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Evidence for the Effectiveness of Psychoanalytic Psychotherapies

Evidence-based literature unequivocally demonstrates the efficacy of long-term individual and group psychoanalytic psychotherapies in treating a broad range of psychological conditions, particularly the more severe forms of mental dysfunction. (Bradshaw et al, 2009; Kachele et al, 2000; Solms, 2018; Lorentzen et al. 2015) Meta-analyses demonstrate a  mean effect size for psychoanalytic psychotherapies in excess of 0.8 (compared, for example, with a mean effect size of 0.31 for antidepressant medications approved by the US FDA between 1987 and 2004). (Shedler, 2010)The evidence strongly suggests that psychoanalytic models are much more appropriate to this client population than the shorter-term models which do not provide for the establishment of a patient-therapist relationship and time frame appropriate to the nature of the work. There is also research support for the application of short-term psychoanalytic therapies in certain circumstances. (Abbass et al, 2014) The depth of therapeutic work engaged in by psychoanalytic practitioners provides one of the most effective means of helping those presenting with the most entrenched and crippling mental health difficulties.
 

For example the British Tavistock Adult Depression Study of people with “treatment resistant” depression (defined by failure of two prior attempts at treatment using brief approaches) showed that 44% of the patients who received 18 months of weekly psychoanalytic psychotherapy no longer had major depressive disorder, while for those receiving the NHS treatments currently provided the figure was only 10%. At two-year follow-up, 30% of participants who attended weekly psychoanalytic psychotherapy showed sustained improvement, compared to only 4.4% of the “treatment as usual” control group. (Fonagy, Rost, Carlyle, McPherson, Thomas, Fearon, Goldberg & Taylor, 2015; Rost, Luyten, Fearon, & Fonagy, 2019) Interestingly, while both groups showed improvement at the end of treatment, the gains of the “treatment as usual” group declined steadily over the follow-up period, while the psychoanalytic treatment group sustained their gains. These data suggest that end-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit of psychoanalytic treatments and therefore unfairly represents their outcomes. Other studies have also suggested that the longer term outcomes of other evidence-based treatments such as CBT reveal a fading treatment effect with longer term follow-up. (Shedler, 2010)


Other studies demonstrate the effectiveness of both individual and group psychoanalytic psychotherapies. (Leuzinger-Bohleber & Kachele H, 2015; Burlingame, et al. 2016) These studies also show that patients continue to improve even after treatment has ended and for longer follow-up periods. Statistically significant and clinically meaningful improvements in panic, depression, anxiety, and functional impairment – both at treatment termination and at follow-up six months after completion – occur with psychoanalytic therapy. (Milrod et al, 2000.) A meta-analysis of the effectiveness of long-term psychoanalytic psychotherapy showed that it “was significantly superior to shorter-term” modalities and that long-term psychoanalytic psychotherapy yielded large and stable effect sizes in the treatment of patients with personality disorders, multiple mental disorders, and chronic mental disorders. (Leichsenring & Rabung, 2008, 2011.) These patients are commonly regarded as “difficult”, and it is particularly with respect to such patients who have “failed” or been excluded from other, briefer, therapies that psychoanalysis, or longer-term psychoanalytic psychotherapy have proven effective. Doidge, in an earlier review of the efficacy of psychoanalytic approaches, makes the observation that with such patients, “therapeutic benefit is consistently and strongly associated with treatment length” (p123). He also points out that significant health care cost savings arise from the reduction of demand for other services. (Doidge,1997.) 


Research also shows that patients diagnosed with Borderline Personality Disorder who completed a program of longer-term psychodynamic psychotherapy not only maintained their substantial gains at the end of treatment but also showed a statistically-significant, continued improvement on outcome measures. (Bateman and Fonagy, 2001.) A similar outcome, with a similar population, has been demonstrated in Australia. (Stevenson & Meares, 1992; Meares, Stevenson & Comerford, 1999; Meares, Stevenson & Comerford, 1999.) This long-term follow up of patients treated intensively using psychoanalytic psychotherapy not only revealed positive clinical outcomes but positive economic outcomes in terms of increased productivity, and reduced demand on other health services. (Stevenson & Meares 1999; Hall, Caleo, Stevenson & Meares, 2001)
 

German research into Analytical Psychology (Roesler et al 2013) showed a significant reduction of health insurance claims: the mean number of days lost due to sickness, the mean number of days of hospitalization, the intake of psychotropic drugs and the number of visits to primary care physicians were all significantly reduced even below the level of the average German member of the health insurance system. 


