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Talk Therapy: Off the Couch and into the Lab

Researchers gather evidence that talk therapy works -- and keeps on working



LisaFX

A remarkably important event has just occurred in the world of psychology:  A leading, peer-reviewed journal has published the strongest evidence yet that psychodynamic psychotherapy -- “talk therapy” -- works. In fact, it not only works, it keeps working long after the sessions stop.

Full disclosure: We report this not as disinterested observers, but as psychotherapists and researchers on the process and efficacy of therapy. Our book, “Handbook of Evidence-Based Psychodynamic Psychotherapy,” summarized the body of research through last year and another will follow late this year. Still, we can state as fact: The movement to establish an evidence base for psychodynamic therapy has taken a giant new step forward.

This new academic paper reports positive findings about the form of therapy that began with Sigmund Freud and has historically been utilized more than any other psychotherapy treatment. What does modern psychodynamic psychotherapy look like? Its distinctive features include several basic building blocks: A focus on emotion and relationships; identification of recurring themes and patterns; discussion of past experiences; a focus on the therapy relationship; exploration of attempts to avoid distressing thoughts and feelings; and exploration of fantasy life.

Overall, the paper found, psychodynamic psychotherapy demonstrates efficacy at least equivalent to other psychotherapy treatments commonly labeled as “empirically supported” and “evidence based.” And in fact, it notes, psychodynamic therapy's "active ingredients" are shared by many other forms of therapy as well.

The paper heralds a turnaround thirty years in the making: Practitioners of psychoanalysis and psychodynamic psychotherapy were notoriously late to the research enterprise. Through the late 20th century, they eschewed the need to enter the rigorous academic world of process and outcome research, claiming that gathering observable data from psychotherapy sessions could not apprehend the essence of treatment that is based on unconscious meaning.

That stance made it ever harder for psychodynamic psychotherapists to convince insurance companies to pay for their services, especially long-term treatments. It also made psychodynamic psychotherapy look somewhat backward compared to schools of therapy that actively did gather efficacy data, such as cognitive-behavioral therapy, a treatment which focuses on patients' irrational beliefs.

In recent years, however, for reasons of self-interest and consumer interest, those attitudes have changed, and psychodynamic clinicians and researchers have engaged in research with growing force. They are measuring treatment variables such as empathy and the therapeutic alliance, the compact between patient and therapist about goals and methods of the therapy. They are also studying physiological markers such as galvanic skin response: they measure skin conductance on the patient and the therapist during sessions, and the greater the concordance between the two, the higher the level of empathy.

Additionally, research from neuroscience is beginning to offer implicit support to the mechanisms of action of psychodynamic psychotherapy. Initial findings, for example,  suggest that as patients learn to regulate their emotions, that change is reflected in the prefrontal cortex, the seat of executive function.

The new paper by Jonathan Shedler, an associate professor of psychiatry at the University of Colorado School of Medicine, appeared in the journal American Psychologist. It carefully analyzes the results of randomly controlled trials -- the gold-standard for scientific studies -- of psychodynamic psychotherapy treatments for a wide range of psychological disorders.    

Shedler’s paper aggregates these studies and presents the encouraging results. He analyzed multiple studies conducted around the world by clustering them into single, larger studies (meta-analyses). And perhaps his most important finding, concluded from five different meta-analyses that he created, is that positive change and patient growth continue to develop beyond therapy termination, as measured in follow-up assessments conducted as long as three years post-treatment. This finding suggests that psychodynamic psychotherapy provides patients with the tools to continue to function better in the world, feel better about themselves, reduce psychiatric symptoms and face life’s challenges with greater flexibility and freedom well beyond the end of their sessions.

Shedler explains that the scope of psychodynamic psychotherapy includes the reduction of psychiatric symptoms but is more ambitious in that it hopes to foster the positive presence of psychological capacities and resources. Improving self-esteem, changing distorted views of self and others and helping patients to find greater satisfaction in relationships while mastering life’s many challenges are often goals of the therapy, mutually determined by patient and therapist.

The second section of the paper delivers the strongest message for both the general public and the larger world of psychiatric care.  Shedler’s analyses demonstrate very strong effects for psychodynamic psychotherapy. As he says, “Randomized controlled trials support the efficacy of psychodynamic psychotherapy for depression, anxiety, panic disorder...eating disorders, substance disorders and personality disorders.” Shedler’s findings withstood unusually rigorous demands of journal reviewers, over a full year, who required three revisions and re-submissions before publication.

The third section of Shedler’s paper describes studies that suggest that many forms of therapy share common “active ingredients” that traditionally characterize psychodynamic psychotherapy. And that may partly explain the positive outcomes they achieve. There may even be active ingredients -- such as empathic listening, establishing a therapeutic alliance, setting treatment goals and the patient’s hopes and expectations -- that are common to all psychotherapy approaches. For example, perhaps the distinctions between an emphasis on cognition, as in cognitive-behavioral therapy, and an emphasis on emotions, as in psychodynamic psychotherapy, are not as critical as theory dictates.

Shedler’s findings are not without detractors, however, and he too describes the limitations of his work. He calls for more research on psychodynamic psychotherapy, explaining that, despite the strength of his current findings, there are not yet an adequate number of studies. And he points out that many of the studies he analyzed are treatments for a range of conditions rather than for specific psychiatric disorders. Other treatments, cognitive-behavioral therapy in particular, have conducted studies for specific disorders -- which allows for a sharper focus on whether the specifics of a treatment are effective for a given disorder. Work to correct that deficit is under way: since 2005, an increasing number of studies have looked at psychodynamic psychotherapy treatments for specific disorders.

Other criticisms have appeared, mostly from researchers in cognitive-behavioral approaches to treatment. The criticism tends to mirror Shedler’s statements of the limitations of his conclusions but takes them to an extreme. For example, some critics dismiss the value of the research entirely because the efficacy studies are for mixed disorders rather than for a specific disorder.

This paper is born into a psychological world that has seen rancorous disputes, often seeming to be guild-based rather than scientifically based. The adherents of cognitive-behavioral therapy understandably resented the arrogance of the psychodynamic practitioners who refused to submit their treatments to research initiatives. Now that psychodynamic psychotherapists have a sense of urgency to provide an evidence base, some cognitive-behavioral researchers can’t find room to consider them scientists. Some even want only their treatments to be considered evidence-based, despite the growing evidence base on psychodynamic psychotherapy, and ask that training programs in psychology teach only their treatment approaches while accusing other psychologists of not being interested in science.

We would counter that psychodynamic psychotherapy has evolved. There is a freshness to its modern forms, which include an emphasis on the healing power of the relationship in addition to Freud's emphasis on making the unconscious conscious.  It's not an outdated relic or a spiritual exercise. As accumulating research confirms, it provides lasting benefits in people's lives and is worth the energy and expense. To those who dismiss it as outmoded we would say: You might want to try it again for the first time.

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