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Is Psychoanalytic Psychotherapy Empirically Validated?

Psychoanalytic Psychotherapy Empirically ValidateIs psychoanalytic psychotherapy empirically validated? The short answer is, yes. And empirical support for this long-established approach is rapidly growing.

Why do some people assume that it isn’t evidence-based? Probably because empirical research on psychoanalytic psychotherapy has been slower in coming than for some other clinical approaches.

There are a number of reasons why empirical validation of psychoanalytic psychotherapy has lagged behind other therapeutic approaches.

First, psychoanalytic psychotherapy is relatively difficult to assess with standard empirical techniques. Empirical research typically relies on quantitative data, observable outcomes, unvarying procedures applied across cases, large sample sizes, and replication of findings. Experiments with random assignment to discrete conditions with a control group (i.e., randomized-controlled studies) are considered the “gold standard” in research because they are highest in internal validity (i.e., determining cause-effect relationships). Each of these elements is problematic for psychoanalytic psychotherapy.

Let’s first consider the type of data involved. The aim of psychoanalytic psychotherapy is not merely to reduce problem behaviors; rather, it is to help deepen self-understanding and to achieve some outcomes that are important for an individual’s quality of life but difficult to measure. Psychoanalysis and psychoanalytic psychotherapy provide a setting where an individual’s personal truths can become known, understood, and shared. Some outcomes may be assessable through self-report, rating scales, or behavioral outcomes. Patient self-reports, however, may not reflect the deeper, sometimes ineffable changes that lead to greater health. Their validity can also be undermined by fabrications and/or a patient’s wish to validate (or invalidate) a treatment process. Even observable behavior change does not always accompany or reflect growth and improved well-being attained in psychoanalytic psychotherapy.

As we are complex creatures, psychoanalytic theories are also inherently complex, providing models for appreciating the uniqueness of the human experience. These models are difficult to understand, let alone to operationalize, by a researcher who is not an experienced psychoanalytic psychotherapist. And most researchers are not experienced psychoanalytic psychotherapists.

Then, there are procedures that must be standardized across cases in research studies. Psychoanalytic psychotherapy considers such constructs as the changing phenomenology of the patient and the transference relationship with the clinician—both difficult, if even possible, to replicate in a meaningful way, as each case is unique. The gold standard of research involves random assignment to condition. Random assignment requires that discrete conditions be pre-determined, which may be difficult, if even feasible, when the clinician’s focus is on responding to the changing, unconscious needs of an individual. Is psychoanalytic psychotherapy empirically validated? Because research involving psychoanalytic psychotherapy has tended to involve observational or case studies, the studies have not always been “counted” as evidence. Hence, the approach is often assumed not to be evidence-based.

Furthermore, psychoanalytic psychotherapy often deals with issues that cannot be resolved quickly. This factor has several implications. First, many researchers depend on number of publications for tenure, academic promotion, etc., making long-term studies less desirable. No wonder there are so many more outcome studies on cognitive-behavior therapy (CBT). And, statistical power relies on having a large enough sample size to reveal subtle differences. When therapy is individualized and longer term, gathering a large sample is impractical.

Finally, psychoanalytic psychotherapy occurs through the relationship with the therapist—a vehicle that is viewed as sacred and to be protected from contamination by outside factors. As such, psychoanalytic psychotherapists have tended to be suspicious of and protective against incorporating empirical assessments that could influence the therapeutic process.

In contrast, cognitive-behavior therapy focuses on modifying observable behaviors and/or conscious cognitions, with protocols that are brief, relatively simple to manualize, and conducive to randomized controlled studies. Consequently, many research studies have been published on this approach, leading some to assume that it is the only valid type of therapy for many conditions. A self-fulfilling prophecy is then also engaged, with greater recognition leading to greater access to further research funding, for even more outcome studies and confidence in the approach.

