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Barber, J., Muran, J.C., McCarthy, K., Keefe, J.R., & Zilchamano, S. (2021). Research on dynamic therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 12.

One of the persistent myths about psychotherapy is that among treatments that are meant to be effective, some treatments are more effective than others. There are complex historical reasons for such claims, but one therapy that has been most negatively affected by this narrative in psychodynamic therapy. Once a prominent treatment model up to the 1970s, psychodynamic therapy has fallen out of favor among some researchers and is sometimes disparaged as having no evidence base to support its efficacy. In this part of the chapter, Barber and colleagues review the research on the efficacy for psychodynamic therapy for a variety disorders. At the time of writing the chapter, the authors identified 245 randomized controlled trials of psychodynamic therapy. Randomized controlled trials are considered by some as representing the highest quality evidence for interventions. In a number of meta analyses, psychodynamic therapies have demonstrated efficacy compared to control groups in the treatment of mood, anxiety, personality, and somatic disorders, with effects lasting into posttreatment follow-up. In the treatment of suicidality and self-harm, psychodynamic therapies are more effective than control treatments, such as treatment as usual, routine psychiatric care, enhanced usual care, placebo, or any other comparison, including with a different psychological therapy. Long-term psychodynamic therapies for complex or chronic disorders (e.g., borderline personality disorder; treatment-resistant depression) outperformed active and inactive controls. A meta-analysis assessing statistical equivalence in trials comparing psychodynamic therapies to other gold-standard treatments found no evidence that other treatments were more effective. In treatment of unipolar mood disorders, adding short-term psychodynamic therapy to psychopharmacology improved depression symptoms over medications alone (g = 0.26 at termination; g = 0.50 at follow-up).

Practice Implications

Some who practice psychodynamic therapy may feel that the research has been stacked against this treatment modality. And while the narrative is certainly one sided, the evidence is not. Psychodynamic therapy has a robust evidence base for a variety of disorders for which it was tested. Meta analyses consistently demonstrate psychodynamic therapy is as effective as other so called gold standard treatments and provides added value to the treatment of depression over and above medications alone.

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148

Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.

Practice Implications

The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.

Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A., Furukawa, T.O. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283-293.

Depressive disorders are common, and they have an important negative impact on quality of life and on mortality. For that reason, the treatment of depression is critical. The most commonly tested psychotherapy is CBT but others like interpersonal psychotherapy (IPT), psychodynamic therapy (PDT), and behavioral activation (BA) have also been tested. In this network meta analysis, Cuijpers and colleagues simultaneously test the effects of different psychotherapies for depression. Network meta-analysis, fundamentally, works by the transitivity assumption: if treatment A = treatment B, and treatment B = treatment C, then treatment A = treatment C even if Treatments A and C were never tested against each other in the same study. This procedure is not without controversy: what if the studies of treatment A vs B are all higher quality (thus resulting in lower effects) than studies of treatments B vs C? Is it fair to equate the studies by comparing treatments A and C when we know study quality impacts effect sizes? Nevertheless, network meta-analyses are used by some to aggregate many studies and to estimate relative outcomes across treatment types. Cuijpers included 331 studies (representing over 34,000 patients) in their network meta-analysis. CBT was tested in over 63% of trials, but other therapies (PDT, IPT, BA) were tested as well. All psychotherapies were more efficacious than care-as-usual and wait list controls with almost no significant differences between therapies for treating depression, except non-directive therapy was less efficacious than other therapies. (Non-directive therapy was often treated as a placebo control condition in studies, and so it may have been delivered in a way that limited its efficacy). CBT, IPT, PDT and BA all were more efficacious than care as usual at 12 months follow up.

Practice Implications

Overall, this network meta-analysis of psychotherapies for depression echoes the findings of many meta-analyses that preceded it. All psychotherapies that were examined, except for non-directive therapy, were equally efficacious for treating depression. When initiating therapy, it may be more important for therapists to be responsive to patient characteristics than to focus on which brand of therapy to deliver. For example, patients with internalizing coping styles may do better with insight oriented therapies, those with high levels of resistance/reactance may require a therapist that is less directive, and patients from marginalized race and ethnic communities may do better with a therapist who is multiculturally competent.

Keefe, J. R., McMain, S. F., McCarthy, K. S., Zilcha-Mano, S., Dinger, U., Sahin, Z., Graham, K., & Barber, J. P. (2019, December 5). A meta-analysis of psychodynamic treatments for borderline and Cluster C personality disorders. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

Personality disorders are common mental conditions affecting between 6.1% and 9.1% of the population. Having a comorbid personality disorder predicts a number of negative outcomes from psychotherapy including lower remission rates, greater resistance to therapy, and greater relapse after therapy. Psychodynamic therapies are one of two classes of therapy that have been repeatedly tested in clinical trials for personality disorders (the other being cognitive-behavioral therapies). Psychodynamic therapies aim to help patients improve their personality functioning, including attachment, mentalization, and maturity of defense mechanisms. Dynamic therapies for personality disorders include transference-focused therapy, affect-phobia therapy, mentalization based treatment, and good psychiatric management. In this meta-analysis, Keefe and colleagues systematically assessed whether psychodynamic therapy was as effective as other active treatments and more effective than no treatment. They also evaluated the quality of the studies. They found 16 randomized controlled studies of over 1100 patients that directly compared psychodynamic therapy to another therapy or to a control condition. Outcomes included personality disorder symptoms, suicidality, general symptoms, and drop-out rates. Overall, psychodynamic therapy was as effective as other therapies when it came to all of these outcomes, and the drop-out rates were equivalent. Psychodynamic therapy was more effective than no treatment for personality disorder symptoms (g = 0.63; 95% CI [0.87, 0.41], SE = 0.08, p = .002), suicidality (g = 0.67; 95% CI [1.13, 0.20], SE = 0.15, p = .020), and general symptoms (g = 0.38;95% CI [0.68, 0.08], SE = 0.13, p = .019). Average study quality was high, suggesting that one could be confident in the overall findings of this meta analysis.

