Psychodynamic therapy: a poorly defined concept with questionable evidence (original) (raw)
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Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria
The Lancet Psychiatry, 2015
Psychodynamic therapy (PDT) is an umbrella concept for treatments that operate on an interpretive-supportive continuum and is frequently used in clinical practice. The use of any form of psychotherapy should be supported by suffi cient evidence. Effi cacy research has been neglected in PDT for a long time. In this review, we describe methodological requirements for proofs of effi cacy and summarise the evidence for use of PDT to treat mental health disorders. After specifying the requirements for superiority, non-inferiority, and equivalence trials, we did a systematic search using the following criteria: randomised controlled trial of PDT; use of treatment manuals or manual-like guidelines; use of reliable and valid measures for diagnosis and outcome; adults treated for specifi c mental problems. We identifi ed 64 randomised controlled trials that provide evidence for the effi cacy of PDT in common mental health disorders. Studies suffi ciently powered to test for equivalence to established treatments did not fi nd substantial diff erences in effi cacy. These results were corroborated by several meta-analyses that suggest PDT is as effi cacious as treatments established in effi cacy. More randomised controlled trials are needed for some mental health disorders such as obsessive-compulsive disorder and post-traumatic stress disorder. Furthermore, more adequately powered equivalence trials are needed.
The Empirical Status of Psychodynamic Psychotherapy - An Update: Bambi's Alive and Kicking
Psychotherapy and psychosomatics, 2015
The Task Force on Promotion and Dissemination of Psychological Procedures proposed rigorous criteria to define empirically supported psychotherapies. According to these criteria, 2 randomized controlled trials (RCTs) showing efficacy are required for a treatment to be designated as 'efficacious' and 1 RCT for a designation as 'possibly efficacious'. Applying these criteria modified by Chambless and Hollon, this article presents an update on the evidence for psychodynamic therapy (PDT) in specific mental disorders. A systematic search was performed using the criteria by Chambless and Hollon for study selection, as follows: (1) RCT of PDT in adults, (2) use of reliable and valid measures for diagnosis and outcome, (3) use of treatment manuals or manual-like guidelines, (4) adult population treated for specific problems and (5) PDT superior to no treatment, placebo or alternative treatment or equivalent to an established treatment. A total of 39 RCTs were included. Foll...
A Quality-Based Review of Randomized Controlled Trials of Psychodynamic Psychotherapy
American Journal of Psychiatry, 2011
describe a "hierarchy of evidence" ranging from case studies and uncontrolled trials to randomized controlled trials that support the utility, if not the effi cacy, of various forms of psychodynamic psychotherapy for treatment of patients with a wide range of DSM-IV axis I and II psychiatric disorders. Although each of these meta-analyses attempts, in its own way, to make use only of studies that are considered of high enough quality to warrant inclusion in a meta-analysis, there is sharp disagreement in the fi eld about whether the quality and number of studies included is suffi cient to warrant the conclusions drawn. Ambiguity about the state of psychodynamic empirical research presents a signifi cant problem for training and practice in the mental health fi elds. The objective evaluation of the quality of randomized controlled trials of psychodynamic psychotherapy is a cogent place to begin the process of correcting this problem. Such trials are widely accepted in medicine as the gold standard for assessing treatment effi cacy, and there is good conceptual The depth and quality of the evidence base for psychodynamic psychotherapy has long been a subject of controversy among psychodynamic and nonpsychodynamic clinicians and researchers. Some have argued that the relative absence of randomized controlled trials has doomed psychodynamic treatments to obsolescence (1). This argument is sometimes used to support the further marginalization or even elimination of training in psychodynamic techniques in psychiatry, psychology, and social work training programs, to be replaced by "evidencebased treatments" (2). Others have argued that a body of empirical evidence for psychodynamic treatments exists and is underappreciated in the context of contemporary emphasis on shortterm, manualized, and symptom-focused treatments and targeted medications (3-5). Over the past several years, meta-analyses have appeared in mainstream research outlets that argue for the effi cacy of psychodynamic treatments for specifi c disorders (6-11). Gabbard et al. (12)
The Efficacy of Psychodynamic Psychotherapy
Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as " empirically supported " and " evidence based. " In addition, patients who receive psychody-namic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsy-chodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings .
