Friday, May 14, 2010

Jonathan Shedler, PhD - The Efficacy of Psychodynamic Psychotherapy

Back in January of this year, Jonathan Shedler, PhD published "The Efficacy of Psychodynamic Psychotherapy" (American Psychologist, Vol. 65. No.2), a ground-breaking look at meta-studies of psychodynamic therapies that found not only that they work, but they continue to work and the effects increase AFTER the therapy has ended. (The link above opens a PDF of the whole article, but if you want the Cliff Notes version, this press release from the APA summarizes the article: Psychodynamic Psychotherapy Brings Lasting Benefits through Self-Knowledge.)

I highly recommend the article, so here is the abstract and introduction to whet your appetite:
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 psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, non-psychodynamic 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.

Keywords: psychotherapy outcome, psychotherapy process, psychoanalysis, psychodynamic therapy, metaanalysis

There is a belief in some quarters that psychodynamic concepts and treatments lack empirical support or that scientific evidence shows that other forms of treatment are more effective. The belief appears to have taken on a life of its own. Academicians repeat it to one another, as do health care administrators, as do health care policymakers. With each repetition, its apparent credibility grows. At some point, there seems little need to question or revisit it because “everyone” knows it to be so.

The scientific evidence tells a different story: Considerable research supports the efficacy and effectiveness of psychodynamic therapy. The discrepancy between perceptions and evidence may be due, in part, to biases in the dissemination of research findings. One potential source of bias is a lingering distaste in the mental health professions for past psychoanalytic arrogance and authority. In decades past, American psychoanalysis was dominated by a hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research. This stance did not win friends in academic circles. When empirical findings emerged that supported nonpsychodynamic treatments, many academicians greeted them enthusiastically and were eager to discuss and disseminate them. When empirical evidence supported psychodynamic concepts and treatments, it was often overlooked.

This article brings together findings from several empirical literatures that bear on the efficacy of psychodynamic treatment. I first outline the distinctive features of psychodynamic therapy. I next review empirical evidence for the efficacy of psychodynamic treatment, including evidence that patients who receive psychodynamic therapy not only maintain therapeutic gains but continue to improve over time. Finally, I consider evidence that nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize interventions that have long been central to psychodynamic theory and practice.
When most people hear the words psychoanalytic or psychodynamic they generally think of Freud. The reality is that there are so few actual Freudians left in the world today that no one probably calls themselves Freudians. And few, if any therapists have their patients lie on a couch (well, maybe some psychoanalysts still do this) and meetings are generally one to three times a week, with therapy often lasting about a year.

Shedler points out that there are a lot of elements we take for granted in modern psychotherapy, no matter which school of thought, that come directly from the early Freudian tradition:
In a very basic sense, all mental health professionals are “Freudian” because so many of Freud’s concepts have simply been assimilated into the broader culture of psychotherapy. Many Freudian ideas now seem so commonplace, commonsense, and taken-for-granted that people do not recognize that they originated with Freud and were radical at the time. For example, most people take it for granted that trauma can cause emotional and physical symptoms, that our care in the early years profoundly affects our adult lives, that people have complex and often contradictory motives, that sexual abuse of children occurs and can have disastrous consequences, that emotional difficulties can be treated by talking, that we sometimes find fault with others for the very things we do not wish to see in ourselves, that it is exploitive and destructive for therapists to have sexual relations with clients, and so on. These and many more ideas that are commonplace in the culture of psychotherapy are actually “Freudian.” In this sense, every contemporary psychotherapist is a (gasp) Freudian. Even the practice of meeting with clients for regularly scheduled appointments originated with Freud. (Shedler, 2006, p. 5)
Modern psychoanalytic theory and practice includes object-relations therapy, ego states therapy, attachment theory, interpersonal neurobiology, relational psychotherapy, self psychology, and probably several others.

According to James & Gilliland, there are seven basic processes associated with the various forms of psychoanalytic therapy:
Auld and Hyman (1991, p. 17), citing Rapaport (1967), identified seven postulates or assumptions that have driven psychoanalytic therapy from the middle of the twentieth century to the 1990s:
1. Access to unconscious functioning comes through the associative process.
2. Later mental structures have to be explained by earlier experiences, by turning back to the past.
3. Psychic continuity is a lifelong process.
4. Mental life has meaning.
5. Determinism, the conviction that nothing that happens is accidental, is an accepted principle.
6. Instinct, that is, as the source of motivation in bodily processes, is an accepted concept.
7. The assumption of the concept of the unconscious is necessary because conscious experiences leave gaps in mental life that unconscious processes bridge.
Auld and Hyman hold that postulate one (which they added to the other six assumptions developed by Rapaport), is the guiding rationale for psychoanalytic technique.
With that foundation, here is an interview with Jonathan Shedler from Shrink Rap Radio. I listened to this while working out yesterday and found it both educational and entertaining. The discussion covers the current state of psychodynamic therapies, the article above, and the struggle he had in getting the paper published.

#236 – The Efficacy of Psychodynamic Therapies with Jonathan Shedler

photo of Dr. Jonathan Shedler

Jonathan Shedler, PhD is Associate Professor of Psychiatry at the University of Colorado School of Medicine, Director of Psychology at the University of Colorado Hospital Outpatient Psychiatry Service, and Founder of Digital Diagnostics Inc. He is co-author of the Shedler-Westen Assessment Procedure (SWAP) for personality diagnosis and author of the Quick PsychoDiagnostics Panel (QPD Panel) for mental health assessment in primary care. Dr. Shedler lectures to professional audiences nationally and internationally and consults to health care organizations and government agencies. He is also a certified professional ski instructor and, in a former life, taught skiing in Aspen, Colorado.

A psychology podcast by David Van Nuys, Ph.D.

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James, R. K. & Gilliland, B. E. (no date). Psychoanalytic Therapy. In Theories and Strategies in Counseling and Psychotherapy, (5th ed.); Boston: Allyn and Bacon.

Shedler, J. (2006). That Was Then, This is Now: Psychoanalytic Psychotherapy for the Rest of Us. Unpublished manuscript;

Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist, Vol. 65. No.2.

1 comment:

Anonymous said...

Great article, but what do critics say?