Is psychoanalytic psychotherapy empirically validated? Despite the many challenges, the quality and quantity of research testing psychoanalytic psychotherapy is increasing. More proponents of the approach are becoming convinced of the importance of providing research evidence and becoming creative in ways to test its complex features. Midgley et al. (2021) recently published a narrative synthesis of such outcome studies, including a growing number of randomized-controlled studies involving psychodynamic techniques.

There are future challenges, however. More funding is needed for studies that are complex and difficult to operationalize. Randomized-controlled studies have routinely been favored by the scientific community; hopefully, observational studies will also come to “count” as empirical evidence. As noted by Midgley et al. (2021), “Whilst the findings of these studies cannot be considered as ‘rigorous’ as those of experimental studies, such studies may be more representative of a ‘real-world’ context, where treatments are not often delivered according to a specific manual, treatment length is not predetermined, and patients often present with a mixed picture of mental health issues” (p. 12).

I value the words of Eric Kandel, neuroscientist and Nobel Laureate: “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (1999, p. 505). https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.4.505

To learn more about Midgley et al.’s (2021) narrative synthesis of outcome studies on psychodynamic psychotherapy, please see their open-access article: Midgley, N., Mortimer, R., Cirasola, A., Batra, P., & Kennedy, E. [2021]. The evidence-base for psychodynamic psychotherapy with children and adolescents: A narrative synthesis. Frontiers in Psychology12, 1-18. doi: 10.3389/psyg.2021.662671.

You may also earn 2 CE credits for reviewing the article by registering for the online course, Evidence Base for Psychodynamic Psychotherapy With Children and Adolescents: https://www.psychstudies.net/product/evidence-base-for-psychodynamic-psychotherapy-with-children-and-adolescents/

You may also enjoy our blog, Is Psychodynamic Psychotherapy Evidence-Based?

Is Psychodynamic Psychotherapy Evidence-Based?
Evidence-Based Psychodynamic Psychotherapy

Is Psychodynamic Psychotherapy Evidence-Based?

The public—and many clinicians—often assume that it is not. In fact, many university courses teach that only cognitive-behavioral approaches have current empirical support. This assumption is false and does a disservice to the field and to the public alike. A growing number of studies demonstrate that psychodynamic psychotherapy is evidence-based, and support the value of psychoanalytic and psychodynamic approaches, especially for complex cases and long-term change. 

Some Psychological Approaches Are Easier to Research Than Others

Clinical psychology is a multifaceted discipline, with a history that spans over 100 years. Since its origins, approaches and perspectives have come and gone in popularity. Classical psychoanalysis, object relations theory, and ego psychology; humanistic client-centered, gestalt, and existential therapies; behavior therapies; cognitive, cognitive-behavioral, and mindfulness-based cognitive therapies; interpersonal therapy; eye movement desensitization therapy; dialectical behavior therapy; integrative or holistic therapy—and the list continues to grow. Some approaches have been studied more than others. Many show promising results in some studies, only to be found to be limited in others. Some win favor because they are simple to research, and so garner publicity and research grants. Others draw attention because they are easy to teach and to master, or are short in duration and so inexpensive. Psychoanalytic and psychodynamic approaches are complex; they are not easily taught and they pose challenges to research. But, despite this, they continue to have many followers and are gaining impressive scientific support.

A Growing Body of Research Supports the Value of Psychodynamic Psychotherapy, Despite Its Complexity

Is psychodynamic psychotherapy evidence-based? Absolutely! Numerous current scientific studies support the value of psychodynamic and psychoanalytic approaches. In fact, meta-analyses—studies that gather evidence across multiple studies—demonstrate the effectiveness of psychodynamic and psychoanalytic work and indicate that, in some cases, psychodynamic approaches may be more effective in the long-run than other therapeutic models (e.g., Abbass et al., 2014; Baardseth et al., 2013; Bastos, Guimaraes, & Trentini, 2015; Buchheim et al., 2012; Busch, 2015; Grande et al., 2009; Johansson et al., 2010; Kallestad, Valen, McCullough, Svartberg, Høglend, & Stiles, 2010; Klug, Zimmermann, & Huber, 2016; Leichsenring, & Rabung, 2011; Midgley & Kennedy, 2011; Parker & Turner, 2014; Rizeanu, 2016; Shedler, 2010; Shepherd & Beail, 2017; Soares et al., 2018; Waldron, Gazzillo, Genova, & Lingiardi, 2013; Waldron, Gazzillo, & Stukenberg, 2015).

