The effectiveness of psychodynamic psychotherapies: An update

Abstract

This paper provides a comprehensive review of outcome studies and meta-analyses of effectiveness studies of psychodynamic therapy (PDT) for the major categories of mental disorders. Comparisons with inactive controls (waitlist, treatment as usual and placebo) generally but by no means invariably show PDT to be effective for depression, some anxiety disorders, eating disorders and somatic disorders. There is little evidence to support its implementation for post-traumatic stress disorder, obsessive-compulsive disorder, bulimia nervosa, cocaine dependence or psychosis. The strongest current evidence base supports relatively long-term psychodynamic treatment of some personality disorders, particularly borderline personality disorder. Comparisons with active treatments rarely identify PDT as superior to control interventions and studies are generally not appropriately designed to provide tests of statistical equivalence. Studies that demonstrate inferiority of PDT to alternatives exist, but are small in number and often questionable in design. Reviews of the field appear to be subject to allegiance effects. The present review recommends abandoning the inherently conservative strategy of comparing heterogeneous “families” of therapies for heterogeneous diagnostic groups. Instead, it advocates using the opportunities provided by bioscience and computational psychiatry to creatively explore and assess the value of protocol-directed combinations of specific treatment components to address the key problems of individual patients.

http://onlinelibrary.wiley.com/doi/10.1002/wps.20235/full

Little evidence for its use in psychosis. I wonder if @notmoses has a view on this.

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So what are psychodynamic therapies?

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He does. (Well… you asked. Hahahahaha. :open_mouth: :grin: :relaxed: ) And here it is:

The PDPs are tremendously useful for developing a sense of how one came to have symptoms that were interpersonally conditioned (e.g.; how one became caught in seeming irreconcilable conflicts owning to double-binding by parents or other, usually older, family members) and consciously recognizing that the shame, guilt, worry, remorse, regret and morbid rumination the pt has is not his or her own invention.

In some cases, just understanding the linkages – or connecting the dots – between the complex causes and effects will produce a cognitive, emotional and/or even (reactive) behavioral “lift-off.” More often, however, a major disconnect from the causes to the conditions (in AA speak) will not occur. BUT… the PDP will have provided an awareness of the causes and conditions that can then be subjected to other approaches, including behavior modification, cognitive work, traumatic memory “untangling,” mindfulness and (just recently) somatic experiencing.

Most MA/MS-level therapists are not – it seems to me – sufficiently skilled to utilize an “eclectic mix” of psychotherapies to resolve the really deeply embedded issues. This appears to owe to a lack of breadth in both conceptual grasp thereof, as well as in technique. BUT… many are. (How does the pt know the difference? I doubt that one can unless he or she has been edified in these matters.)

Those with the Psychologist Doctor – or Psy.D. – degree at least tend to come out of the much longer schooling with a deeper and broader immersion into developmental theory and research, as well as various therapies. The Psy.D. typically charges a lot more, but is usually worth it even in the short run, because many Psy. D.'s will oversee and refer pts to less-costly MA/MS therapists for courses of specific therapies that will collectively “get the job done.”

The major problem for the truly psychotic pt with respect to the PDPs is less an issue of “strange beliefs” than it is of “emotional dysregulation.” If the pt is not medicated effectively – and, as a result, “stabilized emotionally” – the pt will be unable to connect any dots. Sz, and other psychotic spectrum pts, will almost always have to be medicated to a point withing a range between “too much” and “too little” that makes it possible for them to interpret reality functionally, as well as not over-react to their projections of threat.

The Psy.D. almost always understands this; many MA/MS therapists seem not to.