mixed or moderate pathology.

Challenges and conclusions

One ongoing challenge in the research is that the studies of psychodynamic therapy often involve patients with different diagnoses, making it hard to draw conclusions about how effective this approach will be for individual patients. Moreover, many studies provide inadequate details about treatment methods or use "control" situations (such as a waiting list) that don't actually control for the benefits of active intervention, no matter what technique is being employed.

Nevertheless, there is now enough research available to support the claim that psychodynamic therapy is an evidence-based treatment with effect sizes similar to or superior to those reported for other psychotherapies. In the current reimbursement environment, however, a significant practical challenge is whether psychodynamic therapy will also prove to be cost-effective — especially in the "real world," where practitioners vary in terms of skills and experience, and patients vary in commitment to continuing therapy.

Yet it is encouraging that the benefits of psychodynamic therapy not only endure after therapy ends, but increase with time. This suggests that insights gained during psychodynamic therapy may equip patients with psychological skills that grow stronger with use.

De Maat S, et al. "The Effectiveness of Long-Term Psychoanalytic Therapy: A Systematic Review of Empirical Studies," Harvard Review of Psychiatry (Jan.–Feb. 2009): Vol. 17, No. 1, pp. 1–23.

Gabbard GO, ed. Textbook of Psychotherapeutic Treatments (American Psychiatric Publishing, 2009).

Shedler J. "The Efficacy of Psychodynamic Psychotherapy," American Psychologist(Feb.–March 2010): Vol. 65, No. 2, pp. 98–109.

For more references, please see www.health.harvard.edu/mentalextra.

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