Psychodynamic Psychotherapy Is Often Misperceived

As noted by Shedler (2010) in an article published by the American Psychologist—a well-regarded publication of the American Psychological Association, “the perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings” (p. 98). This faulty perception has led some educational programs to downplay its significance or even dismiss it as an “outdated” approach. It is in the public interest that the field conduct scientific inquiry into the potential benefits and mechanisms of all therapies that clinicians have found to be valuable. Researchers cannot adequately investigate theories that they do not fully understand—research draws from a theoretical base (Britzman, 2012), which must be clearly understood before meaningful studies can be conducted regarding its mechanisms (e.g., Gazzillo et al., 2017; Laska, Gurman, & Wampold, 2014; Waldron et al., 2015). It is, therefore, crucial for science as well that the field continue to be educated about the premises of these valuable therapeutic approaches. Unlike some behavioral theories, many of the constructs of psychodynamic and psychoanalytic theory can only be assessed indirectly. Fortunately, many researchers are accepting the creative challenge.

It Is Important to Continue Researching All Psychotherapy Approaches

It is important for psychologists, psychoanalysts, and counselors to stay current, with scientifically grounded evidence, regarding issues relevant to enhancing their service to the public and the profession. Research, and informed discussion and practice, strengthen the profession. Is psychodynamic psychotherapy evidence-based? Yes, psychodynamic and psychoanalytic therapies are indeed empirically validated as valuable approaches for a wide range of disorders and clients. And, to quote Eric Kandel, neuroscientist and Nobel Laureate, “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (1999, p. 505).

References for Evidence-Based Psychodynamic Psychotherapy

Abbass, A. A., Kisely, S. R., Town, J. M., Leichsenring, F., Driessen, E., De Maat, S., Gerber, A., Dekker, J., Rabung, S., Rusalovska, S., & Crowe, E. (2014). Short-term psychodynamic psychotherapies for common mental disorders (review). Cochrane Database of Systematic Reviews, 7, 1-108.  doi: 10.1002/14651858.CD004687.pub4

Baardseth, T. P., Goldberg, S. B., Pace, B. T., Wislocki, A. P., Frost, N. D., Siddiqui, J. R., Lindemann, A. M., Kivlighan III, D. M., Laska, K. M., Del Re, A. C., Minami, T., & Wampold, B. E. (2013). Cognitive-behavioral therapy versus other therapies: Redux. Clinical Psychology Review, 33, 395-405. http://dx.doi.org/10.1016/j.cpr.2013.01.004

Bastos, A. G., Guimaraes, L. S. P., & Trentini, C. M. (2015). The efficacy of long-term psychodynamic psychotherapy, fluoxetine and their combination in the outpatient treatment of depression. Psychotherapy Research, 25(5), 612-624. https://doi.org/10.1080/10503307.2014.935519

Britzman, D. P. (2012). What is the use of theory? A psychoanalytic discussion. Changing English: Studies in Culture and Education, 19(1), 43-56. https://doi.org/10.1080/1358684X.2012.649143

Buchheim, A., Viviani, R., Kessler, H., Kächele, H., Cierpka, M., et al. (2012). Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy. PLoS ONE, 7(3). https://doi.org/10.1371/journal.pone.0033745

Busch, F. N. (2015). Discussion: Psychoanalytic research: Progress and questions. Psychoanalytic Inquiry, 35, 196-203. https://doi.org/10.1080/07351690.2015.987607

Gazzillo, F., Waldron S., Gorman, B. S., Stukenberg, K. W., Genova, F., Ristucci, C., Faccini, F., & Mazza, C. (2017). The components of psychoanalysis: Factor analyses of process measures of 27 fully recorded psychoanalyses. Psychoanalytic Psychology, advance online publication, 1-12. http://dx.doi.org/10.1037/pap0000155