Practice Implications

For all outcomes, psychodynamic therapies were as effective as other active treatments and more effective than no-treatment controls for borderline personality disorder and for mixed Cluster C disorders (dependent, avoidant, and obsessive-compulsive personality disorders). The authors concluded that psychodynamic therapies are effective in treating personality disorders like borderline personality disorder and those with Cluster C personality disorders.

Clients of Therapists Who Are Flexible Have Better Outcomes

Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94–103.

Psychodynamic and cognitive-behavioral (CB) treatments are quite different in how therapy is delivered, but both are equally effective for depression. Such findings suggest that various types of specific interventions can positively impact client outcomes. A possible mechanisms of therapeutic action is that effective therapists may be particularly responsive to their clients’ behaviors and needs. That is, effective therapists may be flexible in how adherent they are to the techniques of a therapeutic orientation. Therapists who are flexible in their adherence to a therapeutic technique may promote a better therapeutic alliance (i.e., a therapist’s and client’s collaborative agreement on the goals of therapy and what to do in therapy). In this study, Katz and colleagues examined whether the flexible use of some CB techniques by psychodynamic therapists was related to better client outcomes in terms of depressive symptoms. Forty six patients diagnosed with depression were treated by 26 advanced graduate student therapists who were trained to practice psychodynamic therapy. Psychodynamic therapy techniques included: a focus on affect and affect expression, identifying relational patterns and patterns of thoughts and feelings, emphasizing past experiences and interpersonal relationships, working on the therapeutic alliance, and restructuring defense mechanisms. The researchers video recorded two early sessions of therapy which were independently rated to assess the degree to which therapists adhered to psychodynamic therapy principles or to CB therapy principles. Client depression outcomes were assessed pre- and post-therapy. Higher ratings of psychodynamic therapy adherence were related to better patient depression outcomes at post-treatment. In addition, the clients of psychodynamic therapists who used some CB techniques early in therapy had the best outcomes. In other words, the use of psychodynamic techniques was sufficient for clients to improve, but flexible use of some CB techniques by psychodynamic therapists provided added benefit. The CB techniques that were most often integrated by the therapists included: actively initiating topics and therapeutic activities, explaining the rationale of an intervention, focusing on the future, and providing psychoeducation about symptoms.

Practice Implications

Clients in this study improved on average from psychodynamic therapy, and psychodynamic interventions were related to better outcomes. However, clients of therapists who flexibly integrated a small amount of CB techniques benefitted more from the psychodynamic techniques. Research is increasingly showing that therapist flexibility in treatment adherence is related to better patient outcomes. For psychodynamic therapists, flexibility in treatment adherence leads to clients being more responsive to the interventions and having better outcomes.

Fonagy, P., Lemma, A., Target, M., O'Keeffe, S., Constantinou, M., Ventura Wurman, T., . . . Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 1-10. Online first publication. doi:10.1017/S0033291719000928

Most psychotherapies are equally effective when it comes to treating depression. However, no single therapy is uniformly effective, so that about 50% of patients might improve when it comes to symptom reduction. So, although there is a large evidence base for treatments like CBT, therapists and patients need access to a range of available treatments. There is less research on psychodynamic therapies, although a number of trials and meta-analyses indicate their effectiveness to treat depression. In the United Kingdom (UK), the health system may offer a stepped care program that provides patients with low intensity guided self-help based on a CBT model followed by more intensive treatment with CBT or IPT if patients did not benefit from self-help. The UK health system rarely offers Dynamic Interpersonal Therapy (DIT), and DIT has never been studied in a randomized controlled trial within the UK health system. Fonagy and colleagues designed this randomized controlled trial to test the efficacy of DIT when compared to the CBT-oriented self-help program as offered in the UK. The study also included a smaller randomized sample of those who received the intensive version of CBT for depression. In total, 147 participants with moderate to severe depression were randomly assigned to DIT, CBT guided self-help, or the intensive version of CBT. The DIT is informed by attachment theory and by mentalization theory, and it views depressive symptoms as responses to interpersonal difficulties or perceived attachment threats. The results of the trial showed a significantly greater effect of DIT compared to guided self-help with regard to depressive symptoms, overall symptom severity, social functioning, and quality of life at post-treatment. The patients receiving DIT maintained these gains up to 1-year post-treatment. Over half of DIT patients showed clinically significant improvements, but only 9% who received the CBT-based guided self-help achieved such improvement. There were no significant differences on any of the outcomes between DIT and the more intensive version of CBT.

Practice Implications

One of the benefits of DIT, according to the authors, is that it offers a treatment manual and curriculum that enables those without a lot of background in psychodynamic therapies to deliver it. This makes DIT potentially widely-applicable in publicly funded health systems like in the UK, Canada, and others. DIT may offer yet another effective option of psychotherapy to therapists and their patients who experience depressive symptoms. The study also points to the limits of offering only guided self-help to those with moderate to severe depression.

Author email: p.fonagy@ucl.ac.uk