A Swedish study, the Stockholm Outcome of Psychotherapy and Psychoanalysis (STOPP) Project, of more than 400 people during and after, subsidised psychoanalysis or longer-term psychotherapy showed continued improvement following the completion of treatment. (Sandell et al, 2000; Blomberg et al, 2001) It has been shown to result in markedly reduced medical utilization (sick days, hospital days, number of physician visits, drug intake) in the majority of patients studied in a review of health insurance. (Keller et al 2006.) This research indicates that patients reduced sick days by two thirds in the year after therapy, and by a further 50 per cent after five years. Hospital days were reduced by 87.5 percent in the year after therapy and 50 per cent after five years. These observations lend support to the notion that psychoanalytic treatment initiates a process that continues in the patient after the formal termination of treatment. The implication is that an advantage exists for extended, in-depth psychotherapy or psychoanalysis over short-term therapy and/or medication for a group of complex problems. For many people, psychodynamic forms of psychotherapy may foster inner resources and capacities that allow richer, freer, more productive and fulfilling lives. (Shedler, 2009.) Recent studies have established the efficacy of psychodynamic psychotherapies at a neurobiological level (Cozolino, 2002, 2006; Buchheim et al, 2012). The brain restructures itself during psychotherapy and “the more successful the treatment the greater the change”. (Doidge 2007, p.234.) The evidence emerging in these studies emphasises the role of the relationship between therapist and patient and the need for a significant time to enable these changes to become expressed as physical changes in the brain.
 

A similar body of evidence is accruing for the effectiveness of longer term, more intensive treatments with children. A review of 15 years of work on the outcomes of child psychoanalytic therapy concluded that: “The follow-up study is consistent with the long-term good outcome of the early treatment of these relatively seriously disturbed children. We were again and again surprised to meet adults who, as children, manifested serious and in many instances “hopeless” conditions; yet who, following successful treatment, had become relatively high-achieving individuals with stable social circumstances and no history of further psychiatric problems.” (Fonagy & Target, 2002, p 54)

 

A number of other studies and reviews have shown the effectiveness of psychodynamic therapies with children and adolescents:

- Extensive reviews (Kennedy & Midgley, 2007; Midgley & Kennedy, 2011) of research in child and adolescent psychotherapy found that psychodynamic therapy is beneficial. The magnitude of the effect is approximately 0.7, thus about the same effect as in psychotherapy with adults. 

- The positive change continues after the termination of treatment. ie there is a positive, so-called, “sleeper effect”. When tested, it emerges that this effect is maintained in adulthood. (Schachter, 2004; Schachter & Target, 2009; Midgley and Target, 2005; Midgley et al., 2006; Midgley et al, 2009) 

-Less disturbed children seem to have been able to be helped by therapy once a week. (Muratori et al., 2003; Fonagy and Target, 1996) 

- More disturbed children need more intensive and longer treatment. (Lush et al., 1998; Schachter and Target, 2009; Heinicke and Ramsay-Klee, 1986) If the psychotherapy is too short or not sufficiently intensive, or if parallel work with parents is lacking, psychotherapy may in certain cases be damaging for seriously disturbed children, (Target and Fonagy, 2002; Szapocznik et al., 1989)   


Psychotherapy has been found in formal studies to be effective for children with:

- Depression (Target and Fonagy, 1994b; Trowell et al., 2007; Horn et al., 2005) 

- Poorly controlled diabetes (Fonagy and Moran,1991)  

- Anxiety disorders (Kronmüller et al., 2005;Target and Fonagy, 1994b)  

- Personality disorder (Gerber, 2004)  

- Specific learning difficulties (Heinicke and Ramsey-Klee, 1986)  

- Pervasive developmental disorders (Reid et al., 2001)  

- Eating disorders (Robin et al., 1999)  

- Infants exposed to violence (Lieberman et al., 2005)  


Psychotherapy has had significant therapeutic benefits for severely deprived children, children in foster care and sexually-abused girls. (Lush et al., 1998 ; Trowell et al., 2002) In the UK, studies have resulted in psychodynamic psychotherapies (eg Dynamic Interpersonal Therapy) being included as a  form of treatment available in public health care (NICE Guidelines).


There is also evidence of the effectiveness of psychoanalytic psychotherapy for couples whose psychological difficulties could result in a costly divorce, and emotional turbulence for children of the relationship. (Hewison et al, 2014; Hewison et al, 2016) 


Details of the studies cited in this brief review, and other useful references are available in the selected bibliography on this website.