Grande, T., Dilg, R., Jakobsen, T., Keller, W., Krawietz, B., Langer, M., Oberbracht, C., Stehle, S., Stennes, M., & Rudolf, G. (2009). Structural change as a predictor of long-term follow-up outcome. Psychotherapy Research, 19(3), 344-357. https://doi.org/10.1080/10503300902914147

Johansson, P., Høglend, P., Ulberg, R., Amlo, S., Marble, A., Bøgwald, K.-P., Sørbye, Ø., Sjaastad, M. C., & Heyerdahl, O. (2010). The mediating role of insight for long-term improvements in psychodynamic therapy. Journal of Consulting and Clinical Psychology, 78(3), 438-448. http://dx.doi.org/10.1037/a0019245

Kallestad, H., Valen, J., McCullough, L., Svartberg, M., Høglend, P., & Stiles, T. C. (2010). The relationship between insight gained during therapy and long-term outcome in short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Psychotherapy Research, 20(5), 526-534. https://doi.org/10.1080/10503307.2010.492807

Kandel, E. (1999). Biology and the future of psychoanalysis: New intellectural framework for psychiatry revisited. American Journal of Psychiatry, 156, 505-524. https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.4.505

Klug, G., Zimmermann, J., & Huber, D. (2016). Outcome trajectories and mediation in psychotherapeutic treatments of major depression. Journal of the American Psychoanalytic Association, 64(2), 307-343. https://doi.org/10.1177/0003065116644742

Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51(4), 467-481. http://dx.doi.org/10.1037/a0034332

Leichsenring, F., & Rabung, S. (2011). Long-term psychodynamic psychotherapy in complex mental disorders: Update of a meta-analysis. The British Journal of Psychiatry, 199, 15–22. https://doi.org/10.1192/bjp.bp.110.082776

Midgley, N., & Kennedy, E. (2011). Psychodynamic psychotherapy for children and adolescents: A critical review of the evidence base. Journal of Child Psychotherapy, 37(3), 232-260. http://dx.doi.org/10.1080/0075417X.2011.614738

Parker, B., & Turner, W. (2014). Psychoanalytic/psychodynamic psychotherapy for sexually abused children and adolescents: A systematic review. Research on Social Work Practice, 24(4), 389-399. https://doi.org/10.1177/1049731514525477

Rizeanu, S. (2016). Psychotherapy of borderline personality disorder. Romanian Journal of Experimental Applied Psychology, 7(3), 76-81. doi: 10.15303/rjeap.2016.v7i3.a7

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. doi: 10.1037/a0018378,

Shepherd, C., & Beail, N. (2017). A systematic review of the effectiveness of psychoanalysis, psychoanalytic and psychodynamic psychotherapy with adults with intellectual and developmental disabilities: Progress and challenges. Psychoanalytic Psychotherapy, 31(1), 94-117. https://doi.org/10.1080/02668734.2017.1286610

Soares, M. C., Mondin, T. C., Silva, G. D. G. D., Barbosa, L. P., Molina, M. L., Jansen, K., Souza, L. D. M., & Silva, R. A. D. (2018). Comparison of clinical significance of cognitive-behavioral therapy and psychodynamic therapy for major depressive disorder: A randomized clinical trial. Journal of Nervous and Mental Disease, 206(9), 686-693.

Waldron, S., Gazzillo, F., Genova, F., & Lingiardi, V. (2013). Relational and classical elements in psychoanalyses: An empirical study with case illustrations. Psychoanalytic Psychology, 30(4), 567-600. Waldron, S., Gazzillo, F., & Stukenberg, K. (2015). Do the processes of psychoanalytic work lead to benefit? Studies by the APS Research Group and the Psychoanalytic Research Consortium. Psychoanalytic Inquiry, 35, 169-184. https://doi.org/10.1080/07351690.2015.987602

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