Does psychodynamic counselling and psychotherapy work?
It’s tempting just to give a one word answer to the question of whether going to see a therapist will be beneficial. I’ll explain how successful psychotherapy is in general but also what is different about a psychodynamic approach and what advantages it might have compared to other forms of therapy.
I’m going to summarise Jonathan Shedler’s paper “The efficacy of psychodynamic psychotherapy” published in 2010. The paper begins by refuting the myth that psychodynamic psychotherapy is the same as Freudian analysis or psychoanalytic psychotherapy. There is certainly a strong link with analysis in terms of theory but in practice it is quite different. Analysis takes place very frequently, about three to five times per week and the client lies on a couch with the analyst out of view. This is quite different from meeting once a week and sitting face to face. It feels different for the client in quite significant ways and you can read more about that in chapter 1 of this paper, also by Jonathan Shedler.
What is different about a psychodynamic approach? When Shedler examined the literature on comparisons between psychodynamic therapy and CBT he found seven distinct things that psychodynamic practitioners consistently do during the course of seeing a client:
- Focus on affect and expression of emotion.
Psychodynamic therapy encourages exploration of a full range of emotions, including unrecognised or unacknowledged emotion and contradictory feelings. With a CBT approach the focus is on thoughts and beliefs. Intellectual insight is not the same as emotional insight. Exploration of emotion gives a greater depth of focus than intellectualising alone.
- Exploration of attempts to avoid distressing thoughts and feelings.
Avoidance of difficult feelings are referred to in the theory as defences or resistances and many of them are done unconsciously or semi-consciously. Exploration of these behaviours and the difficult feelings behind them can give great insight and greater self-awareness. Psychodynamic practitioners actively focus on and explore these defences.
- Identification of recurring themes and patterns.
These patterns could be thoughts, feelings, self-concept, relationships and life experiences. Sometimes clients are already aware of patterns but don’t know how to escape them and at other times only become aware of the patterns when the therapist helps them to identify, explore and understand them.
- Discussion of past experience.
Related to the identification of recurring themes and patterns is the recognition that past experience, especially early childhood experiences, affects us and our relationships in the present. This plays out in the present in ways which are not always obvious. The focus is not on the past for its own sake, but on how the past sheds light on current psychological difficulties. The goal is to free us from these past bonds so we can live more fully.
- Focus on interpersonal relationships.
We cannot exist without relation to others, it’s part of what it is to be human. So there is an emphasis on relationships and interpersonal experience (this is called object relations and attachment in the theory). How we relate to others can be problematic and it is very useful to focus on how we interact with others in order to explore non-adaptive interpersonal patterns which can interfere with our ability to have our emotional needs met.
- Focus on the therapy relationship.
The things that cause problems in our lives will manifest within the therapy relationship. For example someone who distrusts others may have real difficulty trusting the therapist, or someone who fears abandonment and rejection my have the same fear that the therapist will reject them. These issues and others like them will play out in unconscious ways and sometimes quite subtly. Therapy provides a unique way to explore and work through these difficulties in real time with the therapist. The goal being a greater flexibility and enhanced capacity to meet interpersonal needs.
- Exploration of fantasy life.
This is something that most other therapies do not touch on. Desires, fears, fantasies, dreams or daydreams are not always easy to speak about freely but a psychodynamic therapist will help clients with this as dreams can reveal a great deal about the underlying beliefs and feelings about self and others, interprets and makes sense of experience and avoids or interferes with our ability to find greater joy and meaning in our lives.
Psychodynamic work can take a long time but this is not to say that symptom relief is only achieved slowly. Relief of symptoms of distress can happen very quickly but what takes longer and is unique to this way of doing things are the changes in psychological capacity and resources. This might include, but isn’t limited to, the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a more realistic sense of self-esteem and face life’s challenges with greater freedom and flexibility.
Shedler then examines the literature on general psychotherapies and finds than on the whole all psychotherapy are very effective. In the case of depression it seems psychotherapy alone is around four times more effective than anti-depressants alone. The results are similar or better for other mental health conditions. With a psychodynamic approach not only do clients reap benefits during short-term therapy (around 20 sessions) but also continue to improve after therapy has ended, measurable positive outcomes over 12 months later. In the longer term, over a year of therapy (50+ session), positive results were measured five years post treatment. Not only were the results still measurable, the effect sizes were larger. This means not only was therapy successful many years later, the positive results grew larger over time. This shouldn’t surprise anyone who has been to see a therapist, as they will often feel that going to therapy helped change their lives, but may be surprising or even shocking to others who not experienced therapy; as these positive results are not generally widely reported. It’s worth noting that the effect sizes in Shedler’s paper are the result of meta-analyses, not individual studies. A meta-analysis pools the results of many comparable studies thus giving a more accurate measure of success, since the numbers treated are larger in pooled results.
It’s worth reading in detail the results around personality disorder from the bottom of page 102 to 103. It seems, compared to the most popular therapy designed to treat personality disorder in the USA, psychodynamic therapy leads to permanent long-term benefits which would result in the absence of symptoms leading to the diagnosis. There are caveats mentioned; this result is only based on two studies rather than a meta-analysis.
When the details of what transpires in non-psychodynamic therapy, even cognitive behavioural therapies, Shedler finds that they often use the techniques mentioned above which have always been at the core and centrally defining of psychodynamic therapy. So psychodynamic therapy is not only comparable to other therapies which claim an empirical or evidence base, these other therapies are often using psychodynamic techniques along with their own techniques. In addition psychodynamic therapy appears to offer lasting benefits that extend long after symptom remission.
So does psychodynamic therapy work? Hell, Yeah!
If you’d like to read more by Jonathan Shedler (and you should, he writes amazing stuff), you can find links to it here on his website.
If you’d like to read an overview of other ways of working have a look at this blog post.