Psychotherapy, 2012
The aim of this research was to examine the extent to which the use of research-specific procedures in psychodynamic psychotherapy impacts upon treatment effectiveness and which variables moderate this potential relationship. Effects of audio/video recording of sessions, use of treatment manuals, and checks of treatment fidelity were examined. A meta-analysis was conducted on randomized controlled trials of psychodynamic psychotherapy. Forty-six independent treatment samples totaling 1615 patients were included. The magnitude of change between pretreatment and posttreatment aggregated across all studies (45 treatment samples) for overall outcome was large (d ϭ 1.01), and further improvement was observed between posttreatment and an average 12.8-month follow-up (d ϭ 0.18). Subgroup analyses comparing studies that used research-specific procedures and those that did not revealed that for posttreatment data no differences in treatment effects were found. However, the use of treatment manuals and fidelity checks were significantly associated with improvement between the end of treatment and follow-up assessment. Within the limitations of analyses, this data offered preliminary evidence that use of research-specific procedures does not contribute in a negative manner to posttreatment outcomes in psychodynamic psychotherapy, and their use contributes to positive differences that emerge with time. These findings, although observational in nature, make a case for reconsidering how dimensions of clinical utility and experimental control may be integrated in psychodynamic psychotherapy to enable further elucidation of principles that evidently work.
Comparative Effects of Short-Term Psychodynamic Psychotherapy
1991
In a review of 19 clinically relevant comparative outcome studies published 1978-1988, short-term psychodynamic psychotherapy (STPP) was evaluated as to overall effects, differential effects, and moderating effects visa -vis no-treatment controls (NT) and alternative psychotherapies (AP), respectively Overall, STPP was superior to NT at posttreatment, inferior to AP at posttreatment, and even more so at 1-year follow-up. STPP was inferior to AP in treating depression and, in particular, to cognitive-behavioral therapy for major depression. STPP was equally successful with mixed neurotics. As research quality increased, STPP grew less superior to NT. Furthermore, STPP decreased its overall superiority over NT and increased its overall inferiority to AT on a series of clinically relevant variables. Improvement in research quality from 1978 to 1988 was noted. Evidence, although limited, supported the view that STPP approaches do seem to differ along a few major dimensions.
The Empirical Status of Psychodynamic Therapies
Annual Review of Clinical Psychology, 2008
The goal of the current review is to examine the evidence for the efficacy of dynamic psychotherapy, primarily focusing on studies that meet the rigorous criteria proposed by . We examine whether any progress has been made over the past decade in evaluating the efficacy of dynamic psychotherapy using well-controlled randomized designs. Over the past decade, multiple studies have been published supporting the efficacy of dynamic psychotherapy for the treatment of specific mental disorders. Dynamic psychotherapy should now be included as a possibly efficacious treatment for panic disorder and borderline personality disorder, as well as the original designation of possibly efficacious in the treatment of opiate dependence. In the context of medication usage, dynamic psychotherapy should be considered efficacious in the treatment of major depressive disorder (MDD). Studies suggest that dynamic psychotherapy has great promise as a monotherapy for MDD and alcohol dependence and thus should be evaluated further.
Psychodynamic Psychotherapy Vindicated
Over the years, research in psychotherapy has focused on simple treatments that are easily replicable, intentionally taking the person of the therapist out of the equation. This practice has led to a de facto divide between psychotherapy researchers and clinicians, as many clinical researchers began to view any therapies not empirically validated through randomized controlled trials (RCTs) as invalid. Since these researchers published in journals almost exclusively read by other researchers, practicing clinicians, on their part, tended to view research as esoteric and irrelevant to their work. At the same time, many researchers became contemptuous of the more complex and long-term therapies which were more dependent on clinical skill and thus more difficult to research. It is not surprising that this schism has hampered efforts to translate research into practice and vice versa. Patients and psychotherapists are all concerned about making sure that treatment is as brief as possible ...